Inspection on 17/02/06 for Glebe Court Nursing Home

This inspection was carried out on 17th February 2006.

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

Glebe Court Nursing Home 18/11/08

Glebe Court Nursing Home 03/12/07

Glebe Court Nursing Home 23/10/06

Glebe Court Nursing Home 16/08/05

Glebe Court Nursing Home 11/01/05

Glebe Court Nursing Home 09/08/04

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

CARE HOMES FOR OLDER PEOPLE Glebe Court Nursing Home Glebe Way West Wickham Kent BR4 0RZ Lead Inspector Mrs Susan Hall Unannounced Inspection 17th February 2006 09:20 X10015.doc Version 1.40 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 Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 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 Older People. 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 Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Glebe Court Nursing Home Address Glebe Way West Wickham Kent BR4 0RZ 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) 020 8462 6609 Glebe Housing Association Ms Gillian Payne Care Home 51 Category(ies) of Old age, not falling within any other category registration, with number (51) of places Glebe Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing Notice issued 10 October 1997 Date of last inspection 30th November 2005 Brief Description of the Service: Glebe Court is a large detached purpose built care home for older people with nursing needs. It is part of Glebe Housing Association, which is a non-profit organisation which provides accommodation for older people. The home is situated in the grounds of Bencurtis Park Estate, which includes sheltered accommodation; this does not form a part of the inspection process. Glebe Court has close links with public transport, and is within walking distance of shops and local facilities. Car parking is provided at the front, and there is a sheltered garden at the rear. Accommodation is provided in mostly single rooms on two floors (ground and first). All rooms are provided with en-suite toilet facilities. Communal rooms include a large lounge and dining room on the ground floor, a conservatory, and a smaller lounge on the first floor. Glebe Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place from 09.20 – 14.40. The previous inspection had been carried out in August 2005, and the Inspector was following up requirements and recommendations given at that time. Only a selection of the National Minimum Standards was inspected at this visit. The Manager was on leave on the day of the inspection, and the Administrator and nursing staff assisted the Inspector with locating information. The inspection included reading documentation, talking with staff and service users, reading care plans and other documentation, and inspecting medication procedures. The Inspector was able to chat with 4 service users, and 1 relative, as well as with 9 staff members. These included the Administrator, 3 nurses, and kitchen, laundry and domestic staff. The Inspector was also able to meet the home’s Director. The home was seen to be clean throughout, and was running calmly and smoothly. Care staff were seen to be interacting well with service users, and to show care and respect for them. Service users said that they were well treated, and were mostly happy in the home. One who was unhappy had recently experienced some family trauma, and indicated that her unhappiness was not directly attributable to the home. A programme of activities for the week was on display, and the Inspector saw that a significant number of service users enjoyed meeting in the lounge for the morning’s activity, which was hymn singing. What the service does well: The Activities Co-ordinator arranges a different programme of activities each week, and displays these on a notice-board. These include plenty of variety, and relate to any special days or events – such as “Valentine’s Day” which had just taken place. The dining room had been decorated to reflect this, and a suitable “Valentine’s” menu had been arranged with catering staff. Service users had helped to create the craft work which was included in the decorations. The home arranges for nurses to work supernumerary hours, to ensure that they have the necessary time to complete documentation thoroughly. This was reflected in the high standard of the care planning and nursing assessments. Glebe Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 6 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. Glebe Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glebe Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 The home provides detailed information, which enables prospective service users to make an informed decision about coming to live in the home. EVIDENCE: The Inspector had not previously visited this home, and found that the home’s Statement of Purpose and Service Users’ Guide gave clear information about the way the home operates. These documents are prepared and written in a style which is easy to follow, and to access specific information. All new service users are provided with a Service Users’ Guide, and this includes the complaints procedure, and terms and conditions of residency. These are signed as a contract between the two parties, when a service user comes to live at the home. The details show the level of fees required, and items which are not included in the fees, such as: toiletries, hairdressing and newspapers. Terms and conditions of residency specify such items as the period of notice required, and rules about smoking, alcohol and pets. New service users are also sent a letter of confirmation of the placement prior to moving in. Glebe Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 9 Pre-admission assessments are usually carried out by the Manager, and these contain detailed information about the service user’s nursing needs, medical history, communication needs, nutrition, medication and social preferences. The home would not admit service users who are in a different category of