Inspection on 27/07/07 for Glanmore

This inspection was carried out on 27th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Glanmore 09/10/06

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

CARE HOME ADULTS 18-65 Glanmore 156 Holyhead Road Wellington Telford Shropshire TF1 2DL Lead Inspector Rebecca Harrison Key Unannounced Inspection 27th July 2007 09:00 Glanmore DS0000065368.V340864.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 Glanmore DS0000065368.V340864.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. Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glanmore Address 156 Holyhead Road Wellington Telford Shropshire TF1 2DL 01952 251975 01902 873730 glanmore@tracscare.co.uk suehullin@tracscare.co.uk Tracscare Group Ltd 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) Ms Patricia Mary Ferguson Care Home 7 Category(ies) of Learning disability (7), Mental disorder, registration, with number excluding learning disability or dementia (7) of places Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home may accommodate adults aged 18-65 years with a learning disability with or without associated mental health needs. Service users accommodated on the second floor must be fully ambulant. This service may accommodate within existing numbers one named service user with mental disorder only. 9th October 2006 Date of last inspection Brief Description of the Service: Glanmore is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and personal care for a maximum of six adults with a learning disability with or without associated mental health needs and one named person with a mental disorder. The home is a large detached property situated on the outskirts of Wellington, Telford, close to local amenities such as shops, colleges, pubs and medical facilities. Accommodation is provided over three floors comprising a lounge, dining room, kitchen, conservatory and seven single bedrooms all with en-suite facility. The registered provider is TRACS Ltd. Ms Susan Hullin is the responsible individual and Ms Patricia Ferguson is the registered manager of the service. The aims of the home are included in the Statement of Purpose which states that ‘Glanmore is committed to supporting clients towards leading as fulfilled life as possible, in an environment which: - Places value on individual beliefs, choice and aspirations. - Promotes maximised independence and community integration - Provides a safe, nurturing and homely environment. Information about this service is available from the Statement of Purpose and Service User Guide. Inspection reports produced by CSCI can be obtained direct from the provider or are available on CSCI’s website at www.csci.org.uk Fees charged per person range from £1800.00 to £2400.00 per week. Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on 27th July 2007 by one inspector over six hours. A range of evidence was used to make judgements about this service to include information from the provider sent to CSCI, discussions with service users, the staff and manager, a tour of the home, looking at a number of records and all aspects of care provided for two people using the service. Some views obtained about the service are included in the report. The purpose of the inspection was to assess all 22 ‘Key’ National Minimum Standards for Younger Adults and to review the requirements made at the previous inspection undertaken on 9th October 2006. A quality rating is provided throughout the report based on each outcome area for the people who use the service. These ratings are described as excellent/good/adequate or poor based on findings of the inspection. What the service does well: The manager completed a form about the home and sent this information to the Commission for Social Care Inspection and stated: ‘We are a new service continuing to expand, grow and change. We have gone through a series of changes since opening in July 2006, which has strengthened the team and improved Glanmore for the clients. We react well to change’. Glanmore has an open culture that allows the people who use the service to express their views and concerns in a safe and understanding environment. People spoken with had a clear understanding of the homes complaints procedure. Records seen show that all complaints no matter how small are recorded and actioned. The building is equipped to a high standard and soft furnishings are of good quality and provide people with a comfortable and homely place to live. People have personalised their own bedroom and it is evident that staff respect people’s own space. Views gained during the inspection include: ‘Staff are very good at their jobs, the house is superb, we have good food here and everything is well documented. The manager is fantastic, always helpful and here for you’. ‘The home has a very strong staff team who work very well together to provide a good service to our service users, and we aim to meet their needs as individuals and support them to become independent’. Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 6 ‘TRACS are an excellent organisation to work for. I love it here and wouldn’t change my job for anything’. What has improved since the last inspection? What they could do better: The service is currently performing well with no requirements for improvement made as a result of this unannounced inspection. It is strongly recommended that staff receive training in ‘Self Harm’ to ensure they are appropriately equipped with the skills to effectively support one individual currently using the service. A fire drill should be undertaken as soon as possible to ensure the temporary and permanently placed service users are familiar with the homes evacuation procedures in the event of a fire. Views gained during the inspection include: ‘I genuinely cannot fault the standards of care in the home and how the staff are so professional in their roles. The only improvements that can be made are the continued review of care plans, development of skills, independence and assessing behaviours that can challenge’. ‘Give the staff team all the support we need so as to enjoy our work more. As a happy staff team will provide a good and happy atmosphere for our service users’. ‘I would prefer to take my evening medication in the comfort of my own bedroom’. Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 7 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. Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 8 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 Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 9 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): 1,2,4 and 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are provided with the information needed to decide whether this service will meet their needs. They have their needs assessed and a contract which clearly tells them about the service they will receive. EVIDENCE: At the time of the inspection there were three permanent service users at the home in addition to three people temporarily placed from another TRACS home as a result of the flooding disaster in Gloucester. These three people were receiving support from their own members of staff and copies of care plans were forwarded to the staff at Glanmore prior to their arrival. The home has a Statement of Purpose in place, which has been amended as required following the previous inspection. The care records belonging to two people who have been admitted to the home since the last inspection were looked at. One person had been transferred to the home from another of the organisation’s homes and reasons for the transfer were clearly stated in addition to an ‘Internal client transfer reassessment report’. It was evident that the home had given serious consideration to how the person would ‘fit in’ with the existing group living at Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 10 Glanmore. Discussions held with two service users indicated that positive relationships have been developed and people get on well with one another. Assessments of need undertaken by the organisation were available on both files examined and were very detailed involving the individual, professionals and family. Other reports to support assessments were available for example an independent social circumstances report and a personal portrait completed by one individual, which provided a clear overview of the person’s specific needs. One person spoken with reported that she had a number of introductory visits to the home to ensure she liked the home and staff. Another person reported that he did not visit the home prior to admission through choice. He reported that he is nearing completion of his thirteen-week initial assessment and that a review is planned shortly to discuss the placement and his future needs. Detailed service level agreements were available on files examined signed and dated by the service user and manager. Since the last inspection one person’s placement was terminated following a referral under local adult protection procedures to safeguard another service user living at the home. Discussions held with the manager evidence that referrals to the service are since given serious consideration to ensure that detailed information about the person is obtained, compatibility with others considered and that staff have the necessary skills to appropriately support an individual prior to a service being offered. Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff are provided with detailed information to ensure service users’ assessed needs are met. The people who use the service are supported to make decisions and are enabled to take responsible risks. EVIDENCE: Support plans were examined for two people who have been admitted to the service since the last inspection. Both plans were detailed covering all aspects of the person’s individual needs with evidence of regular review. Reactive management plans were comprehensive as required by the previous inspection. Discussions held with the two people evidenced that they were involved in planning their care and had signed their plans with the manager. Minutes of individual planning meetings were available in addition to an agenda and invitations to important people for forthcoming meetings. Records seen demonstrate that people are very much involved in planning for their meetings and one person wrote her own written statement in preparation for her review which she was happy to include in this report. Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 12 ‘I would like to take this opportunity to thank all those who are involved in my care, including my family; because without all their encouragement and understanding I wouldn’t of got this far’. Discussions with people who use the service indicate they are actively consulted on how the service runs and regular client meetings are held with people setting their agenda to include day-to-day life, menus, activities, staff appointments and the development of the service. Detailed risk assessments and agreements for empowering individuals with community support, activities, behaviour management and health were available on the files examined with evidence of regular review. Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 13 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 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their life style, and supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: Discussion held with service users evidence that individuals are encouraged to try out new life opportunities and develop their skills coordinated with their designated key worker. Independent life skills assessments are undertaken and these were available on the files examined. One person spoke about the educational courses that she has accessed since moving into the home and has her own computer, which she regularly uses. She has also attended the local church where she has made new friends. Another person spoke about his interests and the activities he enjoys in the local community. During the inspection he was supported to walk into the town and purchase ingredients to cook the evening meal. Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 14 People living at Glanmore are encouraged to develop and maintain relationships with family and friends and all contact is recorded. One person said that she regularly visits a family member and links with the home are well established. Another person said that he is supported to write letters to his family. People spoke about their rights being promoted and that they are treated with respect. A staff member was seen to knock on bedrooms doors during the inspection. Where there are limitations on choice or facilities, it is in the person’s best interest. Discussions held with two people evidenced that they understand and agree the limitations, which are fully documented and reviewed on a regular basis to ensure their ongoing relevance. Service users said that they are encouraged and supported with domestic tasks around the home and take responsibility for their own room, assist with menu planning, shopping and the cooking of meals. The menu seen offered choice and records evidence that individuals with special dietary needs are catered for. One person said ‘The meals are very good here’. Another person said ‘The home caters for my dietary needs but generally the home doesn’t buy enough food’. Since the last inspection one person has been supported to grow a range of fresh produce for the home. Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 15 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. The home has a satisfactory system of handling, storing and managing medication, which safeguards the people who use the service. EVIDENCE: Preferences in relation to support requirements were available on both files examined and people spoken with said they regularly access health appointments with support if required and outcomes recorded. Records evidence that people from different organisations regularly attend meetings arranged by the home in the best interests of those accommodated. A detailed prevention plan in the event of a relapse was available in addition to specific information to support a person with a medical condition. Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 16 Medication procedures appeared satisfactory at the time of the inspection. The service has developed local guidelines in relation to medication and the manager was able to demonstrate a clear understanding of her role and responsibilities in relation to how this is managed. It was reported that five members of staff have undertaken accredited training via the distance-learning route. An audit of medication practices has been undertaken by the dispensing pharmacy with no concerns identified. The home has obtained a copy of guidance on Administration and Control of Medicines in Care Homes and this was seen readily available. All service users are assessed on their ability to self-administer their medication and their medication is regularly reviewed by the appropriate healthcare professional. One person reported that he would prefer to administer his evening medication in his own room for reasons of comfort, which the manager agreed to look into. Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service and their representatives are able to express their concerns and have access to an effective complaints procedure. Appropriate procedures are in place to safeguard service users from potential abuse. EVIDENCE: The manager completed a form about the home and sent this information to the Commission for Social Care Inspection and stated: ‘All clients have the complaints procedure fully explained on arrival and have help to access and complete complaints forms as and when the client need’. This was confirmed in discussions held with two people who use the service. The procedure is displayed in the home and following a review of the complaints log it is evident that all complaints no matter how small are recorded and actioned. The manager confirmed that the home does not have any outstanding complaints and stated that no external complaints have been received by the home since the last inspection as confirmed by records seen. No concerns or complaints have been raised with CSCI concerning this service since the last inspection. One person stated ‘the complaints procedure is available but I have never made a complaint as there is nothing to complain about here. I’m very happy living here and Pat (the manager) is quick at sorting any niggles out’. Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 18 Two referrals have been made under local adult protection procedures and meetings with people from different organisations have been held. One case has since closed and the other is currently ongoing. Although the home took the necessary action to safeguard people, there was a delay in the reporting of alleged incidents under the local procedure. It was reported that six staff have received external training in the protection of vulnerable adults and that all staff receive internal training on a regular basis. The manager committed to ensuring a copy of the local policy and procedure for safeguarding adults is made readily available. Staff receive training in physical intervention and refresher training as required. The manager was due to attend refresher training on the day of the inspection. Staff spoken with considered that the financial policy and procedure for the management of service users monies is robust and safeguards both service users and staff. Financial handling assessments were available on the files examined. Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: Glanmore is equipped to a high standard providing accommodation over three floors consisting of a lounge, spacious conservatory, dining room, kitchen and seven bedrooms, all with en-suite facility. An enclosed garden is provided at the rear of the property and one person has been supported with developing a vegetable patch to grow fresh produce for the home. The three bedrooms currently occupied by permanent residents were very personalised and people spoken with reported that they are happy with the accommodation provided. One person said that he would like his mattress replacing. Externally the home has recently been repainted and a smoke shelter erected in the rear garden. It was reported that a new kitchen is on order. Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 20 It was reported that the home has been inspected by the fire authority or environment health since initial registration and that there are no outstanding requirements. The home was found clean throughout during this unannounced inspection and responsibility concerning household tasks were seen on the files examined and people were observed assisting with tasks around the home during the inspection. Cleaning schedules are in place and personal protective equipment readily available. Products hazardous to health are appropriately stored and data sheets and assessments available although are in need of review. The manager stated that infection control training is undertaken in-house although she is hoping to arrange external training through Shropshire Partners in Care shortly. Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 21 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): 32,33,34,35 and 36 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people who use the service are supported by a trained, committed staff team and are safeguarded by the homes recruitment procedures. EVIDENCE: Discussions held with two people using the service evidenced they have confidence in the staff and management team. They spoke very positively about the service provided and the relationships developed with the staff supporting them. Observations made evidence that the staff have the skills to communicate effectively with all service users. The team consists of eight support workers, one deputy and one manager. It was reported pre-recruitment checks are currently being undertaken for a further two support staff. Discussions with the manager demonstrate that the provider is proactive and has a good understanding of equality and diversity of the team, which reflects the gender of the people using the service. One support worker holds an NVQ level 3 qualification and a further four people are due to complete their award this month. A minimum of two staff are deployed on each shift to support the current people accommodated. One person stated Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 22 ‘Sometimes current staffing levels limit things that we can do and we only have one driver here’. Another person stated ‘Staff are very good at their job, my key worker is very good and I get on well with him’. Staff spoken with considered staffing is sufficient and that the team are effective in meeting the individual needs of the people accommodated. Since the last inspection six staff have been appointed. Three personnel files were randomly selected and examined and contained all the documentation as required by Schedule 2 of The Care Homes Regulations, as amended. The manager committed to ensuring certificates to evidence training and qualifications are placed on file. One service user reported that she has been involved in staff selection and it was evident that she very much enjoyed this process and considered that the rest of the panel listened to her views. A newly appointed staff member spoken with reported that he had previous care experience and was very impressed with the organisations recruitment procedures and service users being involved in choosing their staff. One member of staff stated ‘The organisation is excellent to work for and they provide us with good training opportunities’. He spoke about the training received over the last twelve months to include mandatory and service specific training and that training needs are identified through regular supervision and appraisal. The manager has developed an overall training matrix as advised following the last inspection and staff have individual training records. The manager stated that she intends to source training in ‘self harm’, which CSCI strongly supports following the number of notifications received since the last inspection in relation to one person. The staff member most recently appointed is currently undertaking accredited induction training over a twelve week period and his workbook was seen and his induction process discussed with him during the inspection. It is evident that the service sees induction and the probationary period as being an extension of recruitment. Staff meetings are held regularly and service users take it in turns to attend the meetings and detailed minutes are held. Evidence of staff supervision and appraisal was seen on files examined and confirmed in discussions with staff. Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 23 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service is effectively managed, aspects of performance are reviewed and the health and safety of service users and staff promoted. EVIDENCE: The registered manager has obtained the qualifications required of her position since the last inspection and has attended various training courses. Discussions held with service users and staff in relation to how the service is managed strongly evidence that the ethos of the home is open and transparent. One person said ‘The manager is fantastic, she is fair and always helpful and here for you’. Another person stated ‘The manager is very good, I get on extremely well with her, she is approachable and supportive’. Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 24 Effective quality assurances systems are in place and the views of service users and their representatives are sought through staff and service user meetings. It was reported that a ‘Focus day’ is planned and that the organisation is due to obtain views from users and stakeholders shortly and collate a report based on the findings. Monthly visits required by Regulation 26 are undertaken and comprehensive reports are held on site and a copy forwarded to CSCI. A quality audit of the service was very recently undertaken by the organisation and the home achieved 94 . The manager completed a form about the home and sent this information to CSCI, which identifies the strengths of the home and areas for improvement. Health and Safety procedures were generally satisfactory at the time of the inspection. Service certificates and health and safety files are well organised. The manager is on the Health and Safety Committee for the organisation and attends regular meetings. All accidents are analysed by the organisation on a monthly basis and a report kept. A detailed audit of health and safety is undertaken every six months and records held. Staff spoken with confirmed they are in receipt of training in safe working practices and shortfalls have been identified and training booked for example, manual handling. Risk assessments have been undertaken and are regularly reviewed. The manager committed to undertake a first aid risk assessment to meet new guidelines and arrange a fire drill to ensure all service users are familiar with the homes evacuation procedures in the event of a fire. Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 25 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 4 3 x 4 3 5 3 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 4 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 26 NO Are there any outstanding requirements from the last inspection? 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard YA35 Good Practice Recommendations It is strongly recommended that staff receive training in ‘Self Harm’ to ensure they are appropriately equipped with the skills to effectively support one individual currently using the service. Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Glanmore DS0000065368.V340864.R01.S.doc Version 5.2 Page 28 - 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. 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