Inspection on 23/10/06 for Glebe Court Nursing Home

This inspection was carried out on 23rd October 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 17/02/06

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 Miss Rosemary Blenkinsopp Unannounced Inspection 23rd October 2006 08:30 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.V307901.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 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.V307901.R01.S.doc Version 5.2 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.V307901.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing Notice issued 10 October 1997 Date of last inspection 17th February 2006 Brief Description of the Service: Glebe Court is part of the Glebe Housing Association, which provides housing and support through sheltered housing as well as warden assisted bungalows to elderly persons. The Association has one nursing home which is Glebe Court .This is a purpose built care home for the nursing care of older people. The home is set in its own grounds on Bencurtis Park. There is car parking to the front of the home and a sheltered garden to the rear. The shops at Coney Hall are within walking distance for people with unrestricted mobility and there are various bus routes from Coney Hall or West Wickham. The fees in this home are between £ 525 and £740 with extra fees payable for hairdressing, chiropody, newspapers and toiletries. Glebe Court Nursing Home DS0000010135.V307901.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was conducted unannounced by two inspectors over a five hour period. At the time of the inspection there were fifty residents on site with one vacancy. On the day of the inspection the Manager was on annual leave, the majority of the inspection was conducted by the administrator who was very helpful and knowledgeable about the workings of the home. Prior to the inspection the Manager had completed the pre-inspection questionnaire forwarded this to the CSCI with supporting documentation including Statement of Purpose, staff rotas etc. The lead inspector had sent out questionnaires to individual residents, their relatives, and members of the multi disciplinary team. Prior to the site visit two relatives and two residents questionnaires were received, others were received after the inspection date. The inspectors focused on different areas of the home starting with a tour, meeting with residents followed by inspecting documentation including care plans, personnel files and service certificates. What the service does well: What has improved since the last inspection? Since the last inspection the work relating to refurbishment of the kitchen had been completed and the Clean Food Award was issued up to 2007. The home has managed to engage a group of volunteers who assist with driving the mini bus and are involved in events such as fund raising for the residents. Involvement with the local community has improved which is seen to be beneficial to all parties. Glebe Court Nursing Home DS0000010135.V307901.R01.S.doc Version 5.2 Page 6 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.V307901.R01.S.doc Version 5.2 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.V307901.R01.S.doc Version 5.2 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): 3 The quality rating in this section is good. This is based on all of the information including the site visit. Assessments of residents are conducted by the Manager, prior to admission. More robust assessment information is required to ensure that all health issues are thoroughly explored prior to any placement being agreed. EVIDENCE: The Statement of Purpose was forwarded with the pre inspection information; it was also available within the home. The inspector viewed the assessment procedures for the last admission to the home. The resident’s file showed that the Manager had assessed the prospective resident twice at the hospital, before being admitted to the home. The home had received basic information from the hospital although the inspector recommends that, where there are a number of needs, further medical information should be obtained. The staff had not yet commenced the long term assessment or care plan due to the resident being admitted two days previously. Core areas of care planning must be recorded to ensure staff Glebe Court Nursing Home DS0000010135.V307901.R01.S.doc Version 5.2 Page 9 have the information to hand to deliver the care required. This is particularly important where there are issues indicated on the assessment record. The home had ensured that the resident’s clothing had been recorded but no other property had been documented. Another assessment record was inspected, as was the supporting care plan. The assessment of the resident’s physical health needs was well completed. Information relating to her mental state including a psychological assessment, details of family circumstances and hobbies was not completed. These were without the staff members’ signature or date. Other information was not recorded such as any trial visits or details of that information provided prior to permanent placement. Once admitted residents are issued with contracts. Please see requirement 1. Glebe Court Nursing Home DS0000010135.V307901.R01.S.doc Version 5.2 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): 7,8,9,10 The quality rating in this section is good. This is based on all of the information including the site visit. Care plans are generated for each resident and detail physical health issues although psychological and social issues