care. Glebe Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7-11 The home has a good system of care planning, which enables staff to give effective care to service users. Health and medication needs are well met. Service users are treated with dignity and respect. EVIDENCE: The Inspector examined 3 care plans, and these provided clear and detailed documentation. The home uses the “Standex” system for documentation, and the Inspector was pleased to see that these had been completed to a high standard. Nursing staff carry out admission assessments for all aspects of daily living, such as management of personal hygiene, pressure area care, mobility, continence, sleep pattern, social activities and mental state. These include a psychological assessment, and details of the service user’s preferences – such as their preferred time to get up or go to bed; to join in with activities or stay in their own room. All the assessments are reviewed monthly, and these had been properly signed and dated. Care plans are drawn up from the initial assessments, and these contained good details of care required. This system does not allow much space for writing additional details, or for evaluation purposes, but the Inspector noted Glebe Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 11 that staff had sensibly used extra pages where needed to ensure that up to date information was included. Care plans are instigated according to individual needs, and the Inspector saw plans for management of pain, diabetes, immobility, nutritional needs and wound care among others. The care plan for diabetes was backed up by records for blood sugar tests. Wound care was well documented, enabling the Inspector to see that each wound is documented separately, and each dressing change is recorded, and shows the current state of the wound. Photographs of wounds may be taken with the service user’s permission, so that the healing process can be easily demonstrated. Pressure sore and pressure area care records were appropriately backed up by turn charts for service users who need assistance with changing position, and use of nursing beds and pressurerelieving equipment. Nutritional care plans included a monthly record of the service user’s weight, and specific details about likes and dislikes, and fluid charts where applicable. Dependency assessments are completed monthly, and all records viewed were signed and dated. Nursing staff complete daily records of care, and rely on care staff to give them daily information about any changes they observe. Care staff complete records for fluid charts and turn charts, and those viewed were well completed. Care plans showed evidence of input from other health professionals including GPs, dentist, optician, chiropodist and link nurses (e.g. tissue viability nurse, and diabetic nurse). The home has arrangements with 2 GP surgeries, and GPs visit the home weekly for routine checks, and as needed for emergencies. Medication is stored in a clinical room on the first floor, and is administered via the nomad cassette system. There are separate medication trolleys for each floor. The stock cupboards were in good order and there was no overstocking of medication. Medication Administration Records (MAR charts) had been properly completed. Oxygen was stored correctly, and there was a warning sign on the door. The medication fridge contained eye drops which had been correctly dated on opening. The Inspector found a number of boxes of suppositories which were out of date. There is a recommendation to ensure that sufficient checks are carried out so that there is no out of date medication in the home. Care staff were seen to treat service users with respect, and one service user said that they “ were always there to help her”. They had paid attention to service users’ individual preferences in terms of clothing, and jewellery. The hairdresser was in the home, and service users were looking forward to having their hair done. The home had policies in place for caring for service users when dying, and for unexpected deaths. Provision is made for any specific requests, and friends and relatives can visit at any time – so long as this is the wish of the service Glebe Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 12 user. The Inspector was informed that the policies had been amended since the previous inspection. Glebe Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12-15 The home provides a suitable range of activities for service users’ enjoyment. Visitors are welcome at any time. Service users are assisted in exercising control over their own lives where possible. Food is home cooked and there is a good variety. EVIDENCE: The home employs an activities co-ordinator 5 days per week, who provides a weekly activities programme. This was displayed on a notice board in the dining area, with each day’s activities on a separate coloured leaflet. The coordinator plans a varied programme which includes old favourites, as well as new ideas. Each month there is a themed lunch – and this month it had been for Valentine’s Day. The activities co-ordinator liaises with the catering staff to produce a menu for the occasion, and the dining room is decorated in keeping with the theme. Craft activities fit in with the same subject. The hairdresser visits twice per week, an aromatherapist once per week, and there is a mobile shop taken round the home once a week. The home has a minibus, and the activities co-ordinator takes service users out shopping or for a drive on Saturday mornings in good weather. Care staff also take service users out sometimes on a one to one basis. The home has a large stock of library books in large print, and arranges for outside entertainers to visit the Glebe Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 14 home once or twice per month. Friends and relatives are invited to join in with the life of the home. There is a restaurant in the Bencurtis Estate grounds which are adjacent to the home, and this provides a convenient venue for relatives and service users to have lunch together. The Manager has made