Inspection on 11/07/06 for Glebe House

This inspection was carried out on 11th July 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 House 14/12/05

Glebe House 26/05/05

Glebe House 14/09/04

Glebe House 17/05/04

Glebe House 19/02/04

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

CARE HOMES FOR OLDER PEOPLE Glebe House 8 Mill Street Kidlington Oxfordshire OX5 2EF Lead Inspector Delia Styles Unannounced Inspection 11th July 2006 10:45 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 DS0000013155.V303133.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 DS0000013155.V303133.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glebe House Address 8 Mill Street Kidlington Oxfordshire OX5 2EF 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) 01865 841859 01865 841194 manager.glebehouse@osjctoxon.co.uk The Orders Of St John Care Trust Elaine Ratcliffe Care Home 40 Category(ies) of Past or present alcohol dependence over 65 registration, with number years of age (3), Dementia - over 65 years of of places age (18), Learning disability over 65 years of age (3), Old age, not falling within any other category (40), Physical disability over 65 years of age (10) Glebe House DS0000013155.V303133.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of persons that may be accommodated at any one time must not exceed 40. 14th December 2005 Date of last inspection Brief Description of the Service: Glebe House is a purpose built care home providing personal care and accommodation for 40 older people. The single storey building provides single rooms with shared bathroom facilities and the care home is divided into five wings. Each wing has a small lounge/dining area and there is also a large communal dining area. The home is set in its own grounds within a quiet residential area of Kidlington, although local facilities are within walking distance, and the home has transport available to enable the residents to access the wider community. The home is very much part of life in the local community of Kidlington, and the majority of residents have family or other links with the area. Glebe House DS0000013155.V303133.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. A key inspection looks at the National Minimum Standards for the service considered most important that should be assessed at least once in every 12 months. The inspector arrived at the home at 10.45 and was in the service for 5¼ hours. It was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s owner or manager, and any information that CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the service and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. A total of 7 residents’ comment cards – ‘Have Your Say About Glebe House’ – were received. Six of the 7 questionnaires were completed with the help of residents’ partners or relatives. A total of 10 comment cards were received from GPs from the three surgeries that provide medical care to the residents. One Health care professional who visits the home returned a questionnaire, and one relative. The inspector looked at how well the service was meeting the standards set by the government and has in this report made judgements about the standard of the service. The inspector toured the building, spoke to the manager, a care leader and several staff members and residents during the day. Conversations with 4 visitors about the home also added to the inspector’s information about the home and the standard of care for residents. The inspector joined a group of residents for lunch. A sample of residents’ care plans and records, staff recruitment and induction records and other records about the maintenance and running of the home were examined. What the service does well: The home is clean, bright and well maintained so that residents have attractive and comfortable rooms and shared lounges and sitting rooms, and well maintained and attractive gardens to enjoy outside. Residents and their families are appreciative of the way in which staff keep the home - one person wrote: ‘Glebe is spotless. They take pride in their work and are a very happy bunch. The garden and dining room are a credit to them all’. Glebe House DS0000013155.V303133.R01.S.doc Version 5.2 Page 6 Residents and their relatives are very happy with the care and attention given by the staff. Comments were made such as: ‘we are very happy with the care given and have admiration for the patience of all staff members’; ‘I have no complaints at all with the care and attention which my [relative] receives’. The home has a well-organised plan of activities that is related to the wishes and abilities of the residents. Those residents spoken to were pleased with the amount of activities that were currently on offer. The food was sampled and it was tasty and nutritious. The home has good management and organisational procedures, and runs smoothly to the benefit of the residents. What has improved since the last inspection? What they could do better: There were a few recommendations made at the inspection. Residents’ care plans, though improved, could be better if more detailed instructions about the care to be given by staff is included, especially for residents who have dementia, and about the social and recreational needs of residents. More information should be included about whether the care provided has been successful or needs a different approach. An assessment of residents’ nutritional needs should be done on admission and regularly thereafter, using a recognised, evidence-based method, so that any residents at risk from poor diet will be identified and action taken to improve their nutrition and health. The home should ensure that the drug fridge thermometer is accurate so that medicines that need cool storage are kept within the recommended temperature range so that the medicines’ effectiveness is not impaired. Glebe House DS0000013155.V303133.R01.S.doc Version 5.2 Page 7 Staff recruitment files should be checked and updated to make sure they contain all the required information about people employed in the home, to safeguard residents from staff who may be unsuitable to care for them. The home’s fire safety log should include up to date information about the fire risk assessments in the home and actions to be taken by staff to reduce the risk of fire to protect residents and staff. 