Inspection on 10/04/07 for Glebe House

This inspection was carried out on 10th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 but made no statutory requirements on the home.

Other inspections for this house

Glebe House 22/09/08

Glebe House 23/06/08

Glebe House 28/09/07

Glebe House 03/10/06

Glebe House 25/10/05

Glebe House 23/11/04

Glebe House 19/07/04

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

CARE HOMES FOR OLDER PEOPLE Glebe House The Broadway Laleham Middlesex TW17 0DU Lead Inspector Helen Dickens Unannounced Inspection 10th April 2007 09:40 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 House DS0000049209.V333106.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 House DS0000049209.V333106.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glebe House Address The Broadway Laleham Middlesex TW17 0DU 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) 01784 465273 Surrey Rest Homes Ltd Post Vacant Care Home 24 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (24), of places Sensory Impairment over 65 years of age (2) Glebe House DS0000049209.V333106.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Of the 24 residents accommodated, up to 3 may fall within the category of DE(E) The age/ age range of the persons to be accommodated will be OVER 65 YEARS OF AGE Of the 24 (twenty four) residents accommodated 2 (two) may have a sensory impairment. 3rd October 2006 Date of last inspection Brief Description of the Service: Glebe House is a large detached property located in the village of Laleham, Middlesex. The home is owned by Surrey Rest Homes Ltd and provides accommodation and care for up to 24 older people, 3 of whom may have dementia and two of whom may have a sensory impairment. The accommodation is arranged over three floors, with a passenger lift and a stair lift available to access the first floor. The second floor is reached by stairs. There are 22 single occupancy rooms, 19 of which have en-suite facilities, and one double room. Those rooms without en-suite facilities are located close to toilets and/or bathrooms. The communal areas include a large lounge leading onto a conservatory, a dining room and another conservatory at the far end of the building. There is a large, enclosed, garden with a patio to the rear of the property and parking for several cars to the front. The current fees are from £350 per week sharing the double room, to £570 per week for a single room with en-suite toilet and hand basin. Glebe House DS0000049209.V333106.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over seven and a half hours. The inspection was carried out by Helen Dickens, Regulation Inspector. The manager represented the establishment. A partial tour of the premises took place. Discussions were held with most residents over lunch, and with two residents in their rooms. The manager and one staff member were also interviewed. Returned ‘comment cards’ from residents, relatives and professionals involved with the home were also used to write this report. Two resident’s care plans and a number of other documents and files, including two staff files, were examined during the day. The Commission for Social Care Inspection would like to thank the residents, relatives, manager and staff for their hospitality, assistance and co-operation with this inspection. What the service does well: What has improved since the last inspection? The new manager has made a number of improvements including refurbishing some of the bedrooms, the dining room looks better with linen tablecloths and matching napkins, and there are fresh flowers on the tables and throughout the home. Arrangements for keeping and administering medication have improved and the Requirements made at the last inspection on this matter have been met. Glebe House DS0000049209.V333106.R01.S.doc Version 5.2 Page 6 A number of staff have been on the protection of vulnerable adults training course and all staff have now received training in manual handling. Arrangements for staff supervision have improved, and the timetable for supervision sessions throughout the coming year was on schedule. The kitchen area has improved and some staff have had training regarding the new food hygiene regulations; a ‘coach mentor’ from the council had been allocated to the home to assist them to implement the Safer Food, Better Business system. Both cooks are now doing an NVQ Level 2 in catering. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Glebe House DS0000049209.V333106.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 House DS0000049209.V333106.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. More work needs to be done to ensure prospective residents have sufficient written information available to them to assist them to make an informed choice about living at this home, and to ensure that existing residents have contracts. Resident’s needs are assessed prior to entering the home, however the admissions process does not always take into account the home’s current registration categories and conditions. EVIDENCE: Prospective residents are encouraged to come to Glebe House for a day and the manager was showing around the relatives of a prospective resident on the day of the inspection. This gives prospective residents and their relatives the opportunity to view facilities and to ask questions about the home. One comment card received from a resident who had moved in recently said that they did have enough information about the home before they moved in. Glebe House DS0000049209.V333106.R01.S.doc Version 5.2 