were less well evidenced. Supporting documentation and risk assessments must be kept under review and appropriate action taken if risks are identified. Medications are well managed. EVIDENCE: During the initial tour the inspector saw evidence of various types of equipment available, and in use, including mobility aids and pressure relieving mattresses. Staff were observed to use the equipment correctly and demonstrate patience with the residents during manual handling procedures. Supporting documentation such as turn charts were in bedrooms. Two residents were very aphasic and others seemed confused. There seemed a high level of dependency amongst some of the residents. There appeared be sufficient staff to provide the care needed, in an unhurried manner. Call bells were answered promptly. Glebe Court Nursing Home DS0000010135.V307901.R01.S.doc Version 5.2 Page 11 Care plans were selected for inspection, this home uses the Standex system. This system of care planning is a good format although it needs time, care and attention to fully complete it. In this home qualified nursing staff are provided with supernumerary hours to complete documentation. A selection of care plans were viewed. The care plans of those residents whose assessment documents had been inspected, were included. The care plan reflected he initial assessment and detailed physical health issues, which were dated and reviewed. There were no issues addressing the psychological aspects, and as this resident had suffered a stroke these may have been present. This resident was catheterised, and included within the interventions section was reference to input of two litres fluid a day. The resident was not on a fluid chart, so it was difficult to ascertain if this was being addressed. The supporting documentation indicted that her nutrition risk was in the category “very high risk”. Reviews had taken place in 2005 and January 2006 nil since. Within the nutrition guidance it refers to seeking dietetic advice if high risk as identified. The inspector checked the multi disciplinary sheet for referral to the dietician, this could not be located . The resident was difficult to weigh therefore this to impacts on her presenting problems as staff have no indication of weight loss/gain. Whilst it is accepted that the resident was difficult to weigh there was no indicators as to other evidence of weight loss/gain. More regular reviews and appropriate action need to be addressed to manage this problem. The reviews for waterlow assessments were in place although a gap between January 2006 and September 2006 was evident. The waterlow score was 22, which again indicates significant risk posing skin integrity problems with the possible development of pressure sores. Another care plan was inspected. The resident had met with the inspector. The resident was seen to be tearful, distressed and very “clingy”. The resident was aphasic, and although unable to communicate verbally, the body language was very telling. The resident needed a lot of reassurance and contact. The care plan included many health needs, which had arisen as a result of her physical condition, however it did not reflect that which was evident to the inspector namely ongoing psychological support. Some of the issues identified in the care plan were without the nurses’ signature or that of the resident/advocate. Under the problem identified as” self harm” it stated that one to one supervision must be in place at all times. This had been generated 6/10/06. During the inspection period it was evident that one to one care was not being Glebe Court Nursing Home DS0000010135.V307901.R01.S.doc Version 5.2 Page 12 provided simply general supervision as for all residents. This needs to be amended. In addition her waterlow and nutrition assessments had not been recently reviewed. The waterlow score was stated as 19 on 11/7/06 and her nutrition 14 on the 11/8/06. There was information in both care plans relating to multi disciplinary team visits including the GP, physiotherapist and chiropodist. The medication systems were inspected. Medication is stored in a clinical room on the first floor, and is administered from the trolley, via the nomad cassette system. There are two medication trolleys one for each floor both were maintained in a tidy and organised manner. The stock cupboards were inspected and no overstocking of medication was noted. Medication Administration Records (MAR) charts had been completed with the residents’ photograph attached. On some charts the abbreviation, NKDA was used, which stands for “no known drug allergies”. Abbreviations of any description should be avoided. The qualified nurse rectified this immediately. Those medications received into the home were recorded as such, and records for medication disposed of, were in place. A registered contractor collects the disposed medication monthly. Those medications, which are administered “ as required “, had the reason for administration and the maximum dose stated. The medication fridge contained eye drops that had been correctly dated on opening. Calogen is in use for some residents, which has a short self life once opened, this too needs dating on opening, again the nurse addressed this immediately . Those medications that were checked were in date. The medication fridge temperature records were available although gaps were identified for 13/14 and 21/22 October 2006. Please see requirement 2. Glebe Court Nursing Home DS0000010135.V307901.R01.S.doc Version 5.2 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): 12,13,14,15 The quality