Inspection on 27/02/04 for 49 Glendale

Care Homes For Adults (18 ­ 65)49 GlendaleSwanley Kent BR8 8TPUnannounced Inspection27th February 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment 49 Glendale Address Swanley, Kent, BR8 8TP Email Address Tel No: 01322 614349 Fax No:Name of registered provider(s)/Company (if applicable) Mr David Curling Mrs Anne-Marie Curling Name of registered manager (if applicable) Mrs Anne-Marie Curling Type of registration Care Home No. of places registered (if applicable) 2Category(ies) of registration, with (number of places) Mental disorder, excluding learning disability or dementia (2) Registration number H060000043 Date First registered 11th July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 11th July 2002 yes NO 18/07/03 If Yes Refer to Part C49 GlendalePage 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector Name of Inspector Name of Inspector 1 2 327th February 2004 02:30 pm Lorraine Pumford x x xID Code105215Name of Inspector 4 Name of Lay Assessor (if applicable) Lay assessors are members of the public independent of the NCSC. They accompany inspectors on some inspections and bring a different perspective to the inspection process Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at the time of inspectionx x Mrs Curling49 GlendalePage 2 CONTENTSIntroduction to Report and Inspection Inspection visits Description of service Part A: Summary of Inspection Findings Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods Used & Findings The Standards. National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: Part E: E.1. E.2. E.3. Compliance with additional conditions of registration ( if applicable) Lay Assessors summary (where applicable) Providers Response Providers comments Action Plan Providers agreement49 GlendalePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the NCSC in respect of 49 Glendale. The inspection findings relate to the National Minimum Standards (NMS) for Care Home published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000 and the Children Act 1989 as amended. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.49 GlendalePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. The property is detached and situated in a quiet road on the outskirts of Swanley town centre. Where there is a range of shops, a weekly market, a sports complex and other amenities. The proprietors provide care in their own home, for two female service users who have mental health difficulties. No other member of staff are employed, a part from when the proprietors have their annual holiday.49 GlendalePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The focus of this inspection was to address the remaining standards. On the day of the inspection the homeowner and one of two service users assisted the inspector. As this report was made following an unannounced visit and may not cover the standards in sufficient depth for the reader to make a judgment about the home, it is recommended that a copy of the last announced inspection report be also obtained. The summary contains the record of the inspection to support the reader to obtain a clearer picture of standards in the home. This unannounced inspection took place on 16 October 2003. It found those National Minimum Standards inspected had been met and the overall quality of care provided was very good. Choice of Home (Standards 1-5) Of these 5 standards 3 were addressed during the previous inspection 2 were inspected on this occasion. Discussion took place around the procedure for admitting new service users, The home owner stated generally this would take place over several weeks with short visits leading up to over night visits however the most recent person to move in was unable to follow this process as an establishment was closing and a move needed to take place at short notice. The homeowner stated an assessment did take place before admission and relevant information was provided by the social worker which enabled her to feel confident they would be able to meet the needs of the new service user. The new service user had been given a copy of the house contract detailing the terms and conditions of residency and both parties rights and responsibility, however as yet this had not been signed the homeowner was advised to do this as soon as possible and retain a copy for her own reference. A contract between the other service users and homeowner still needs to be addressed this issue remains outstanding pending input from the service users social worker. Individual Needs and Choices (Standards 6-10) Of these 5 standards 1 was addressed during the previous inspection 4 were inspected on this occasion. From discussion with the home owner and service user it is apparent service users are encouraged to make decision in relation to their own life as well as issues in the home. Service users are involved menu planning, meal preparation and cooking and choose the activities they wish to be involved in. Service users either manage their own financial affairs or are assisted by a relative. One person receives support from an advocate during periods of employment. Generally risk assessments are undertaking by hospital team with the home 49 Glendale Page 6 owner undertakes to monitor, service users are given a daily plan to refer to i.e. the route to work, buses to catch etc. Detailed records are provided for the member of staff who covers during the homeowners annual leave. The homeowner is aware of issues in relation to confidentiality records are kept in a locked cupboard when not in use. Lifestyle (Standards 11-17) Of the 7 standards assessed 3 were addressed during the previous inspection 4 were inspected on this occasion. The service user stated she has access to recreational facilities in the area i.e. sports facilities and theatres. Service users access public transport as required. The homeowner stated peoples names are on the electoral role to enable them to vote. The home maintains good relations with the neighbours and local community. The service user spoken with stated she attend craft groups on a regular basis and attends adult education classes periodically. At present the service user spends annual holidays with relatives discussion took place around standard 14.4 which