Inspection on 28/09/07 for Glebe House

This inspection was carried out on 28th September 2007.

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 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 10/04/07

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 Staines Middlesex TW18 1SB Lead Inspector Helen Dickens Unannounced Inspection 28th September 2007 09:30 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 House DS0000049209.V344712.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.V344712.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glebe House Address The Broadway Laleham Staines Middlesex TW18 1SB 01784 465273 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) helen@surreyresthomesltd.co.uk 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.V344712.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. 10th April 2007 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.V344712.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 7.5 hours. The inspection was carried out by Helen Dickens, Regulation Inspector. The acting manager and service manager represented the establishment. A partial tour of the premises took place. The inspector spoke to four residents on a one-to-one basis and talked briefly with many of the remaining residents during lunch. One relative was also interviewed. Thirteen questionnaires returned to CSCI were also used in writing this report. Three resident’s care plans and a number of other documents and files, including three staff files, as well as risk assessments and maintenance records, were examined during the day. The Annual Quality Assurance Assessment completed by the home prior to the inspection has also been used in writing this report. The Commission for Social Care Inspection would like to thank the residents, relatives, acting manager, service manager and staff for their hospitality, assistance and co-operation with this inspection. What the service does well: Glebe House offers a homely environment for residents and visitors are welcomed. A number of very positive comments were received both in questionnaires, and during the inspection. One care manager said the home ‘welcomes support from the social care team.’ Relatives were also complimentary, one saying ‘Staff are always attentive and helpful.’ Another wrote that ‘They regard the care home as literally my mothers home – the surroundings are very attractive – and my mother likes her room and always said how much she likes the food. Staff give kindness and friendship – I have been amazed at times by their patience.’ One resident who made a number of other positive comments, also noted that ‘I get clean clothes every day.’ The food received praise and there were no complaints on this subject from residents/relatives. The home offers a pleasant dining experience and the main meal of the day is tailored to meet individual resident’s preferences. Glebe House DS0000049209.V344712.R01.S.doc Version 5.2 Page 6 The home has an equal opportunities policy in place. They employ some workers from overseas and from ethnic backgrounds other than white British. Notes are kept from interviews to demonstrate fairness in recruitment. The cultural and religious needs of residents are recorded on their care plans and the home supports those residents who wish to follow a particular faith, including having monthly religious services within the home. Information for residents, for example the complaints procedures and care plans, are in plain English accessible formats and readily available for them in their bedrooms. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Glebe House DS0000049209.V344712.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.V344712.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): 3 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. No service user moves into the home without having their needs assessed and assured these will be met. EVIDENCE: There is an admissions policy in place and the acting manager said residents had the opportunity to make visits to the home prior to moving in; this might be to come to Glebe House for a meal, for a whole day, or to stay overnight. Three resident’s files were sampled and found to contain the necessary documentation to ensure residents were not admitted without having their needs properly assessed. Those residents admitted through care management also had a community care assessment on file. Glebe House DS0000049209.V344712.R01.S.doc Version 5.2 Page 9 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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care planning arrangements have improved and now reflect resident’s care needs and how they would like to be supported with those needs. Healthcare arrangements at this home ensure resident’s health needs are met. The home’s policies and procedures on the administration of medication protect residents. People who live at Glebe House are treated with respect but more work needs to be done to promote their privacy and dignity. EVIDENCE: Three resident’s care plans were sampled and found to have improved considerably since the previous inspection. They are now presented in a very clear format, documenting residents needs as well as how each resident would like support to be given to them. The care plans are signed in agreement by a resident and/or their relative where appropriate. Residents now have a copy of their own care plan kept inside their wardrobe door. Care plans were being reviewed regularly every month, no negative issues were raised by residents in Glebe House DS0000049209.V344712.R01.S.doc Version 5.2 Page 10 relation to their care needs being met. A very elderly resident at this home, who has been there for 17 years, gave their permission to be quoted and said one of the reasons they had lived to such a great age was the care and attention they had received over the years at Glebe House. Resident’s health care needs are documented on their files and visits by community health professionals are noted. There is a chiropodist, community optical service and community dental service visiting the home, in addition to care managers, district nurses and the local GPs. Resident’s were regularly weighed and any discrepancies discussed with the relevant healthcare professionals. Some very positive comments were received from healthcare professionals who deal with this home including references to the ‘good working relationship’ and ‘nice homely atmosphere’ at Glebe House. One stated that ‘Instructions are carried out to the letter – residents likes and dislikes taken into account – and I look forward to visiting.’ One resident spoken to asked the inspector about seeing a healthcare professional and the acting manager said she would arrange this herself. One comment from a healthcare professional concerned communication at this home and this was discussed with the acting manager and service manager. Medication administration is well organised at this home and the Requirement from the previous inspection to ensure written guidance is available for staff on the administration of ‘as required’ medication is now in place. One medication administration session was observed. A member of staff was being supervised as she was undertaking training in the administration of medication. Records are well kept with no unexplained gaps and residents were heard to be given choices about whether or not they wanted their ‘as required’ medication. The medication cabinets were checked and found to be clean and tidy and organised in such a way as to minimise any errors, for example having a separate night medication cabinet. This home receive their medication advice and regular pharmacy inspections from a local pharmacy. There were no negative issues raised in relation to privacy, dignity and respect from residents themselves, and a number of outside professionals and relatives commented that the home performed well on this. One noted that ‘Resident’s choice is well respected’ and another that ‘Dignity and privacy are given priority.’ The Requirement from the previous inspection regarding keeping individual resident’s incontinence supplies out of sight has been met. On the day of the inspection it was noted that resident’s care plans were not locked away. The acting manager said she would be moving them to a lockable cupboard as part of the reorganisation in the office. It was also noted that some areas of the home were not odour free. This does not promote residents dignity. One corridor and at least two residents bedrooms needed attention in this regard and this was discussed with the acting manager and service manager. Glebe House DS0000049209.V344712.R01.S.doc Version 5.2 Page 11 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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents have opportunities for social and community activity, and are encouraged to exercise choice and control over their lives. Meals and mealtimes at this home offer a pleasant experience for residents. EVIDENCE: Improvements have been made in regard to leisure and social activities since the last inspection. There is now a published programme with at least one activity each day. Activities now include carpet bowls, exercises, bingo, board games, painting, and sing-a-longs. There is an activities folder where a note is kept of who joins in with the various activities so that staff are aware of which residents may need more individualised social activity, for example one resident has ‘talking books’. Care plans identify which activities residents enjoy. There were no negative comments from residents in relation to activities during the inspection, or on the questionnaires returned to CSCI. One relative who made a number of complimentary remarks about the home in general, also noted ‘That staff are good at providing activities and stimulation.’ Glebe House DS0000049209.V344712.R01.S.doc Version 5.2 Page 12 The home encourages contact with the local community. Residents use local health facilities such as the health centre and have local health professionals come into Glebe House as mentioned earlier under healthcare. Some residents go to church, and there is a monthly religious service held at the home. Some residents belong to the local Derby and Joan Club and were going out to this on the afternoon of the inspection. One resident was overheard to say they needed to take raffle prizes with them, and the acting manager immediately brought them packets of biscuits and other items to take for the raffle. The local ‘pat a pet’ dogs call at the home, and there is also a local lady who leads a sing-a-long, which the acting manager said residents enjoy. There is a policy on visiting the home, which is more or less open visiting, and the home has now started holding relatives meetings to try and encourage as much involvement from relatives as possible. Residents have opportunities to exercise choice and control and throughout the day residents were seen to be given choices or have their opinion taken into account. The lunchtime arrangements provide the best example where virtually every one spoken to knew what was on the main menu in advance and several told the inspector that they would be having a variation on this. Some had fish, chips and peas, others sausage, chips and beans, one preferred egg and chips. Another resident who chose to eat in her room showed the inspector that the cook had remembered to put her tomato sauce on the side, which she liked with every meal. Other examples included residents being asked if they wanted their ‘as required’ medication, and regular resident’s meetings, the notes of which were put in the display box in the hallway for all to see. Residents now also have a copy of the home’s complaints procedure on the back of their bedroom door. Mealtimes at Glebe House appeared pleasant. The dining room has wooden panelling and individual tables are set with linen tablecloths. The inspector visited the dining room at breakfast and lunchtime and spoke with a few residents at each table. There were no complaints about the food. Resident’s likes and dislikes were known to the cook who tailored set main meals to individual requirements. Residents can eat in the dining room or in their own rooms, and though most residents were managing independently with their lunch, there were staff on hand should assistance be required. Resident’s are weighed regularly and weight loss or weight gain is monitored. There is a printed menu and as mentioned earlier, all residents spoken to knew exactly what they were having. It was suggested that the other choices available each day, for example an omelette, baked potato or fish, be added to the bottom of the printed menu to ensure all residents realise there is an alternative to the main meal. Glebe House DS0000049209.V344712.R01.S.doc Version 5.2 Page 13 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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents can be confident their complaints would be listened to, and they are