rating in this section is good. This is based on all of the information including the site visit. Choice and preferences are facilitated in the resident’s daily lives. Activities are provided, which are varied and age appropriate. Visitors are welcomed into the home. EVIDENCE: The home employs an activities co-ordinator sixteen hours a week spread over five days. The lady provides a weekly activities programme. This was seen on display in the lift and other areas throughout the home. The co-ordinator plans a varied programme, which includes old favourites, as well as new ideas. On the day of the inspection an “Olde tyme” sing a long was organised and many residents not only participated but also enjoyed it. Comment cards confirmed that lots of activities were available within the home. Positive comments were received regarding the activities and the coordinator. One such comment was that she “makes everyone’s life a joy”. In preparation for lunch the dining room was nicely laid with condiments serviettes and decorations. Lunch consisted of two choices served with vegetables and afterwards a dessert. Staff were seen to assist residents to eat and in an unhurried manner. Relatives were also present during this time and Glebe Court Nursing Home DS0000010135.V307901.R01.S.doc Version 5.2 Page 14 they too helped. Adapted cutlery and plate guards may have benefited some residents, although these were not used, however were said to be available. The inspector received variable comments regarding the quality of the food some positive, others not so. This is something that has been identified internally for action. In communal areas newspapers, magazines, books the TV, and a music centre were all available for recreational purposes. In individual bedrooms many residents had their own TV’s and radios. There is a visiting library to the home. The home has an active relatives committee that meets regularly and participates in the events in the home. Visitors were seen in the home at various times throughout the day. Visiting is open and encouraged. Glebe Court Nursing Home DS0000010135.V307901.R01.S.doc Version 5.2 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 quality rating in this section is adequate. This is based on all of the information including the site visit. Information is available to residents and relatives on how to make a complaint. External avenues are included in the information. Staff had a basic understanding of abuse and whistle blowing, although were aware of the key features in abuse, that of reporting the information. EVIDENCE: There was a complaints policy on display, which contained time frames for responses. The complaints information is referenced in the Statement of Purpose. There is a hard backed book, which is used for recording of complaints. Within this book there was details of the date of the complaint, content, action taken and copies of the investigation and correspondence. It needs to include reference in the outcome as to whether the complainant was satisfied or not with the response. The correspondence retained in this book was not attached in which case they may become mixed up and/or lost. The inspector noted within one complaint there was a copy of staff supervision records. The supervision record was for a staff member who had been part of a complaint and the supervision record was to evidence that the area raised as a complaint had been discussed. The inspector was concerned about confidentiality however the administrator confirmed that this record was securely stored and only accessible by the Manger and herself. Glebe Court Nursing Home DS0000010135.V307901.R01.S.doc Version 5.2 Page 16 The administrator advised the inspectors that there had been no referrals under POVA. Staff with whom the inspector met had a satisfactory knowledge of abuse and whistle blowing and were aware of the importance of reporting any incident. Some staff indicated to the inspector that they had not received adult protection training during their employment whilst at Glebe Court. This was confirmed by the training list that was provided with the pre inspection information. Adult protection and whistle blowing are covered in the NVQ training, which twenty-two staff have completed. All staff must have training on adult abuse including care staff and ancillary workers. Please see Recommendation 1. Glebe Court Nursing Home DS0000010135.V307901.R01.S.doc Version 5.2 Page 17 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 quality rating in this section is good. This is based on all of the information including the site visit. The home is maintained in a domestic homely manner with evidence of personalisation in individual bedrooms. On going maintenance is addressed through a rolling programme of improvement. EVIDENCE: The home is a purpose built facility spread over two floors with lift access between floors. Bedrooms are located throughout the home and there are a number of communal areas that residents can choose from. 