states service users are entitled to a seven-day holiday included in the contract price of the placement. Relatives and friends visit service users in the home there is a study which is comfortably furnished and equipped with TV and stereo system which is available for private conversation and telephone calls etc. The home owner stated prospective service users are asked if they would like a key to their bedroom door, both occupants have a locked facility in their bedrooms solely for their own use, mail is opened by the named recipient. Service users insolvent in house hold tasks is in the service user guide. The home has a no smoking policy, which is clearly stated in the service user guide. Personal and Healthcare Support (Standards 18-21) Of these 4 standards 2 were addressed on a previous occasion 2 were inspected on this occasion. There is minimal need for direct personal care. Service users receive on going specialist health care support. The homeowner has recorded services users wishes in the event of action to be taken following death. Concerns, Complaints and Protection (Standards 22-23) 2 of the 2 standards assessed were met The homeowner stated service users are provided with a copy of the homes complaints procedure. Information in relation to this was seen by the inspector in the service user guide it included in the contact address and telephone number for the N. C. S. C. the homeowner stated in the event of a complaints being made to her she would undertake an investigation and record the outcome. CRBs have been carried out in relation to the homeowners and the member of staff who covers the house during their holiday. Discussion took place in relation to the POVA list. The homeowner was advised to obtain a copy of the Department of Health document no secrets in relation to whistle blowing. Environment (Standards 24-30) All of the 7 standards were assessed during the previous inspection Staffing (Standards 31-36) All of the 3 standards were assessed in during the previous inspection. Conduct and management of the home (Standards 37-43) Of the 7 standards assessed 3 were assessed during the previous inspection 4 were inspected on this occasion. The homeowner has developed policies and procedures listed in appendix three which are 49 Glendale Page 7 relevant to the establishment. The inspector advised the homeowner to record the date the document was implemented and a date for review. The homeowner stated she was aware of the data protection act 1998 and records and information about service users are kept in a locked cupboard when not in use. Although the building is a small-scale registered home the homeowners have installed smoke detectors, extinguishers and a fire blanket, a record is kept to indicate batteries are regularly checked throughout the year. The homeowner has arranged to go on a food hygiene and first aid course in the near future. Discussion took place in relation to the safe storage of hazardous substances. The proprietor stated appropriate insurance is in place in relation to service users, the building and its contents.49 GlendalePage 8 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for actionAction is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)49 GlendalePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, the National Minimum Standards and the relevant sections of the Childrens Act. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action NONERECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard * 1 YA5 A contract detailing the terms and conditions of residency and both parties rights and responsibility* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.49 GlendalePage 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs) YES NO NA YES YES NO NO NA YES NO YES NA NA YES NA NA NA NO NO YES 1 X X NO NA NO YES X X 27/02/04 14.30 2.0049 GlendalePage 11 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.49 GlendalePage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to `test drive the home. Each service user has an individual written contract or statement of terms and conditions with the home.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives, philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. X X Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Key findings/Evidence Not inspectedStandard met?0Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user using an appropriate communication method, and with an independent advocate as appropriate. 0 Key findings/Evidence Standard met? Not inspected49 GlendalePage 13 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? Not inspectedStandard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis, before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? See summaryStandard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 2 Key findings/Evidence Standard met? See summary49 GlendalePage 14 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · Service users know their assessed and changing needs and personal goals are reflected in their individual plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on and participate in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home and how these services will meet current and changing needs and aspirations and achieve goals. 0 Key findings/Evidence Standard met? Not inspectedStandard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions and that right is limited only through the assessment process, involving the service user and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? See summary49 GlendalePage 15 Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day-to-day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? See summaryStandard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? See summaryStandard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998 and in the best interests of the service user. 3 Key findings/Evidence Standard met? See summary49 GlendalePage 16 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate, personal, family and sexual relationships. Service users rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 0 Key findings/Evidence Standard met? Not inspectedStandard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities 0 Key findings/Evidence Standard met? Not