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 House DS0000013155.V303133.R01.S.doc Version 5.2 Page 8 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 DS0000013155.V303133.R01.S.doc Version 5.2 Page 9 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using this service have good information about the home so that they and their representatives can make an informed decision about whether the home is right for them. Personalised assessment of care needs means that prospective residents’ diverse needs are identified and planned for before they move in to the home. Standard 6 is not applicable: this home does not provide intermediate care. EVIDENCE: All of the 7 residents who completed comment cards said they had received enough information about the home before they moved in and 6 said that they had a contract (one person could not remember receiving one). Four residents’ care records were looked at. There was evidence that assessment of their care needs had taken place before they were admitted and Glebe House DS0000013155.V303133.R01.S.doc Version 5.2 Page 10 that care managers and other professional carers, and relatives had contributed to information about the resident’s usual care. Prospective residents are encouraged to visit Glebe House for a day’s assessment with family or representatives. Comment cards indicated that some residents had had family members who were former residents in the home, or who had got to know the home and staff during respite stays, so this helped them to decide that the home would suit their needs. Glebe House DS0000013155.V303133.R01.S.doc Version 5.2 Page 11 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health needs of residents are well met with evidence of good multi disciplinary working taking place on a regular basis. The systems for the administration are good with clear and comprehensive arrangements being in place to safely meet residents’ medication needs. Personal support in the home is offered in a way that promotes residents’ privacy, dignity and independence. EVIDENCE: The care plans and records of 4 residents were looked at. These showed that further improvements have been made to record keeping by staff. However, the records still need to have more detailed instructions for care staff about the ways in which they should provide help and care to residents, especially for those with dementia, and about their social and recreational care. The doctors and health care professional who completed comment cards were positive about the standard of care to residents overall. One doctor commented that the care had improved over recent months, with staff showing Glebe House DS0000013155.V303133.R01.S.doc Version 5.2 Page 12 better understanding of residents’ health care needs. Six of the seven residents said in the comment cards that they ‘always’ received the medical support they need, with one stating this was ‘usually’ the case. The inspector looked at the medication storage, records of receipt and disposal of medicines and the Medication Administration Records (MAR). The records were up to date and correctly completed. One doctor had commented that the system used by the home - where the residents’ prescribed medicines are put into individual cassette boxes by the pharmacist each week - makes it difficult for changes to be made to the residents’ prescriptions. This was discussed with the manager and care leader and the inspector suggests that this should be raised with the doctors and pharmacist to see if the system could be improved. There was evidence that all staff responsible for giving out residents’ medicines have training in the safe handling and administration of medicines. The drug fridge temperature is monitored by staff, using the integral fridge thermometer. However, the temperature displayed and recorded (4-5°C was lower than the reading that the inspector made using a calibrated probe (7.9°C). This indicates that there is a risk that the temperature of the fridge may be higher than the recommended maximum of 8°C at times. The inspector recommends that the home double-check the temperature using a separate fridge thermometer. If there is a discrepancy, contact the fridge manufacturer for advice to adjust the temperature so that the fridge contents are kept between 2 and 8°C and the medicines needing cool storage are not adversely affected. Observation of interactions between staff and residents showed that residents feel comfortable and relaxed in the home and able to influence their care and ‘do their own thing’ as far as possible. From the evidence seen by the inspector and comments received, the inspector considers that the home would be able to provide a service to meet the needs of individuals of various religious, racial or cultural needs. Glebe House DS0000013155.V303133.