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. The garden was tidy and garden furniture provided. The ground floor lounge and the adjacent dining room had been redecorated. Communal areas were retained in a homely fashion. The dining room was nicely presented prior to meals. There is parking to the front of the building. Glebe Court Nursing Home DS0000010135.V307901.R01.S.doc Version 5.2 Page 18 As the inspectors arrived there was a smell of urine in the entrance hall although it was early morning this was attributed to an incontinent resident adjacent to this area. The remainder of the home was free from odours. Bedrooms varied in the amount of personalisation that had taken place. The cupboard housing COSHH items had a digital lock for security purposes. There was evidence of pressure relieving equipment in place although in some cases the mattresses were silenced, this was noted in bedrooms 21,34. In the event that the mattress should fail then staff would not be alerted to such and these may cause skin integrity problems with residents who are already at risk. In some areas, particularly corridors, there was evidence of wear and tear, which is caused by the amount of equipment in use. Some staining was noted to carpets, example room 29. A rolling programme of on going maintenance and refurbishment is in place. The kitchen has recently been fully refitted. A signs stating “Barrier Nursing” was on the door of bedroom 44. Clinical signs of this nature should be avoided. Glebe Court Nursing Home DS0000010135.V307901.R01.S.doc Version 5.2 Page 19 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): 27,28,29,30. The quality rating in this section is adequate. This is based on all of the information including the site visit. Staff are provided in sufficient numbers to address the needs of residents as well as complete the required documentation. Recruitment procedures did not provide evidence that robust checks are made prior to employment specifically those of CRB’s and exploration of gaps in employment. EVIDENCE: The home works with two trained nurses on duty day and at night. There is always one qualified nurse available for each floor. There are also supernumerary shifts for qualified nurses varying between one and two a week. The supernumerary hours allows staff to address record keeping and documentation. In addition there are nine care staff during the day time period and four at night. The Manager is supernumerary to these numbers. This is a good skill mix and number of staff. The inspector met with three staff, one qualified, one care staff and a domestic. The domestics are not under the management of Ms Payne.This is something which is about to change. The two nursing/care staff confirmed an induction period of two days, which covered a number of home related issues, health and safety and well as some of the statutory training. Glebe Court Nursing Home DS0000010135.V307901.R01.S.doc Version 5.2 Page 20 Staff stated on going training took place with topics such as fire, health and safety manual handling all included. Basic food hygiene was going to be conducted the next day. The training list provided with the pre-inspection questionnaire detailed that in the last twelve months subjects including incontinence, wound management, deafness and pressure sores had been addressed. Other topics such as communication and confusion, which are relevant to residents’ needs, would further enable staff to better understand these conditions. The domestic was asked about infection control, MRSA and COSHH all of which are topics that she would deal with first hand. She was aware of basic principles such as hand washing but limited in further measures. She was using gloves at the time. She stated that she is due to start NVQ 1 in housekeeping October 06. She was unable to answer questions on abuse or whistle blowing. Three staff recruitment files were inspected .The inspector was unable to locate the CRB for this employment only those from their previous work. CRB’s are not portable and must be applied for by the organisation for whom the staff work. There was evidence relating to the employee’s proof of identity. Certificates relating to training and checks made regarding the qualifications for nurses with PIN number checks recorded. One file viewed did not contain a reference from the last employer and also one of the references was one-dated 2004. There were no records relating to interview schedules of notes made or questions asked. Gaps in employment histories were not explored and no checks made as to why the employee left their last employment in care. Some references were headed “to whom it may concern”. These must be addressed to a specific person i.e. the named Manager. The home provided the inspectors with a copy of the staff roster for a two week period. Discussions with relatives showed there to be a high level of agency staff used recently. The pre inspection questionnaire stated that ten staff had left in the twelve month period, eight of whom were qualified nurses. The home also has administrator, receptionist, domestic and catering staff. Induction training is provided to all new care staff in line with TOPSS specifications. The Manager is currently reviewing this training in light of changes made by the Skills Sector Council (formerly TOPSS). In the personnel files, there was recorded evidence of this training taking place and staff undertaking moving and handling and fire training during their initial training. Glebe Court Nursing Home DS0000010135.V307901.R01.S.doc Version 5.2 Page 21 NVQ training was on going; so far twenty two staff have completed this. Amongst the staff group there are fourteen trained nurses. Please see requirement 3. Please see recommendation 2. Glebe Court Nursing Home DS0000010135.V307901.R01.S.doc Version 5.2 Page 22 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): 31,33,35,38. The quality rating in this section is adequate. This is based on all of the information including the site visit. The home is managed by an appropriately qualified nurse who has many years experience in care homes. Health and safety aspects are