Inspection on 28/11/06 for Glebe Cottage

This inspection was carried out on 28th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glebe Cottage 05/11/08

Glebe Cottage 19/01/06

Glebe Cottage 10/08/04

Glebe Cottage 20/04/04

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

CARE HOME ADULTS 18-65 Glebe Cottage Glebe Cottage Sandhills Lane Virginia Water Surrey GU25 4DS Lead Inspector Vera Bulbeck Unannounced Inspection 28 November 2006 10:30 Glebe Cottage DS0000013650.V302559.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 Glebe Cottage DS0000013650.V302559.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. Glebe Cottage DS0000013650.V302559.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glebe Cottage Address Glebe Cottage Sandhills Lane Virginia Water Surrey GU25 4DS 01344 844144 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) Welmede Housing Association Ltd Mr Kuruppuage Upali Seela-Natha Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Glebe Cottage DS0000013650.V302559.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: UNDER 65 YEARS OF AGE 19th January 2006 Date of last inspection Brief Description of the Service: Glebe Cottage is a large two-storey Victorian house situated in a residential area in the village of Virginia Water, Surrey. It is within walking distance of local shops and amenities. The home offers accommodation and care to six residents, all under the age of 65, and is owned and managed by Welmede Housing Association. Residents have their own bedrooms and there are communal facilities on the ground floor including a lounge, activities room, dining room and kitchen. There are toilet and bathing facilities on both floors. There is a small garden to the front of the property with car parking, and a larger garden to the rear. Glebe Cottage DS0000013650.V302559.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first site visit to be undertaken by the Commission for Social Care Inspection as part of a key inspection. Mrs Vera Bulbeck, Regulation Inspector, carried out the inspection. The registered manager for the home Mr K Upali Seela-Natha was present. The inspection took 6 hours commencing at 10.30am and finishing at 16.30pm. There are currently six residents living in the home, and all the residents have lived in the home for some considerable time. One resident was on a home day on the day of the site visit, the majority of the residents were at the day centre and one resident was on holiday. The inspector was able to speak with residents during this time. However, communication was difficult. The residents are mobile and able to undertake some of the jobs around the house with support from the staff, this includes, cleaning, cooking and duties set out by the home. The home has just returned to Glebe Cottage after a complete refurbishment, the home is nicely decorated and homely. The two members of staff on duty on the day of the site visit were spoken to and one member of staff commented the home is operating an open management style and the staff team feel supported and work together as a stable team. A number of comment cards were sent to relatives before the inspection to obtain their views regarding the service and six have been returned. Comments received were complimentary towards the staff team and also commented that the home is “well run always clean and tidy”. Another comment stated a relative was not aware of the homes complaints procedure and had not had the opportunity to read the inspection report. Five comment cards were received from residents; they were completed with support from the care manager and staff. Positive comments were made about the care provided in the home. Comments included “staff are wonderful and very caring”, and another resident stated that “the home is warm and my bedroom is very comfortable”. A comment form another resident stated “to many changes to staff and unable to understand their language”. A full tour of the premises was undertaken. Three care plans and three staff files were inspected. The fees range from £1177.00 per week. The inspector would like to thank the residents and staff members for their time, assistance and hospitality during the inspection. Glebe Cottage DS0000013650.V302559.R01.S.doc Version 5.2 Page 6 The service users living in the home wish to be called residents, therefore service users will be referred to as residents throughout the report. What the service does well: What has improved since the last inspection? What they could do better: There were nine requirements made at the time of the last inspection dated 19th December 2005. Two requirements were not met and will be carried Glebe Cottage DS0000013650.V302559.R01.S.doc Version 5.2 Page 7 forward to this inspection report. Two recommendations of good practice were made which remain outstanding and will be carried forward. However, the registered manager did explain the move to other premises while the refurbishment of Glebe Cottage was undertaken has been difficult. A number of records were packed and access to these records was difficult. On the day of inspection the registered manager was still in the process of sorting out paper work and finding documents that had been packed away, for example he was unable to locate the previous inspection report. It was noted that some staff require updates to training. On the day of the site visit it was noted that a new member of staff was working in the home and a Protection of Vulnerable Adult (POVA) check had not been undertaken. The Criminal Record Bureau (CRB) was in progress and not available. However, the member of staff informed the inspector he had a CRB from previous employment, the management of the home should request a copy of the CRB until the up to date CRB is completed. There were a number of areas in the home that require attention these are due to the home recently moving back to Glebe Cottage. The registered manager explained to the inspector the work has already been identified and is currently waiting for the maintenance person to undertake the necessary jobs. 