protected from abuse. EVIDENCE: The home have a copy of their complaints procedure in their policies manual, in the service user guide in the hallway, on the notice board in the hallway, and on the back of the door in every resident’s bedroom. Those residents who returned questionnaires or who were spoken to on the day, knew how to make a complaint if they needed to, and several referred the inspector to the copy on the back of their door. No complaints have been received at CSCI about this home since the last inspection. The home has received two complaints, and these have been dealt with according to their procedures. The complaints manual contains written guidance for staff about how to record complaints. The home has reviewed its policy on safeguarding (protection of vulnerable adults) since the last inspection and the policy now fits well with the local procedures. The remaining staff have also had training on this subject and, though there is currently no up-to-date central training record, the certificates had been kept separately and the acting manager counted them to show that Glebe House DS0000049209.V344712.R01.S.doc Version 5.2 Page 14 all staff are now trained. Arrangements are in place to safeguard resident’s finances, and these are described under Standard 35. The Requirements made in relation to these Standards at the last inspection have now been met. Glebe House DS0000049209.V344712.R01.S.doc Version 5.2 Page 15 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 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Glebe House provides a homely environment for residents but more work needs to be done to complete the current programme of refurbishment. Whilst laundry facilities are satisfactory, the floor is not impermeable and therefore difficult to keep clean, and there are unpleasant odours in some parts of this home. EVIDENCE: Glebe House provides a homely environment for residents and there is currently a refurbishment programme underway. Decorators were in the home on the day of the inspection. The lounge has already been completed, and they are now working on the hallways and the stairs. New carpets have been ordered for the lounge, dining room and hallway. The acting manager said new chairs had been ordered for the lounge as well as other furniture such as a TV Glebe House DS0000049209.V344712.R01.S.doc Version 5.2 Page 16 table and bookcase. There is now a large flatscreen TV on the wall and the acting manager said this was popular with residents. As already mentioned, the dining room also offers a comfortable environment for residents to enjoy their meals. The grounds and garden are nicely kept and offer a pleasant outdoor space. An additional bathroom has been fitted out but needs further work before residents can use it; when it is completed it will provide an extra and very well furnished facility. Further work needs to be done to complete the current refurbishment programme, and in particular the decorating, which is unavoidably disruptive for staff and residents alike. Workmen need to be properly supervised and the safety of residents given priority. Loose dust sheets, tools and other items such as the vacuum cleaner, were lying around, and someone had propped open a fire door with a fire extinguisher. The acting manager remedied this immediately. Whilst the bedrooms visited were generally clean and well furnished, two rooms and one corridor had an unpleasant odour. This was discussed with the acting manager and needs further urgent attention. The laundry was clean and tidy and is now kept locked. There is a risk assessment which has been copied and is posted on the wall so that all staff are aware of their responsibilities. The appliances, one washer which also has a sluice programme, and one drier, are commercial models, and the acting manager said that they are usually repaired quite quickly if they breakdown – otherwise laundry would be taken to one of the other Surrey Rest Homes. The floor covering in this room is not impermeable and therefore it is difficult to keep it clean – the acting manager and service manager were informed that this will need to be reviewed. Glebe House DS0000049209.V344712.R01.S.doc Version 5.2 Page 17 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 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s needs are being met by the current staff, but more work must be done on recruitment and training to ensure they are in safe at all times. EVIDENCE: On the day of the inspection resident’s needs were being met by the number of staff on duty and when extra assistance was needed, for example at lunchtime, it was available. There is a rota in place and there were no negative comments received from residents or relatives about staff. There were however many positive comments on questionnaires, and during the inspection about staff. These comments, taken from one questionnaire, sum up the sentiments of the remarks made about staff: - ‘You couldn’t wish for a more caring staff – nothing is too much trouble. My relative is very happy at Glebe House. Residents are very happy and are looked after very well. No improvements are necessary.’ Standard 28 recommends that a minimum of 50 of care staff are qualified to NVQ Level 2 or above by the end of 2005. Glebe House does not currently have this percentage, but in addition to the two staff who already have this qualification, 7 others (out of 17 care staff) are registered on the course, and the acting manager said some of these have nearly finished. Glebe House DS0000049209.V344712.R01.S.doc Version 5.2 Page 18 Recruitment arrangements continue to improve and files are now in better order. Three staff files were checked and found to have had the required CRB (Criminal Records Bureau) and POVA (Protection of Vulnerable Adults) checks – however there were still shortfalls regarding taking a full employment history; someone had a reference missing; and another had a reference which hadn’t been signed. The Requirement on recruitment will be repeated. Glebe House have made some progress with regard to training and in particular all staff have now had training in the protection of vulnerable adults. It was noted that there was a reminder to staff about the importance of keeping up with the mandatory training courses and a list of current courses on offer was displayed in the office. DVDs have been purchased on a variety of subjects, which staff watch and then carry out a test afterwards to check how well they have understood the material. However, the