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have a good range of activities and social opportunities available that suit their preferences. The meals in this home are good, offering choice and variety to residents. EVIDENCE: The home employs a part-time activities organiser: she was on holiday at the time of the inspection. Residents who completed questionnaires were mostly satisfied that the activities arranged by the home were ones that they wanted to take part in. Posters on display in the corridors showed the programme of planned events and activities; these include Bingo, quizzes, crafts, flower arranging, exercises, bowls, skittles and sing-a-longs. Residents and staff were looking forward to a summer barbeque, to which family and friends were invited. The day after the inspection, the manager was taking 6 residents to the theatre in Oxford. The home has its own minibus for taking small groups out to places of interest and shopping trips. A ‘Pat dog’ is a regular and appreciated visitor to the home. Residents commented that they like to ‘join in with the old songs’ when visiting entertainers come to the home. Glebe House DS0000013155.V303133.R01.S.doc Version 5.2 Page 14 The manager is sensitive to the special needs of residents with dementia and has arranged for a staff member to be available to talk with and assist with activities in the early evening. Situated in a large village, residents have access to local shops, garden centre, pubs, churches and a library. On the day of the inspection residents were having their hair done in a purpose built hairdressing room. The inspector joined a group of residents in the dining room for lunch. The dining room is bright and spacious with residents seated at tables for a maximum of four. Residents who prefer to can take their meals in their own room or the smaller lounge rooms on each unit. Residents all expressed complete satisfaction with the food and choices of food. Lunch was unhurried with staff helping those less able to enjoy their meal. Of the 6 residents who answered the question about meals in the home, 2 said they ‘always’ like the meals (one added that the meals are ‘excellent’) and 4 stated that they ‘usually’ like the meals. The home has no restrictions on visiting, and several visitors were seen in the home during the day. The inspector had conversations with four visitors who all said that they were made welcome by the staff and how they appreciated the care and attention their relatives received in the home. Glebe House DS0000013155.V303133.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents feel safe and listened to and they and their representatives know how to raise any concerns. EVIDENCE: The home’s complaints policy was clearly displayed on the notice board. Residents’ comment cards showed that they, or their relative on their behalf, know how to make a complaint. One relative’s comment card stated that they were not aware of how to make a complaint, but had done so. Discussion with the manager showed that a complaint has been made to the home since the last inspection. The inspector judges that the provider has met the regulations in relation to complaints. However, the home’s complaint record did not show the response to the complainant (a relative of a resident) that had been made by a senior manager on behalf of the OSJCT. The complaints log should clearly show the dates and responses and outcomes of any complaints investigation undertaken by the home and whether the issues have been satisfactorily resolved. Staff receive training about safeguarding vulnerable adults in their care at induction and with regular updates. All new staff receive a copy of the local Adult Protection Codes of Conduct, and information about how to report suspected abuse. Glebe House DS0000013155.V303133.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment both in and outside this home is good, providing residents with an attractive and homely place to live. EVIDENCE: The inspector walked around the home: all areas of the home were clean, tidy and fresh smelling. Residents and visitors were particularly complimentary about the standard of cleanliness and the upkeep of the home and gardens. One wrote: ‘Glebe is spotless, they take pride in their work and are a very happy bunch. The gardens and dining room are a credit to them all’; another wrote ‘This is a hard job, very well done’. The home has a programme of redecoration and upgrading of the premises: several rooms and the dining room have been redecorated, 2 bathrooms retiled and 2 toilets replaced since the last inspection. Window and doorframes Glebe House DS0000013155.V303133.R01.S.doc Version 5.2 Page 17 were being repainted on the day of this inspection. New armchairs have been purchased for lounge areas. Outside, the garden and grounds are very well maintained and attractive, with lawns, flower borders and container plants and a rose garden. Each unit overlooks a small patio area and garden, with garden seating and shades, so that residents can enjoy the use of the grounds fully. A fishpond is another attraction in the patio garden next to the entrance to the rear garden. Staff have disposable protective aprons and gloves available. The laundry room is well equipped and there is a member of staff who is employed to deal with the laundry work for the home. Glebe House DS0000013155.V303133.R01.S.doc Version 5.2 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, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has robust training and supervision systems in place for staff and progress has been made in addressing staffing shortages, so that residents receive a consistent and good standard of care. EVIDENCE: The inspector looked at copies of the duty rota and discussed staffing levels with the manager. Staffing numbers have improved recently and the home has greatly reduced the need to use agency staff in recent months. Analysis of the duty rota, and checks of the numbers of staff working on the day of the inspection, showed that the number and skill mix of staff met the needs of the residents. Residents’ comment cards showed that 5 felt that there are ‘always’ staff available when they need them and 2 stated this is ‘usually’ the case. One added that ‘at weekends it can be rather busy for staff’. One of the 10 GPs wrote that there is not always a senior member of staff to confer with and a relative’s comment card raised concerns about staff availability at certain times of the day. The manager should discuss staff deployment and how visitors can be assured about staff availability when they come into the home, during staff, residents and relatives meetings. Glebe House DS0000013155.V303133.R01.S.doc