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. Glebe Cottage DS0000013650.V302559.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 Glebe Cottage DS0000013650.V302559.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs and aspirations are fully assessed and documented on an ongoing basis in regular reviews. There have not been any new admissions to the home for some considerable time. EVIDENCE: Any new residents would be admitted to the home following a full needs assessment, which would be undertaken by the registered manager or deputy manager. This was evidenced by sampling, written records and discussion with the staff on duty. There have not been any new residents placed in the home for some considerable time. The registered manager informed the inspector that the home has a working tool for staff to assess any potential new residents, to ensure the home is able to meet their needs. Glebe Cottage DS0000013650.V302559.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The resident’s individual plans are clear and comprehensive including details of needs and goals. They also incorporate known or indicated preferences and choices, and also include in-depth risk assessments. EVIDENCE: The inspector was informed the care plans are in the process of being changed to person centred plans. All residents are not involved with their care planning and relatives are made aware of the care plan and invited to be involved. However, the registered manager stated that relatives are generally happy with the care provided and this was evidenced in the comment cards received from relatives and the care manager. The registered manager informed the inspector that he has a good working relationship with relatives and keeps them up to date with any areas that need to be discussed by telephoning or writing. Care plans need to include reasons for residents not being able to hold a key for their bedroom door and reasons for locking a residents wardrobe. There are regular six monthly reviews with care managers and relatives if possible, Glebe Cottage DS0000013650.V302559.R01.S.doc Version 5.2 Page 11 residents are not involved with their care planning. The inspector would advise management of the home to involve an advocate for the residents who have no family contact. Staff stated that residents are supported to make decisions affecting their lives in a number of ways. Each resident has an allocated key worker, who is trained to offer one to one support and who knows the resident well and understands his needs. Formal residents meetings are not held, however staff discuss with the residents, any planned activities to enable residents to make decisions and choices, for holidays, menu planning and outings. The residents are unable to take control of their finances, the registered manager is the appointee for the resident’s finances and this process is monitored by head office on a regular basis. All residents are aware of the fire drill and move out of the building when necessary, this information was recorded in the fire record book of all residents being involved and residents when out of the building within a few minutes. Glebe Cottage DS0000013650.V302559.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 at least once during a 12 month period. 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. Resident’s rights and responsibilities are recognised and actioned. EVIDENCE: All residents attend various day centres for education, training and activities. The majority of the residents are not employed and it would be difficult for the majority of the residents to be employed. However, one resident is employed and delivers leaflets, he is paid for the work he does. Staff stated that they actively encourage and support residents to be independent, to make their own choices and to live their lives as they wish, as far as they are able. One resident was on holiday at the time of the site visit. Residents attend a number of activities these include meals out, bowling, swimming, music, horse riding, cooking, fishing, rambling, art and craft class, shopping, going to the pub and during the summer months water ski-ing. The residents are also involved with the local community group planting flowers. Transport is mainly by the homes mini bus which seats eight persons, but at times taxis are used. Glebe Cottage DS0000013650.V302559.R01.S.doc Version 5.2 Page 13 It was observed, that staff knock before entering residents bedrooms and that personal care is offered discreetly. Residents are addressed in the way that they prefer. Residents are registered on the electoral roll. However the residents have expressed no desire to vote. Some household routines are undertaken by the residents with staff support to enable residents to share their home’s facilities and to maintain harmony within the household. Residents who have declined to hold a key to their bedroom, care plans must be documented to include the reasons for not holding a key. However, one resident is not happy that another resident wanders into his room. Resident’s individual choices of meals were recorded on the weekly menu plan. Staff advised that information is provided to residents to assist with decisionmaking and this is in a format to suit their individual needs. The inspector would advise the management of the home to involve the services of a nutritionist to ensure the meals are nutritionally balanced. The majority of staff working in the home has attended a food and hygiene course. Any new members of staff who has not undertaken the training should not be handling food. Glebe Cottage DS0000013650.V302559.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 at least once during a 12 month period. 