arrangements with Bromley Advocacy Alliance for any service users who require advocacy assistance. Three or four service users had benefited from this help in the last year. The Inspector saw lunch being served. Meals are transferred from the kitchen in the basement to a servery area adjacent to the dining room. Service users confirmed that they have a good choice of menus, and said that the food was good. Lunch time meals looked well prepared and presented. Care staff offered a variety of cold drinks to accompany the meal. The home has changed over the past year from buying in pre-prepared meals to home cooking. There is good interaction between the catering staff and the service users, so that they get to know their likes and dislikes, and they discuss proposed changes of menus with the Manager. The kitchens were basically clean and tidy, and there is a controlled cleaning programme in place. Some alterations are needed, and these are included in the section for the environment, under Standard 19. Glebe Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The complaints procedure has been updated and is satisfactory. Staff recruitment checks and staff training programmes protect service users from abuse. EVIDENCE: The Inspector viewed the complaints procedure which had been updated. This included the correct information, and is available for service users and relatives to access. It is included in the Service Users’ Guide. A hard-backed notebook is used to record all complaints and the action taken in response. There had been 5 complaints since the last inspection, and these had all been appropriately dealt with. Several complaints had been made by the same person. The Inspector noted that relatives had been invited in to discuss situations of concern, and staff meetings had included discussions about how to prevent some issues from re-occurring. Staff training records included training in the recognition and prevention of adult abuse. All staff are checked with the Protection of Vulnerable Adults (POVA) register, and with the Criminal Records Bureau (CRB) prior to confirmation and commencement of employment. Glebe Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 – 26 The home has benefited from some redecoration since the last inspection visit, and is generally well maintained. It provides a pleasant and homely environment for service users. The kitchen requires some upgrading. The home has suitable equipment in place to meet service users’ nursing needs. EVIDENCE: The home has a number of communal areas so that service users can choose where to sit. As well as a large lounge on the ground floor, there is a smaller lounge on the first floor, which is often used for crafts and other activities. There is a conservatory on the ground floor with under floor heating, enabling it to be used all the year round. This leads out into the gardens. The ground floor lounge and the adjacent dining room had been redecorated since the last inspection. Their function had been changed after discussion with service users – so that the previous dining room is now the lounge, and vice versa. Service users said that they much prefer the new format. These rooms had been redecorated to a good standard, and had good quality furniture and Glebe Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 17 furnishings. The home was clean throughout, and there were no unpleasant smells. The Inspector talked with one of the cleaning staff, who said that they have a deep-cleaning machine for carpets, and use this whenever necessary. This was an improvement from the last inspection. Bedrooms were suitably decorated, and included personal items such as small furniture items and photographs. The Inspector viewed a few of the bedrooms. A new linen cupboard had been made on the first floor, so that linen was no longer stored untidily on trolleys. The Inspector saw that the kitchen was in poor condition at one side where the sinks and dishwasher are situated, and this area particularly needs refurbishment. This was noted at the previous inspection, and the Administrator informed the Inspector that there is a programme for kitchen refurbishment in place for this year. The Inspector was also concerned that since the change of catering management (i.e. from pre-prepared meals to home-cooked food), there is insufficient space for food preparation, and more work surface space is needed. There is a requirement for this work to be done, in conjunction with any specific requirements or advice from the Environmental Health Officer. The home is suitably equipped for the nursing needs of service users. There is a passenger lift to all floors, a call system in each room, and assisted baths and hoisting equipment. One bathroom on the ground floor was in the process of being altered into a shower room, to enable service users to have more choice regarding bathing or showering. Each floor has a mobile hoist and a “stand-aid” hoist. These had been properly serviced at six-monthly intervals. The maintenance man checks other equipment on a weekly or monthly basis. This includes checking toilet seats, bedrails, window restrictors, wheelchairs, pipe work and radiators. The laundry room was in good order, and the laundry assistant said that 2 new gas tumble dryers had been fitted in the last 2 weeks. These were more efficient than the previous ones. There are 2 commercial sized washing machines, with sluicing faculties, and 1 smaller machine for delicate clothes. One of the large machines was out of order, and was due to be fixed. There is a red alginate bag system in place for the management of soiled items, and suitable hand washing facilities and infection control procedures. Glebe Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 - 30 The home ensures that sufficient numbers of staff are on duty. Recruitment checks are satisfactory, and the home promotes staff NVQ training. There is a good programme for induction training. EVIDENCE: The home has 2 trained nurses on duty day and night, so that there is always one available for each