Page 9 The home has a general brochure which describes the aims and objectives of care for older people in the three Surrey Rest Homes. Some of the information in the brochure is no longer correct in relation to Glebe House. The Statement of Purpose and Service User guide have not yet been up-dated as requested at the last inspection in October 2006, though the manager stated she was currently working on these documents in her own time on her home computer. Two resident’s files were sampled and found to contain pre-admission assessments carried out by the home in their own assessment of the resident, as well as assessments from the multi-disciplinary team including the hospital staff in one case, and from care managers. It was noted that one file also contained pre-admission risk assessments. Resident’s needs are assessed prior to entering the home, however the admissions process does not always take into account the home’s current registration categories and conditions. One resident’s needs had been assessed prior to admission and were outside the home’s current registration category yet had been admitted to Glebe House. Though the home is currently meeting this residents needs, potential residents must only be admitted within the categories and conditions set out on the home’s certificate of registration. Glebe House DS0000049209.V333106.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans at this home set out the health and personal care needs of individuals, but require further development to include how support is to be given to residents. Arrangements for the administration of medication have improved. EVIDENCE: Two care plans were sampled and found to contain sufficient personal details about residents, including identifying where they needed help for example with personal care and medication. Those residents who needed assistance with their mail had signed to say they would like help from staff in the home. Reviews of these care plans were documented. However, more work needs to be done as, for example, the care plans do not specify how the care will be delivered to residents – the manager had already identified this as a shortfall and said she will be reviewing and re-writing all resident’s care plans. Glebe House DS0000049209.V333106.R01.S.doc Version 5.2 Page 11 Reviews of care plans should be carried out on a monthly basis and several had not been reviewed since November 2006. Residents have access to local health care facilities including GPs and specialists such as Community Psychiatric Nurses. One health specialist who completed a comment card said that though they had only been involved with one resident, they felt staff had always tried to meet that persons health needs and would get in contact if they encountered any health problems. A GP who returned a comment card ticked ‘always’ to the questions about whether the service responded to different individual’s needs and supported individuals to live as they choose. The ‘health’ information on resident’s files included a weight monitoring chart, the medication they were on and any side effects, and details of health conditions. However, one community health specialist commented that staff may need more training regarding mental illness, particularly around dementia. Examination of the training schedule showed that only two staff had done any training on dementia yet at least six residents have been diagnosed with this condition. There were several comments on communication made by health professionals in their comment cards, one stating that the care could improve by better staff communication with each other. Feedback from a relative of a past resident also highlighted communication shortfalls with regard to keeping families up to date with resident’s ill health. The manager had identified concerns about a visiting professional to the home and intended to address this with that person. The inspector observed part of one medication administration session. The medication was kept securely and the cabinets were clean and tidy. The home use blister packs provided by the local pharmacist. The medication administration records of three residents were sampled and no unexplained gaps were noted; the manager said there is a system in place for monitoring this. One senior staff member has overall responsibility for medication and both senior staff have been on a specialist training course regarding administering medication. One resident self-administers a cream, and there is a risk assessment in place. The shortfalls identified at the last inspection have been remedied. The manager was asked to ensure that there was written guidance for staff regarding the administration of medication prescribed ‘as required’, especially where residents had dementia. The manager was also asked to contact the community pharmacist regarding a visit to look at their systems and practise, as staff said no recent visit had been made and no record could be found regarding previous visits. During the inspection staff were noted to be respectful to residents and to knock on doors before entering resident’s bedrooms. One relative commented that sometimes when she is visiting she overhears staff in neighbouring rooms knocking on the doors before they enter, and being courteous to residents. Residents spoken to on the day of the inspection did not raise any negative Glebe House DS0000049209.V333106.R01.S.doc Version 5.2 Page 12 issues in relation to privacy. Those who wish to receive visitors other than in their bedrooms may use the dining room or the conservatory though neither is entirely satisfactory as the conservatory is used for smoking and the dining room is not always available. It was noted that not all residents had two chairs in their bedrooms making it difficult to receive visitors. The manager said some rooms may be unsuitable to hold a second large armchair and she was looking at purchasing smaller comfortable chairs – currently a chair is carried into a room by staff if there is not enough seating for visitors. It was also noted that incontinence pads were being stored on top of a resident’s wardrobe which did not protect their privacy and dignity, particularly if they received visitors in their room. The manager stated she was making alternative storage arrangements. Glebe House DS0000049209.V333106.