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. Personal care and healthcare support and assistance is planned and was seen to be provided, where needed, in a respectful and sensitive manner. EVIDENCE: The inspector was informed by staff, residents are able to choose when to go to bed and when to get up and staff support residents to choose their own clothes, hairstyles and other aspects of personal grooming. The inspector was also informed that residents are able to choose the members of staff who accompany them on holiday. It was also noted some agency staff work in the home, all the agency staff are employed on a regular basis to ensure residents have the opportunity of knowing the staff well. Healthcare needs were met this was evidenced in the care plans; all the residents have regular health checks by various health professionals and a regular yearly check by the GP. Medication records were well documented and stored appropriately. There are currently no residents who are able to self medicate. The pharmacist gives Glebe Cottage DS0000013650.V302559.R01.S.doc Version 5.2 Page 15 regular advice and all staff has received appropriate training. It was noted that some residents have medication prescribed that is invasive. Staff must be appropriately trained by the community nurse to administer this particular medication. The registered manager informed the inspector, that a number of staff has received this training on 20/07/06. However, it was noted that the list of staff having received this training was not available. Glebe Cottage DS0000013650.V302559.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 at least once during a 12 month period. 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. All required policies, procedures and practices are in place to ensure that residents are safeguarded, as far as reasonably possible, from harm or abuse, and to ensure that residents feel their views will be listened to. EVIDENCE: There were no recorded complaints in the home since the last inspection; the registered manager stated that any complaints received would be dealt with according to the policy and procedure and actioned within 28 days. The complaints procedure needs to be updated the last review date was January 2002. The inspector would advise the management of the home to produce a complaints procedure, which is easy for the residents to understand and all residents to be provided with a copy. The inspector was informed that the complaints procedure has also been discussed with relatives. However, one relative commented on the feedback form that they had not been informed and was not aware of how to proceed with a complaint, but would discuss any issues with the manager. A copy, of the complaints procedure should be provided to all relatives. It was also noted that the home had a copy of Surrey Multi Agency procedures and the two staff on duty confirmed they had received the training. They were also aware of the whistle blowing policy, and staff confirmed they would take action if necessary. Another member of staff who is relatively new had not Glebe Cottage DS0000013650.V302559.R01.S.doc Version 5.2 Page 17 received the training, the inspector would advise the manager to ensure training is provided to this member of staff. Systems are in place to ensure resident’s finances are safe, the registered manager is the appointee and head office monitor the process on a regular basis. All residents have their own bank account. Resident’s finances were inspected and found to be well documented. Glebe Cottage DS0000013650.V302559.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. 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. Improvements to the home have been undertaken to ensure a safe and wellmaintained environment for residents. However, the management of the home is aware of the need to complete a number of jobs around the home that remain outstanding following the refurbishment. The home was observed to be clean and hygienic at the time of the visit. EVIDENCE: The environment is homely and the inspector was satisfied with the cleanliness of the home. Staff were busy with the residents on the day of inspection, some were going out and some returning to the home. Residents are involved with tidying their bedrooms and help with other minor tasks. There are several areas around the home that require attention; these include the hoover was stored in a residents wardrobe, which needed to be removed and stored appropriately. A cover was missing from a toilet seat, some lights in resident’s bedrooms were without shades and the light over a washbasin needs attention. The call bells are to be checked as on the day of the site visit some were not working, and one was missing from the bathroom. However, due to the fact the home has only just returned to Glebe House and these Glebe Cottage DS0000013650.V302559.R01.S.doc Version 5.2 Page 19 areas have already been identified by the registered manger as seen in the maintenance book, no requirements will be made on this occasion. All communal bathrooms, toilets and the kitchen have soap dispensers and paper hand towels fitted. There is a large fish tank situated in the lounge, the tank has been in the home for some considerable time and when the residents moved to another home the fish were neglected and a number died. The residents pay for the maintenance of the tank. Glebe Cottage DS0000013650.V302559.R01.S.doc Version 5.2 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a comprehensive staff recruitment procedure, which is designed to ensure, as far as reasonably possible, that residents are supported and protected. Staff that are trained and competent to support residents. EVIDENCE: All staff has been provided with a copy of the General Social Council and Care document. A Staff training plan was seen and training was up to date apart from some up dates and a new member of staff is still in the process of completing his induction training. Each member of staff has an individual training and development plan certificates for training were seen. The registered manager, who stated he enjoys training the