Inspection on 05/07/07 for Glanmor

This inspection was carried out on 5th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glanmor 02/08/06

Glanmor 05/01/06

Glanmor 18/07/05

Glanmor 01/03/05

Glanmor 07/10/04

Glanmor 17/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Glanmor Bath Road Chippenham Wiltshire SN15 2AD Lead Inspector Alyson Fairweather Key Unannounced Inspection 5th July 2007 10:00 Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glanmor Address Bath Road Chippenham Wiltshire SN15 2AD 01249 651336 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) ABLE (Action for a Better Life) Maricka Elke Hamblin Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7) of places Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd August 2006 Brief Description of the Service: Glanmor is a large, detached house converted from two semi- detached homes. It is situated within walking distance of Chippenham town centre and provides a service for seven residents who have or are recovering from mental illness. The home has a close support network with the local community psychiatric team. Glanmor is managed by ABLE (Action for a Better Life) and Sarsen Housing Association owns the property. There is a large secluded garden surrounding the home, with a paved patio area, and a car park at the rear. Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days in June and July 2007, as the entire staff team and management had a pre-booked training session the first day. Five residents, the manager and several care staff were present and spoken to. Six residents wrote to us, as well as five relatives. Written comments about the home have been received from a Community Psychiatric Nurse who has a client living in Glanmor, and a GP whom some of the residents visit. The manager of Glanmor has been registered with the Commission for Social Care Inspection since 2005, and has a number of years experience of working with people with mental health needs. Glanmor is one of two registered premises managed by ABLE, who also are responsible for two other accommodations for more independent living. The inspector walked round the premises and examined several records, including care plans, risk assessments, health and safety records, and staff training. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. The current fees charged by Glanmor are £600 - £650 per week, although these are subject to review. What the service does well: Staff support residents to manage their own medication whenever they can. The medication records examined were in good order. The home has a policy in place for all medication, and all staff have medication training. The CPN and the GP all said that medication was handled appropriately in the home. The risk assessments which are in place for residents were current and clearly linked to care plans. Risk assessments were in place for a number of issues including anxiety and showing physical aggression to staff as well as potential medication problems. In discussion with the staff, it was clear that they were aware of the ways in which residents could be at risk, and were taking measures to avoid these. One resident wrote to say: “I’m happy at Glanmor”, and relatives told us about several things they thought Glanmor did well. One person said it “provides a secure and caring home”, and another said: “I feel it doesn’t push my daughter Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 6 to do things she cannot cope with and helps her to remain stable in this way. She has not had any inpatient admissions since her arrival at Glanmor”. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will 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. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Prospective clients and families are given information leaflets so that they can choose whether or not they wish to use the service. All residents have their individual needs assessed before they arrive, so that staff know how best to support them. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home has a comprehensive Statement of Purpose and Service User Guide which give an overview of the service which will be provided. This is given to every potential resident, and also gives details of the organisation’s complaints procedure. These have been amended to include details of the legislation relating to smoking on registered acre home premises. Of the six people who responded to the questionnaire, four felt that they had had enough information on the service prior to admission and two didn’t. These people had come directly from hospital, and this had taken place a number of years ago. Most residents have been at Glanmor for some time. One resident has been there since 1995. The most recent resident until recently was 2005, when a new resident came from the organisation’s sister home in Melksham. All information was transferred from there. Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 9 If an independent referral is made, information would be received from medical teams and from various other professionals. Each new resident would be offered a series of trial visits, in order to give them time to get to know the home, the other residents, and the staff. Staff would try to find out what they would like to do with their daily routine before they move in. The referring mental health teams would provide a copy of the most recent Care Programme Approach (CPA) plan, which gives details of how the potential resident can best be supported with their mental health needs. The home also has a service user guide which tells any potential resident about the service they provide. Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. 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. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Care plans reflect the needs and personal goals of residents, who are assisted to make decisions about their own lives. They are supported to take risks where appropriate, and encouraged to be as independent as possible. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A great deal of work has been done by staff in relation to compiling care plans for residents. Each plan now has an index page which quickly shows where to find specific care plans. Care plans include information on communication, accommodation, literary skills, health and social activities, as well as individual’s Care Programme Approach reports (CPA’s). Care plans have been reviewed regularly every six months, but are also done so when the situation has changed, and are signed by the resident. A system of daily records is also in place. One file examined showed that there had been no CPA meeting since February 2006. The manager reported that there was some difficulty obtaining Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 11 appointments through the local psychiatric services, and it is recommended that the manager pursues this vigorously until an appointment is made. A weekly rota of activities is kept for residents, and it was noted that one of these was out of date, and contained references to activities which the resident no longer attends. The manager has been asked to ensure that all care plans contain accurate and up-to date information. Residents are supported to make decisions about their own lives with guidance from the staff. They are encouraged to manage their own finances wherever possible, although some have family involvement and other support. Four people handle their own financial affairs (two with support). One person has a corporate appointeeship, one has a court of protection order and one person’s family manages their money for them. One resident now orders her clothing online. Where restrictions are in place, for example to limit self harm or harm to others, this is clearly recorded and guidelines are drawn up for staff to follow. Of the six residents who responded to our questionnaire, four said they could “always” choose what they liked to do and two said “usually”. One said: “I have a fulfilling life”. There were risk assessments in place for several residents, some of which had recently been reviewed. Risk assessments were kept alongside the medication records, and were on the resident’s file. The ones on file were clearly linked to the resident’s care plans, and these included one for anxiety and showing physical aggression to staff as well as potential medication problems. In discussion with the staff, it was clear that they was aware of the ways in which residents could be at risk, and were taking measures to avoid these. Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. 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. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Social and leisure activities are varied and tailored to individual need, with residents choosing what they wish to do. Residents have as much or as little contact with family and friends as they wish, and are encouraged and supported by staff. Residents’ rights are respected and responsibilities recognised in their daily lives. They are offered a healthy diet and enjoy their meals and mealtimes. Quality in this outcome area is good. This judgement has been made from evidence gathered both before and during the visit to the service. EVIDENCE: Residents can choose when to be alone or in company, and when not to join an activity. They have unrestricted access to the home and grounds, and can come and go as they please. In house activities include the use of a computer, arts and crafts, games, gardening, cooking, key work activities, and a takeaway night. Outside activities include some people going to Moonrakers’ workshop, the Tom Metcalf centre, shopping, going out with a befriender, as Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 13 well as relatives and friends. When asked if the care service supports individuals to live the life they choose, both medical professionals said they believed it did. Residents have as much or as little contact with family and friends as they want. One person often stays with a friend for a few days, and another has a befriender who takes him out. One resident was planning a day trip to Weymouth with a relative. Residents’ responsibility for housekeeping tasks, such as doing their laundry or tidying their room is specified in their care plan. Some residents take great pride in keeping their own rooms neat and clean, and some help with the communal areas too. No resident has an advocacy worker, although one does have a befriender. There is a policy of no smoking in bedrooms, although a designated smoking room is available as well as a large seating area outside. The menu supplied in the home is varied and nutritious, and residents decide on a daily basis what the main meal will be. There was a good supply of fresh fruit and vegetables, and juices and yoghurts were also available. Staff have records of the food likes and dislikes of all residents, and healthy eating options are encouraged. Vegetarian options are available at all meals. There is a small kitchen which residents can use to prepare light snacks and this is equipped with a fridge, a microwave and a toaster. There is also a larger kitchen in which staff prepare main meals, helped by residents when they are able to do so. The dining room is light and airy and comfortably furnished, so people can enjoy mealtimes together. Lunch on the day of the inspection was sandwiches and salad, with cottage pie and quorn cottage pie for tea, along with carrots and cabbage. Staff have recently had training on diet and nutrition. Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. 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 home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Residents’ personal support needs are recorded in care plans so that they can receive this support in the way they wish, and their physical and emotional health needs are met. Residents’ are supported to self-medicate where possible, and are protected by the home’s medication policies and procedures. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Although Glanmor is registered for people with mental health needs, some of the residents develop healthcare problems too, and at such times would require personal support. Many of the residents require prompting, guidance and support in relation to personal support, although some direct physical care is sometimes be needed. Personal care is offered in a sensitive and careful manner, with detailed care plans in place, outlining individuals’ preferences, and how their personal care is managed. One relative wrote to us to say “Some female staff refuse to assist males with rehabilitation/skills of bathing/washing. I am not clear what the protocol is”. The manager explained that this had been raised as an issue by staff and that it was being dealt with Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 15 by the management team. As there are currently no male staff workers at Glanmor, there would be no “same sex” bathing policy at the moment. People receive support from staff to maintain their health care needs and there was evidence of further support from GP’s and community mental health teams. The care plans recorded input from community psychiatric nurses, psychiatrists, GP’s, optician and dentist. People who have diabetes have routine blood sugar monitoring. One resident spoken is extremely anxious about attending the dentist, so is able to have some PRN medication and be accompanied. Another has been supported to buy an exercise bike in order to help with weight control and fitness. Both the GP and the specialist nurse who wrote to us said that the home seeks advice and acts on it to manage and improve individuals’ health care needs. As previously mentioned, the manager has been asked to pursue regular CPA meetings for residents, in spite of difficulties obtaining appointments locally. Medication records examined were in good order. The home has a policy in place for all medication, including homely remedies, and all staff have medication training. When PRN medication was given, it was seen to be recorded both in the communication book and in the diary sheet. The home has PRN protocols in place. There were good, robust systems in place, and regular stock checks are done, when all medication is counted Some residents are being supported with self-medication. One person looks after all their own medication, and takes their dossette box with them when they visit friends. Another is gradually increasing the number of days they do so. Both the GP and the specialist nurse who wrote to us said that the home supports individuals to administer their own medication or manages it correctly where this is not possible. On the day of the inspection an error was made by a staff member whilst administering medication and one resident was given the medication of another. The manager was seen to deal with the situation in a competent manner, and made sure that all the correct steps were taken. The error occurred because the initials of the residents had been hand written on the side of the medication boxes, even though their name was typed in full on the box. This then led to the mistake being made. A recommendation has been made that the initials should be removed from medication dossette boxes so that staff read the residents’ full names. Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Residents’ views are listened to and acted on. The policies and procedures the home has in place try to ensure that residents are safeguarded from abuse and harm. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Weekly resident meetings are held, and people are encouraged to voice any concerns they may have. There is also a complaints book and a suggestions book available for residents. The home has a formal complaints procedure which outlines the steps to take if there are any complaints. This also gives details of how service users and families can contact the Commission for Social Care Inspection (CSCI). A copy of this procedure was recently sent to all resident and their families alongside the quality assurance questionnaire. No complaints had been received about the home by CSCI. Of the five relatives who wrote to us, four said they knew how to lodge a complaint about the home if they needed to, although one person said they couldn’t remember. All five residents said that they knew who to talk to if they were unhappy. The home has copies of the “No Secrets” document, as well as the organisational policy and procedure on responding to allegations of abuse. All staff have had training in Working with Vulnerable Adults, and are encouraged to report any incidences of poor practice. A “Whistle Blowing” procedure is also available for all staff. Recent incidents had been referred to the Vulnerable Adults team by the home, and the matters dealt with appropriately. Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. 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. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Residents live in a homely, comfortable and safe environment, which is clean and hygienic. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Glanmor is a detached house converted from two semi- detached homes. It is a comfortably furnished home with large airy rooms. Residents’ bedrooms were homely and each contained individual personal items. One resident has a playstation so that he can enjoy playing computer games. Most residents have television and stereos in their room. Residents who have small bedrooms have the benefit of another room which can be used as a sitting room. There is a smoking room available, and the main lounge is non-smoking. There is a large secluded garden to the rear of the house, with a patio area and a car park. There have been instances leaks from pipes and tanks have occurred, and staff have dealt with this promptly with the housing agency about repairing the Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 18 damage. Several of the downstairs rooms had been redecorated and loooked comfortable and homely. Several other areas, including the utility room, one bathroom and the main kitchen were due to be done on a programme of rolling maintenance. Residents are encouraged to help with household tasks, although a cleaner is also employed. Two residents said the home was “usually” fresh and clean and two said that it was “always” like that. One said: “The cleaner is very good” and another said: “I can always ask for help to keep my room tidy if I need to”. Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. 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 home’s 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. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Residents’ individual and joint needs are met by staff who have had induction and some specialist training, and are undertaking NVQ. Residents are supported by competent and qualified staff, and by the home’s recruitment policy and practices. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: There are six members of the care staff and one part time cleaner employed by the home, with a vacancy for one more care staff member being advertised. Four members of staff have NVQ Level 2 and one has NVQ Level 3. Staff meetings are held weekly, and a fixed agenda ensures that important issues are discussed, including resident needs and staff training. An index of staff who have achieved NVQ status is kept at the front of the training file, making the information easy to access. Of the six residents who wrote to us, three said that staff “always” treated them well at Glanmor and three said that this was “usually” the case. One relative commented: “Staff are very friendly and helpful. They do a very good job in difficult circumstances”. However, another said they felt that some staff didn’t have: “the right skills for someone with Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 20 schizophrenia whose behaviour/poor personal hygiene is problematic. Their own values and expectations are enforced on the person”. The community nurse who wrote to us said: “I am unsure of everyone’s skill and experience, but the care given demonstrates that the needs of the individual are being met”. There was evidence that new staff have induction training when they start to work at Glanmor. One new staff member spoken to confirmed that she had had induction training in medication administration, POVA Legislation, food hygiene, care planning and key working. Examination of her staff file showed this to be the case. Other staff training has included health and safety, manual handling, basic emergency aid, principles of risk assessment, administration of medicines, coping with aggression in the workplace, mental health awareness, transactional analysis and effective communication. Future training is planned in diet and nutrition. All prospective staff are invited to visit the home prior to being interviewed, in order to get a feel of the home and to enable staff to receive feedback from residents. The person is then interviewed and two references are obtained. Staff sign a declaration of criminal convictions prior to the completion of a CRB and POVA check. All staff receive a copy of the code of conduct and terms and conditions, and have a three-month probationary period. The home has introduced a system where the main office notifies them when a staff member has had their CRB and POVA check done, whether an enhanced check has been done, the reference number and the date of the check. All files were in order by the time of the second visit. Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. 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 home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s 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. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Residents benefit from a well run home, and residents’ views underpin all selfmonitoring and development in the home. The training, policies and procedures in place promote and safeguard the health, safety and welfare of the people using the service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The manager was registered with CSCI in 2005. She has completed her Registered Manager’s Award since then, as well as her NVQ Level 4 in Health and Social Care. She has had experience of working with people with mental ill health and with older people. She has recently had training in manual handling, basic emergency first aid and transactional analysis. Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 22 There are regular meetings which discuss service provision, including staff meetings, and psychiatric reviews about individual residents. Residents meetings were also held on a weekly basis. An annual questionnaire is issued to residents, families and outside agencies, seeking their views on the service and asking how it might be improved. Of the six residents who wrote to us, four said that staff “usually” listened to them, one said always and another said “sometimes”. One person wrote: “From my point of view, not much notice is taken”. As this person had not given their name, it was not possible to discuss what this might mean. However, the same person also wrote that they knew how to make a formal complaint if they wanted to. There is a regular routine of health and safety checks in the home. Some checks are done daily, some weekly and some monthly. Fire equipment checks are done annually and was last done in January 2007. Fire drills are held on a quarterly basis, and the last one was in May 2007 at 7.30 am. There is a fire risk assessment in place for the home. Paper hand towels have replaced the use of linen towels in lavatories, in order to lessen the chances of any crossinfection. Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 X Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15 Requirement All care plans must contain accurate, up-to-date information. Timescale for action 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA19 YA20 Good Practice Recommendations Regular CPA meetings should be sought for those people who have not had one recently. The initials should be removed from medication dossette boxes so that staff read the residents’ full names. Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Glanmor DS0000028637.V335797.R01.S.doc Version 5.2 Page 26 - 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. 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