addressed. Quality assurance, including internal and external audits are conducted. EVIDENCE: The home provides information to residents and relatives on how residents’ monies will be managed by the home. Relatives or representatives provide monies, which is then recorded and placed in a separate wallet. The administrator stated that a receipt for the money is not always given and when the administrator is not around (particularly weekends) money is placed in an envelope and kept in the medicine cupboard of posted under the office door. The inspector strongly recommends that receipts are issued at all times. An Glebe Court Nursing Home DS0000010135.V307901.R01.S.doc Version 5.2 Page 23 audit of three residents’ personal allowances showed there to minimal expenditure except for hairdressing and chiropody etc. There were no receipts for either the hairdressing or chiropody expenditure, although the home keeps a record of which residents have their hair done and the cost. However, this is not signed by the hairdresser to ensure it is accurate. Systems in place for managing personal allowances could be improved further through ensuring receipts are maintained for all expenditure. A number of service contracts were viewed and found to be satisfactory. However the weekly check of the fire alarm had not been completed since 15/9/06 and whilst there was evidence of fire training there was little evidence of fire drills. The administrator was advised that fire drills must be undertaken separate to the fire alarm check with two for day staff and four for night staff in a twelve month period. There was evidence that staff have been provided with statutory training and updates including manual handling; fire; infection control and food hygiene. Ten staff have completed the first aid training. The Employers liability was in place, up to date and with the appropriate level of cover. The home has recently undertaken a survey in relation to the quality of care provided. This information has been analysed to identify the strengths and weaknesses and a letter sent out to the relatives stating in general where improvements are required. The inspector also suggests that a more formal report be produced that identifies more specifically the action the home is taking to address the shortfalls and make improvements. The inspector was also informed that the home is soon due to implement a system for auditing the procedures in the home. In addition Glebe Housing Association has recently commissioned some work through the National Housing Federation. The report contained recommendations for the Association, including Glebe Court. The home also arranges regular meetings for staff; residents and relatives. Minutes of these meetings are taken and maintained in the home. The inspector viewed the accident book detailing accidents to residents. The inspector noted that where the individual had suffered some injury the accident record showed little information on the outcome. This information had been also recorded in the daily records file for the individual. The administrator was advised that where residents require medical attention these incidents must be notified to the Commission as required under Regulation 37. Please see requirements 4,5,6 and 7. Please see recommendation 3. Glebe Court Nursing Home DS0000010135.V307901.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 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 X X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 2 Glebe Court Nursing Home DS0000010135.V307901.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. OP3 Standard Regulation 14 Requirement The Registered Manager must ensure that comprehensive assessment information is received prior to any admission decision and other relevant details recorded including trial visits. The Registered Manager must ensure that care plans are fully reflective of all of their needs including social and psychological, with supporting risk assessments in place, which are kept under review. The Registered Manager must ensure that all staff are subject to robust recruitment checks including CRB’s and appropriate references. The Registered Manager must ensure that all monies retained by residents are safeguarded with suitable records for transactions. The Registered Manager must specify the actions taken resulting out of recent audits which actions highlighted shortfalls. DS0000010135.V307901.R01.S.doc Timescale for action 30/01/07 2. OP7 15 30/01/07 3 OP29 19 30/12/06 4 OP35 20 30/12/06 5 OP33 24 30/12/06 Glebe Court Nursing Home Version 5.2 Page 26 6 OP38 7 OP38 23 37 The Registered Manager must ensure that al staff participate in a fire drill as a minimum annually. The Registered Manager must ensure that all incidents under Regulation 37 are notified to the CSCI. 30/12/06 30/12/06 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 OP16 2 OP30 3 OP35 Refer to Standard Good Practice Recommendations The Registered Manager should ensure that the complaint record, details if the complainant was satisfied with the outcome. All information must be securely retained. The Registered Manager should ensure that all staff receive training appropriate to the work that they perform and this includes adult protection. The Registered Manager should ensure that receipts are issued for all expenditures. Glebe Court Nursing Home DS0000010135.V307901.R01.S.doc Version 5.2 Page 27 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.V307901.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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