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for activities are improving but more work needs to be done including consulting with residents about additional activities. Family contact is encouraged and residents are given some opportunities to exercise choice and control over their lives. Residents are offered a nutritious meal in pleasant surroundings. EVIDENCE: The manager said there has been some improvement in arrangements for activities since the last inspection as one staff member has been given responsibility for co-ordinating arrangements. There is currently no published plan for residents to look at though the manager stated she would be doing this. On the day of the inspection there was a reminiscence quiz for residents in the lounge and the manager said there are a number of such ad hoc activities including occasional musical entertainment and exercises, some outings including to a garden centre, and bingo sessions. Several residents told the inspector they were pleased they could get to church on Sunday. Glebe House DS0000049209.V333106.R01.S.doc Version 5.2 Page 14 Though seven residents who returned their comment cards said there were activities in the home, one said they were left sitting in front of the TV. A visitor commented that it would be useful to have a handout of the forthcoming activities. Several residents commented that they would like prizes for bingo and the manager said that would be happening by the following week. To meet this Standard in full the home will need to provide, in consultation with residents, more activities, and proper information for residents which is available in advance. The home should pay particular attention to appropriate activities for those residents who have been diagnosed with dementia. The manager said family and friends are welcomed at the home and the notice about the forthcoming resident’s meeting in the main hall specifically invited family and friends. Some very positive comments were received from relatives on their comment cards including one who stated in response to the question – ‘What does the home do well’ they replied ‘Everything.’ Other comments included ‘Kind and helpful staff’ and the home is ‘clean, comfortable and warm.’ Most respondents agreed that the home contacted them on matters relating to their relative who lived at Glebe House. Residents are given some opportunities for choice and control for example there are regular resident’s meetings. One resident spoken to preferred to eat in their own room and staff accommodated this wish. One of the relative’s comment cards noted that some residents chose to eat in their rooms. From a partial tour of the premises it was evident that resident’s rooms were personalised with their own photographs and pictures, and other memorabilia. Some residents are not managing their own financial affairs and one was concerned that she could not get access to her own money; the inspector agreed to take this up with their care manager. Residents are offered a home cooked lunch in pleasant surroundings. There are matching tablecloths and napkins, a printed menu on each table, and everyone had a cold drink. The chicken pie and creamed potatoes served on the day of the inspection were very tasty though had rather a mixed reception from some residents who preferred not to have the chicken in a sauce. Generally the comments on food were good and when asked, residents said that they had input into the home’s menus at residents meetings. The manager stated that all the puddings are also home made. There is only one main course on the daily menu and the manager was asked to review this to ensure residents had a choice, not just if they did not like the main course, but if they wanted something different. She agreed to have 2 or 3 regular alternatives such as baked potatoes and salad, or fish, which residents could order by a certain time. The manager also said they were reviewing suppers in the evening to give more choice to residents. Glebe House DS0000049209.V333106.