Version 5.2 Page 19 The manager said that there are plans to alter the pattern of night duty, discontinuing having two staff and a third ‘sleep-in’ care leader overnight, and having all ‘waking’ staff. Four staff members’ files were looked at. These showed that the recruitment process and necessary police checks had been undertaken for the sample seen and it was clear the manager operates a thorough procedure ensuring the protection of the residents. One staff member’s file did not have a photograph or evidence of completed induction training. The manager said she would make sure this employee’s file was updated. The home has a commitment to staff training and records show that staff have regular mandatory health and safety training and updates. The percentage of staff who have achieved National Vocational Qualification at Level 2 or above (20 ) is below that expected by the Commission - 50 by 2005 - but more staff are enrolled to undertake training and the target should be reached soon. Glebe House DS0000013155.V303133.R01.S.doc Version 5.2 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): 31, 33, 35, 36 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The system for involving residents and their representatives about the way in which the home is run, and the care and facilities, is good and show that residents’ opinions are both sought and acted upon. The health, safety and wellbeing of residents and staff are protected by the home’s policies and procedures. EVIDENCE: Mrs Ratcliffe successfully completed the process for registration with the Commission and has managed the home for 18 months. She has completed the Registered Manager Award - a formal qualification for her role. Residents and visitors were complimentary about the home and the way in which it is managed. Glebe House DS0000013155.V303133.R01.S.doc Version 5.2 Page 21 There are regular staff, and residents meetings and the manager has an ‘open door’ policy, so that residents and staff are able to talk to her freely during the day. The manager also undertakes ‘spot checks’ of the home to ensure that things are running smoothly at any time of the day or night. The OSJCT has its own quality assurance system and residents and their families are invited to complete questionnaires about their opinions of the home and the service it provides. The home receives an annual report about the standard it has achieved and the manager and staff work to improve any shortfalls. The inspector saw a copy of the last quality report for the home: the current report is due to be published. The home is also visited ‘unannounced’ by a senior manager of the OSJCT every month as required under the Care Standards Act (Regulation 26, Provider’s visits). One such visit had recently been made at night (16/06/06) and there was a report that the inspector read. One of the home’s administrative assistants described the home’s system for safekeeping and maintaining records of residents’ personal allowances and expenditure on additional services such as chiropody and hairdressing that are not included in the fees. A sample of residents’ personal accounts was seen. The same accounting and auditing system is used in all the OSJCT homes and ensures that residents’ personal allowances and small amounts of cash are safely managed and there are receipts and records for all transactions. The inspector found that the home has good management and organisational procedures in place. The manager has implemented formal supervision for all staff that ensures that all areas of their practice are monitored and training put in place when necessary. The home’s fire safety record was checked and was up to date, with evidence of regular fire safety training for staff and maintenance of the fire fighting equipment and alarms being routinely undertaken. The fire risk assessments for the home were not up to date according to the logbook. The manager said that these had been undertaken by the home’s designated fire marshal and would ensure that the fire record included the latest assessments. In October 2006, new fire safety regulations will come into force and local fire safety and protection officers will require that care homes undertake and update fire risk assessments to protect residents and staff from fire. Glebe House DS0000013155.V303133.R01.S.doc Version 5.2 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 X X 3 X X N/A 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 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Glebe House DS0000013155.V303133.R01.S.doc Version 5.2 Page 23 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations * It is recommended that further monitoring take place to ensure consistency and quality of care records. * Care plans should be sufficiently detailed to show the action that needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service users are met. Nutritional screening should be undertaken for all residents on admission and subsequently on a periodic basis, using an evidence-based tool such as MUST (Malnutrition Universal Screening Tool). Check that the drug fridge thermostat/display is accurate and that the contents are held within the recommended safe temperature range 2-8°C. Ensure that accurate details of investigation and responses to complaints are entered in the home’s complaints record. DS0000013155.V303133.R01.S.doc Version 5.2 Page 24 2. OP8 3. 4. OP9 OP16 Glebe House 5. 6. OP29 OP38 Ensure that all the required information about staff employed in the home is recorded. Update the home’s fire risk assessment and include these in the fire safety logbook. Glebe House DS0000013155.V303133.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South, Cowley Oxford OX4 2SU 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 House DS0000013155.V303133.R01.S.doc Version 5.2 Page 26 - 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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