staff, undertakes a number of training courses. Two members of staff have completed NVQ Level 2 and three members of staff are in the process of completing NVQ Level 2. Four staff are on the waiting list to commence NVQ Level 2. The registered manager informed the inspector there are currently not enough Assessors to assess the work staff are involved with, therefore this is proving a problem for the home to reach 50 of trained staff. Glebe Cottage DS0000013650.V302559.R01.S.doc Version 5.2 Page 21 Three staff files were inspected and it was noted that the records were well documented and contain full details of the persons. Copies of the Criminal Record Bureau (CRB) checks were on file. Except for a new member of staff and the CRB check is in progress. However, the member of staff informed the inspector a CRB check was undertaken at a previous job, a copy of the CRB needs to be available in the home. All new staff should have a POVA check; the management of the home had not undertaken this. The management of the home need to constantly review the nighttime staffing arrangements. At present there is only one member of staff on duty at night. The rota indicates there is a member of staff on call, within a ten-minute journey. The inspector was informed that every two weeks there is a member of staff who sleeps in either of the homes. However, in an emergency it would be difficult for one member of staff to manage six residents, until another person arrived in the home. The two members of staff spoken to confirmed they are aware of the different needs of the residents and staff work with residents in this area to ensure their needs are being met. Interaction between staff and residents was observed to be good. Glebe Cottage DS0000013650.V302559.R01.S.doc Version 5.2 Page 22 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 at least once during a 12 month period. 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 systems for resident’s consultation are varied and have been devised specifically to enable the residents to make their views known. EVIDENCE: The registered manager is experienced and competent to manage Glebe Cottage he completed the Registered Managers Award in June 2006. The deputy manager has completed NVQ Level 3 in management. The home has an effective quality audit system in place. Regular monthly visits by a designated responsible person is proving to be beneficial to the management of the home, the contents of the reports need to be expanded and give clear guidelines to staff. An annual development plan for the home is in place. The views of family and friends are sought on a regular basis; the registered manager undertakes this process regularly by telephone, or in writing. Glebe Cottage DS0000013650.V302559.R01.S.doc Version 5.2 Page 23 A number of records were observed and it was noted they were well documented. It was noted that in the bathroom on the first floor a bottle of Mr Muscle cleaning material was found under the wash basin, this had been left from the cleaning undertaken a short time previously, the member of staff immediately removed the bottle. There were no residents in the home at the time and a result of the staff member being distracted from the cleaning of the bathroom. All staff must receive further COSHH training to ensure this practice does not happen again. Resident’s finances were checked and these were found to be well documented, and balanced with the records. Receipts were checked and the balance corresponded with the records maintained. A number of policies and procedures were checked and found to be in place. However, the registered manager to ensure policies and procedures are kept up to date and regularly reviewed. Glebe Cottage DS0000013650.V302559.R01.S.doc Version 5.2 Page 24 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 X 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 X 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 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 X X 3 X X 3 X Glebe Cottage DS0000013650.V302559.R01.S.doc Version 5.2 Page 25 Yes 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. 1. Standard YA21 Regulation 12 Requirement The Responsible Individual must ensure that resident’s wishes regarding their ageing and death are documented. This should include a review of Standard 21. (Timescale 19/03/06 not met). To ensure that at all times suitably qualified staff are working at the care home, the Responsible Individual must forward to CSCI an action plan setting out how and when the target of having 50 of staff trained to NVQ level 2 or above will be reached. (Timescale 19/03/06 not met). All new staff must have a POVA check. All cleaning materials must be stored appropriately at all times. All staff requires further training on COSHH. Timescale for action 22/12/06 2 YA32 18 30/03/07 3 4 YA34 YA42 17 13 22/12/06 28/11/06 Glebe Cottage DS0000013650.V302559.R01.S.doc Version 5.2 Page 26 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 YA22 Good Practice Recommendations The home should compile a complaints log and record details of complaint, any investigation carried out, and the outcome. (Carried forward from the previous inspection). The home should pursue the option of independent advocacy for those residents who do not have relatives or friends to represent their interests. (Carried forward from the previous inspection). To seek the advice of a nutritionist. To ensure training undertaken by the community nurse is documented, and a record available in the home. All residents and relatives to be provided with a copy of the complaints procedure. 2. YA22 3. 4. 5 YA17 YA20 YA22 Glebe Cottage DS0000013650.V302559.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 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 Glebe Cottage DS0000013650.V302559.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. 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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