staff training file was not available on the day of the inspection; the acting manager said this could not be found. Nor is there an up-to-date central list of staff training showing which staff have done which training, or a record of when refresher courses are due. More work needs to be done on this and the Requirement made at the last inspection will be repeated. One staff file was sampled for a new member of staff and they were found to be following an induction course which fitted with the Common Induction Standards. There was good progress with this but the acting manager was reminded that each area needs to be signed off. Glebe House DS0000049209.V344712.R01.S.doc Version 5.2 Page 19 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 and 38 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Management arrangements are currently under review and an acting manager has been appointed. The arrangements for quality assurance have improved though more work needs to be done to ensure any shortfalls identified are addressed. Resident’s financial interests are safeguarded. More work must be done to promote the health, safety and welfare of service users. Glebe House DS0000049209.V344712.R01.S.doc Version 5.2 Page 20 EVIDENCE: Several weeks before this inspection, the registered manager informed CSCI that she had resigned. The service manager then wrote to CSCI stating that an acting manager had been appointed in the short term. Though satisfactory interim arrangements have been put in place, this still leaves the home without a registered manager again, after a very short time, and this matter needs to be addressed by Surrey Rest Homes. Quality assurance systems have improved since the last inspection. In addition to the usual resident’s meetings, the home has also started having meetings for relatives and these will take place quarterly. There are questionnaires sent out to residents and relatives and the service manager is considering how he will collate and publish the outcomes from these questionnaires. A new quality assurance folder has been set up and there is a plan on the office wall noting the timetable when the quality assurance activities need to take place. There is an annual development plan in place, and the service manager has reviewed the way Regulation 26 visits are carried out. He now takes an in-depth look at 2 or 3 National Minimum Standards on each monthly visit and makes ‘requirements’ about what needs to be done. However, though the systems for identifying shortfalls have improved, the actions needed to rectify these are not always following. For example, one visit identified unpleasant odours within the home and yet these were still present on the day of the inspection. The need for thermostats was identified by the service manager two months before the April 07 inspection where it was identified as a shortfall. Arrangements for assisting service users with their finances were the same as at the inspection in April and therefore just two cashbooks were sampled, and found to tally with the amount of cash kept in each resident’s wallet. A number of measures are in place for monitoring health and safety within the home including having a health and safety policy, and carrying out regular checks, for example weekly testing of the call bell system. Some of the shortfalls identified at the last inspection have been addressed including setting up systems to prevent Legionella, locking the laundry and having a risk assessment in place, and removing a stair gate which was no longer in use. Thermostats have been fitted to water outlets accessible to residents, to prevent scalding. However, though the new the thermostats are in place (to control water temperatures to around 43 degrees) and there has been regular monitoring of water temperatures, for at least four weeks a number of these had been noted as too hot to record (the thermometer only records up to 50 degrees) yet no action was taken to safeguard residents. The service manager arranged for a plumber to attend immediately and this was remedied. Glebe House DS0000049209.V344712.R01.S.doc Version 5.2 Page 21 The upstairs bedroom window, which was found to be wide open at the last inspection was also found to be wide open again at this inspection. This was remedied immediately by the acting manager who said she would investigate who was removing the restrictor and therefore potentially placing residents at risk. A review needs to be carried out to prevent this ever happening again. There was also some worn tread on one stair carpet and in one hallway the carpet had completely worn through, causing a trip hazard. The decorators in the home needed to be observed more closely to prevent undue hazards to residents, including using a fire extinguisher to wedge a fire door open. Glebe House DS0000049209.V344712.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 3 8 3 9 3 10 2 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 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Glebe House DS0000049209.V344712.R01.S.doc Version 5.2 Page 23 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 OP10 Regulation 12(4)(a) Requirement In order to protect the privacy of residents, arrangements must be made to keep resident’s files securely. All areas of the home must be free from offensive odours. Unmet from 10/05/07. The laundry floor is unsuitable and arrangements need to be reviewed to ensure an easily washable and impermeable floor covering is in place. 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 and 10/05/07. 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 and 10/06/07 A review must be carried out to DS0000049209.V344712.R01.S.doc Timescale for action 05/10/07 2. 3. OP26 OP26 16(2)(k) 23(2)(b) (d) 05/10/07 28/12/07 4. OP29 19 Schedule 2 28/11/07 5. OP30 18(1)(c ) (i) 28/12/07 6. OP38 13(4)(a) 05/10/07 Page 24 Glebe House Version 5.2 (b)(c) ensure the health and safety shortfalls identified during this inspection are rectified and thereafter monitored to prevent recurrence. This must include: • Water temperatures • The upstairs window restrictor which has been left unlocked • Worn stair carpet and the hall carpet posing a trip hazard • The safety of residents whilst the home is being refurbished 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.V344712.R01.S.doc Version 5.2 Page 25 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.V344712.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. 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