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. More work needs to be done to ensure residents and relatives can be confident that their complaints will be listened to and acted upon, and to ensure residents are protected from abuse. EVIDENCE: The home has a notice in the hallway to alert residents and visitors that they can complain, and to whom they may make their complaint. Most returned comment cards showed that people knew how to make a complaint. However, the up-dated policy manual did not contain a ‘procedure’ as such, for example it did not give information about the various stages and relevant timescales within which complaints will be dealt with and this must be remedied. The complaints book was missing and, when it was located, pages had been torn out of the bound book and no complaints were recorded. CSCI was made aware of at least one serious complaint, which should have been entered in the complaints book. In addition, a number of minor issues raised by residents should have been recorded as complaints, and this was discussed with the manager who said she would review the arrangements for recording complaints. A Requirement was made at the last inspection for the complaints procedure to be up-dated, and this will be repeated. Glebe House DS0000049209.V333106.R01.S.doc Version 5.2 Page 16 The home has a copy of the 2005 Surrey multi-agency procedures for the protection of vulnerable adults, as well as their own in-house policy. Ten staff have been on training on this subject and the manager said the basics are covered in induction training for new staff. However, more work needs to be done to fully protect residents. The in-house policy does not dovetail with the local multi-agency procedures mentioned above in that it does not use the same definitions of abuse which could cause confusion; it is not clear at what point social services should be involved; and tells staff not to assume abuse or neglect, but to investigate themselves, which is contrary to the agreed local procedure. One alleged incident is currently being investigated and the home are co-operating with social services, however, this should also have been reported to CSCI by the home under Regulation 37; this will be a new Requirement and discussed later in the report. Six staff have yet to receive training on safeguarding vulnerable adults and this is an outstanding Requirement from the last inspection. Glebe House DS0000049209.V333106.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a pleasant and homely environment though more work needs to be done including refurbishing a bathroom which is currently unavailable to residents. EVIDENCE: A partial tour of the premises was carried out including visiting five resident’s bedrooms, the lounge and dining room, the laundry and the kitchen. Glebe House offers a pleasant environment for residents and the new manager is committed to a programme of refurbishment to continue to improve those areas needing redecoration. Four rooms have been fully refurbished since the last inspection and these were viewed and found to be very pleasant, clean and bright. Glebe House DS0000049209.V333106.R01.S.doc Version 5.2 Page 18 Five resident’s rooms were visited and found to be bright and cheerful, with matching bedcovers, curtains and laundry basket covers. These rooms were noted to be very personalised. Residents spoken to said they were happy with their rooms. Communal areas were also pleasant and bright. It was noted that all radiators had radiator covers fitted. An outstanding requirement from the last inspection has still not been met – this concerned a newly fitted bathroom which was not being used, as it did not meet the needs of residents. The manager said a second contractor is being asked for an opinion but in the meantime this bathroom is still not available to residents. This situation must be remedied in order to ensure that the home has sufficient bathing facilities for resident’s use. One room in the home had a slight odour and the manager was asked to review arrangements for keeping this area odour free. During the tour of the premises it became clear that further risk assessments were needed regarding an upstairs window which was wide open; very hot water in residents bedrooms; and a safety gate on the upstairs landing. These matters are covered under Standard 38 at the end of this report. Laundry facilities were generally clean and tidy and each resident had their own basket both in their rooms and in the laundry to ensure their own clothes were returned to them. There is one washing machine and one tumble dryer in the laundry, and the washing machine has a sluicing programme. Hand washing facilities are good throughout the home and the home was generally clean and odour free, with the exception of one small area mentioned above. The manager was asked to remove (or lock away), some cleaning materials in the laundry which is currently not locked when unattended. A risk assessment will need to be carried out regarding the laundry area. There is a problem with lime scale in local water and the laundry sink needed a thorough clean to remove the excessive build up. Glebe House DS0000049209.V333106.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff training and recruitment arrangements continue to improve but more work needs to be done on improving recruitment checks and on arranging more staff training. EVIDENCE: There is a staff rota in place and on the day of the inspection there were sufficient staff on duty to meet the needs of residents. There was a quiz in the lounge in the afternoon so care staff had time to be involved in activities for residents. Two domestic staff and two cooks are employed therefore care staff involvement in food preparation and cleaning is minimal. Standard 28 sets down that a minimum of 50 of care staff have NVQ Level 2 or above, excluding the manager. Currently only two senior care workers have this qualification (and are now studying for Level 3), though the manager said five others have been enrolled on the course – there are 14 staff in total. Two staff files were sampled and found to contain an application form, two written references, and an almost complete full employment history. Both staff had CRB certificate numbers on their files but, as the certificates were not there, there was no way of