inspected49 GlendalePage 17 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? See summaryStandard 14 (14.1 ­ 14.6) Staff ensure that service users have access to and choose from a range of appropriate leisure activities. Key findings/Evidence Standard met? See summary3Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? See summaryStandard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? See summary49 GlendalePage 18 Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? Not inspected49 GlendalePage 19 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · Service users receive personal support in the way they prefer and require. Service users physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate and are protected by the homes policies and procedure for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? See summaryStandard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No of service users with pressure sores at the time of inspection (from information taken from care notes) Key findings/Evidence Not inspected. Standard met? XX 049 GlendalePage 20 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 0 Key findings/Evidence Standard met? Not inspectedStandard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 3 Key findings/Evidence Standard met? See summary.49 GlendalePage 21 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure which includes the stages of and times-scales for the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days Key findings/Evidence See summary. X X X X X X X Standard met? 349 GlendalePage 22 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence, or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists Key findings/Evidence See summary YESX Standard met? 349 GlendalePage 23 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · Service users live in a homely, comfortable and safe environment. Service users bedrooms suit their needs and lifestyles. Service users bedrooms promote their independence. Service users toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? Not inspected49 GlendalePage 24 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence Not inspected YES NO NO X X X X Standard met? 0 X XX X X X49 GlendalePage 25 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Key findings/Evidence Not inspected. Standard met? 0Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 0 Key findings/Evidence Standard met? Not inspected.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 0 Key findings/Evidence Standard met? Not inspected.49 GlendalePage 26 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 0 Key findings/Evidence Standard met? Not inspected.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of inspection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 0 Key findings/Evidence Standard met? Not inspected.49 GlendalePage 27 StaffingThe intended outcomes for the following set of standards are: · · · · · · Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the homes recruitment policy and practices. Service users individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? Not inspected.49 GlendalePage 28 Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme Key findings/Evidence Not inspected. X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X XXXStandard met?0Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. 0 Key findings/Evidence Standard met? Not inspected.49 GlendalePage 29 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? Not inspected.Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? Not inspected.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. Key findings/Evidence Standard met? Not inspected.049 GlendalePage 30 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · Service users benefit from a well run home. Service users benefit from the ethos leadership and management approach of the home. Service users are confident their views underpin all self- monitoring, review and development by the home. Service users rights and best interests are safeguarded by the homes policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping, policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care or equivalent. Key findings/Evidence Not inspected. NO 0Standard met?Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? Not inspected.49 GlendalePage 31 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems based on seeking the views of service users are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 0 Key findings/Evidence Standard met? Not inspected.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 3 of the National Minimum Standards for Younger Adults. 3 Key findings/Evidence Standard met? See summary.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained up to date and accurate. 3 Key findings/Evidence Standard met ? See a summary.Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? See summary.49 GlendalePage 32 Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 3 Key findings/Evidence Standard met ? See summary49 GlendalePage 33 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateLorraine Pumford Monica Hanscomb 10 March 2004Signature Signature Signature49 GlendalePage 34 PART D(where applicable)LAY ASSESSORS SUMMARYLay Assessor Date Public reportsSignatureIt should be noted that all NCSC inspection reports are public documents.49 GlendalePage 35 PART EE.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 27 February 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the NCSC in response to provider comments: 49 Glendale Page 36 Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. E.2 Please provide the Commission with a written Action Plan by which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. ,You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was requiredAction plan was received at the point of publicationAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planOther: enter details here 49 GlendalePage 37 E.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.E.3.1 I Mrs Anne-Marie Curling of 39 Glendale confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or E.3.2 I Anne-Marie Curling of 49 Glendale am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.49 GlendalePage 38 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!