floor. There are also supernumerary shifts for nurses, and there were 3 in the home on the day of the inspection. This enables the nursing staff to keep up with the important roles of documentation, ongoing assessments, training sessions, and one to one supervision with care staff. Care plans had been well completed, so this system assists with maintaining good practice. The Inspector saw care staff carrying out their duties calmly and efficiently. There are usually 9 care staff for morning shifts, and 8 care staff for afternoon shifts. The Inspector estimated that 19 out of a total of 36 care staff had completed NVQ 2 or 3 training. This is 52.7 , and as it is above the projected minimum level of 50 , the home is commended. Six care staff were in the process of completing NVQ 3, and another 5 were studying for NVQ 2. Recruitment procedures were checked, and found to be satisfactory. Staff files were in good order and easy to access information. All staff have Criminal Record Bureau (CRB) checks and POVA First checks prior to commencement of employment, and all existing staff had been checked. The CRB checks are not Glebe Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 19 retained on staff files - only the reference number. CRB checks are stored separately and confidentially. Staff go through a thorough induction training programme (previously known as TOPSS – and now known as Skills for Care training.) The induction programme usually takes 6 weeks to complete. Care staff are mentored by a trained nurse. All nursing and care staff have a minimum of 3 training days per year. This includes updates in mandatory subjects such as moving and handling, first aid and basic food hygiene; and additional subjects such as prevention of abuse and pressure relief. Glebe Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,36,37,38 The staff show an understanding and awareness of their different roles and responsibilities. Staff meetings, and residents and relatives meetings, provide a forum for discussion and ongoing improvements. Records are well maintained and up to date. Health and safety matters are generally well managed. EVIDENCE: Care staff have specific responsibilities as keyworkers for different service users. These tasks include weekly checks to ensure that service users’ clothes are well maintained and properly labelled; to check that bedrooms are kept tidy; to ensure toiletry supplies are adequate; to check service users have their fingernails cut and cleaned as needed; and to ensure that hairdresser appointments are made, and monthly weights are recorded. They are also able to liaise directly with relatives to ensure the well being of the service users. Glebe Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 21 Staff meetings are held for different levels of staff, and there is sufficient opportunity for staff to share any concerns or ideas for change. There is a Glebe Court Support Group, which provides friends and relatives with the opportunity to take part in the life of the home, and 4-weekly service users’ meetings. These give them a chance to give direct feedback together, and to discuss any changes such as new staff, décor, activities or menus. All staff have one to one supervision. The Manager gives supervision to the nursing staff, and they are then delegated to give supervision to specific care staff. The Domestic and Catering Supervisor oversees supervision for all catering and domestic staff. There is a good format in place for carrying out supervision. The Administrator informed the Inspector that as far as she was aware this was up to date. The Inspector viewed 2 supervision records which were satisfactory. Servicing records were checked for fire records, emergency lighting, water temperatures, water chlorination, hoist servicing, and the fire alarm system, and these were all up to date. The home’s registration certificate and the insurance policy were on display, and up to date. An electrical certificate and PAT (Portable Appliance Testing) certificates were viewed and were satisfactory. PAT testing is carried out on a rolling programme, so that items brought in by service users are tested prior to use. Only one or two policies and procedures were viewed at this visit and they were satisfactory. Other records were well maintained, and appropriately stored. The Inspector viewed mandatory training certificates for one carer, and was shown the staff training matrix. This showed training in place for statutory training such as moving and handling, food hygiene, first aid, and fire training. The Inspector was unable to clarify if all staff were up to date with fire training, as several staff appeared to have fallen behind with this. The Inspector was particularly concerned where this included night staff; it is especially important for night staff to keep up to date with fire training, as there are less on duty at night times, and they are therefore more vulnerable. There is a recommendation to ensure that all staff keep up to date with fire training and fire prevention. Glebe Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 3 3 X X 3 3 2 Glebe Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 23 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 2 Standard OP9 OP19 Regulation 13 (2) 16 (2) (g) Requirement To ensure that there is no out of date medication in the home. To refurbish the kitchen, and to include sufficient work surfaces. To follow any additional requirements or advice from the Environmental Health Officer. Timescale for action 31/03/06 30/09/06 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 OP38 Good Practice Recommendations To ensure that all staff are kept up to date with fire training. Glebe Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Sidcup Local Office River House 1 Maidstone Road Sidcup DA14 5RH 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 Court Nursing Home DS0000010135.V283510.R02.S.doc Version 5.1 Page 25 - 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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