checking if either had been checked against the list Glebe House DS0000049209.V333106.R01.S.doc Version 5.2 Page 20 of people who are deemed unsuitable to work with vulnerable adults. The manager was asked to request that Surrey Rest Homes head office fax evidence to CSCI that both staff have been checked in this regard. Both files were for staff who had been taken on since July 2004 when the Regulations regarding a full employment history were implemented. However, their application forms only asked for ‘10 years’, not a full, employment history. The manager showed the inspector the new application form where the specified 10 years had been removed. More work needs to be done on recruitment and a Requirement will be made in this regard. There is a central list of staff training kept on the wall in the office and this shows the range of training staff have undertaken or need to begin. All staff have done manual handling training, and a number have done adult protection, health and safety and fire safety training. However, all staff must have training in these mandatory areas, and more staff need training in dementia care and awareness (only two staff have had this training), and mental ill-health, given that a number of residents have a diagnosed mental health condition. Glebe House DS0000049209.V333106.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Management arrangements are improving but the current manager is still not registered with CSCI. Some quality assurance systems are in place but more work is needed to fully involve residents. Supervision arrangements have improved since the last inspection. Safeguarding resident’s financial interests, and health and safety measures at this home also need more work. EVIDENCE: The current manager has been at Glebe House since December 06 and has previous experience in managing both residential and non-residential care services. She has a Certificate in Management Studies and stated she is waiting to receive the certificate for the Registered Manager’s Award which she completed in her last post. Glebe House DS0000049209.V333106.R01.S.doc Version 5.2 Page 22 The manager has not yet begun the registration process with CSCI and is in the process of applying for her CRB certificate. There are a number of shortfalls within the home which the manager stated she has little or no control over and therefore the inspector did not believe there were yet clear lines of accountability in the management structure; this needs to be addressed with the Provider. In addition, one of the registered person’s responsibilities is to complete and send Regulation 37 notices to CSCI when anything happens which affects the well being of residents, and there had been shortfalls in this respect. This was discussed with the manager who is now clear about when these should be sent to CSCI. The manager said that the home has a number of ways of seeking feedback from residents including regular residents meetings. The residents spoken to said that they were asked about menus and food for example, at these meetings. Dates for forthcoming meetings are displayed prominently in the hallway and relatives and friends were also invited. The manager also said that she will be starting questionnaires for residents. Other ways of monitoring the service include Regulation 26 visits on behalf of the provider, staff meetings and supervision, and reviews by social services for the clients they have placed in the home. The provider is also introducing a manager’s audit with daily, weekly and monthly checklists – this had arrived at the home but the work has not yet begun. The manager was not aware of an annual development plan for the home and a Requirement will be made that this, and other good practice arrangements listed under Standard 33 will be considered. Residents can keep small amounts of money in the safe and the manager had a written record of income and outgoings on these accounts for example for hairdressing and chiropody. Residents signed to say that they had received some money. Two resident’s cash envelopes were checked and found to contain the amount of money noted on the written record. The manager has purchased proper wallets as an alternative to envelopes to be used from now on. One resident was concerned about getting access to their money and gave permission for this to be taken up with their social services care manager to look into. Arrangements for staff supervision have improved and the manager has devised a schedule for the coming year – in most cases the sessions had happened according to the plan and all care staff were on course to receive the recommended six sessions per year. A number of measures are in place to monitor health and safety including having a health and safety policy and a number of regular safety checks are arranged for example regular firm alarm checks and weekly testing of the call bell system. There is also a health and safety audit checklist which is carried out by senior staff, though the records showed that this had not been done since December 2006; the manager stated this was because she was waiting for an up-dated template from head office. Glebe House DS0000049209.V333106.R01.S.doc Version 5.2 Page 23 However, there were a number of shortfalls on the day of the inspection including an upstairs window which was wide open, disinfectant and washing powders kept in the unlocked laundry, and a safety gate upstairs which needed to be risk assessed; these may potentially have put residents at risk. In addition none of the water outlets accessible to residents had thermostatic controls fitted and water in some outlets tested was extremely hot – exceeding the top of the scale (50C) on the thermometer provided by the manager; an Immediate Requirement was made in this regard. The manager said that the home had recently been tested and found to be clear of legionella, but the policies manual did not contain a policy on how the home would minimise the risks associated with legionella and they were asked to look into this and to get some specialist advice about putting into practice some preventative measures. It was also noted on staff training records that only half the staff have completed health and safety training. Glebe House DS0000049209.V333106.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 2 1 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 1 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 2 3 X 1 Glebe House DS0000049209.V333106.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 4(1)(2) Requirement The home’s Statement of Purpose and Service Users Guide must be updated to ensure that prospective residents have an informed choice whether they would like to live in this home. Outstanding from 03/12/06 Each resident must have a copy of their contract/ terms and conditions regarding their stay in the home. Outstanding from 10/10/06 Care plans must be revised so that they clearly state what help each resident needs, and how that support is to be given. Care plans should be reviewed on a monthly basis. Written guidance must be available to staff on the safe administration of ‘as required’ medication, especially for those residents with dementia. Advice must also be sought from the community pharmacist regarding the home’s policy and practices. DS0000049209.V333106.R01.S.doc Timescale for action 10/05/07 2. OP2 5A,B 10/05/07 3. OP7 15(1)(2) 10/06/07 4. OP9 13(2) 10/05/07 Glebe House Version 5.2 Page 26 5. OP10 12(4)(a) The privacy and dignity of residents must be promoted and in particular, not allow incontinence supplies to be stored on wardrobes or within view of visitors or other residents. The registered person must consult residents about a programme of activities, and make details of the programme available. Attention must also be paid to the activities suitable for residents with dementia. The home’s complaints procedure must be updated and appropriate to the needs of residents in order that any complaints can be dealt with promptly and efficiently. Each resident must be given a copy of the procedure in a format which they can understand. Outstanding from 03/12/06 A record must be kept of all complaints and the actions taken by the home. This record can then be used to supply a summary of complaints to the Commission in accordance with this Regulation. The registered person must ensure that all complaints are properly documented and fully investigated. Arrangements must be made, by training all staff, or by other measures to prevent residents from being harmed or suffering abuse or being placed at risk of harm or abuse. Partially met from 03/12/06 DS0000049209.V333106.R01.S.doc 10/05/07 6. OP12 16(2)(n) 10/05/07 7. OP16 22(1)(2) (5) 10/05/07 8. OP16 22(3)(8) 10/05/07 9. OP18 13(6) 10/05/07 Glebe House Version 5.2 Page 27 The in-house policy on this subject must be reviewed to ensure it is in line with the accepted Surrey local procedures. 10. OP21 23(2)(j) The newly fitted bathroom must be appropriately assessed and re designed in order that the home has sufficient bathing facilities for the residents. Outstanding from 03/12/06 All areas of the home must be free from offensive odours as discussed with the manager. All persons working in the care home must have adequate pre employment checks as set out in Schedule 2 of the Care Homes Regulations 2001 (as amended). Partially met from 03/10/06 All staff must receive training for the work they are to perform for example in first aid, fire safety, health and safety, dementia care and mental ill-health, to ensure the safety and well being of residents. Partially met from 03/12/06 The registered person must introduce an adequate quality assurance system having regard to the items set out under this Standard. Risk assessments must be completed and updated in order to ensure that all activities in which residents participate are so far as possible free from avoidable risks. Particular attention must be paid to: the safety gate on the landing, the laundry area, and the window DS0000049209.V333106.R01.S.doc 10/06/07 11. OP26 16(2)(k) 10/05/07 12. OP29 19 Schedule 2 10/05/07 13. OP30 18(1)(c ) (i) 10/06/07 14. OP33 24(1) 10/06/07 15. OP38 13(4)(a) (b)(c) 10/05/07 Glebe House Version 5.2 Page 28 restrictor which was broken. 16. OP38 37(1) Notice must be given to the Commission of any serious illness or injury to a resident, or other event, which adversely affects their well being, as set down in this Regulation. Specialist advice must be sought to devise and implement arrangements for maintaining safe water systems in the home, including the prevention of legionella. 10/05/07 17. OP38 13(4)(a) (b)(c) 10/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP15 Good Practice Recommendations The registered person should ensure that residents have a choice of main meal each day as discussed with the manager during the inspection. Glebe House DS0000049209.V333106.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Glebe House DS0000049209.V333106.R01.S.doc Version 5.2 Page 30 - 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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