Inspection on 03/10/06 for Glebe House

This inspection was carried out on 3rd October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 22/09/08

Glebe House 23/06/08

Glebe House 28/09/07

Glebe House 10/04/07

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 Glebe House The Broadway Laleham Middlesex TW17 0DU Lead Inspector Suzanne Magnier Key Unannounced Inspection 3rd October 2006 07:30 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.V314405.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.V314405.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glebe House Address Glebe House The Broadway Laleham Middlesex TW17 0DU 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) Kalemchodha@aol.com Dr Ajit Prasad Mrs Nishi Prasad To be confirmed 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.V314405.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. 25th October 2005 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 a double room which is currently being used as a single 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, well maintained garden with a patio to the rear of the property and parking for several cars to the front. The current fees are £336.00-585.00 per week. Glebe House DS0000049209.V314405.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit of the key inspection process took place over ten and a half hours commencing at O7.30 and ending at 17.30. Ms S Magnier regulation inspector carried out the inspection. The home was represented by the service manager and day to day manager. A tour of the premises took place and the inspector saw the majority of the residents and spoke to some of them in more detail. Residents, relatives, friends and other health care professionals comments, which were gained prior to the inspection have been included in the report. Records were also sampled as part of the inspection process including care plans, health and safety records, menus, accident records, policies, procedures and staff files. The inspector would like to thank the residents, staff and managers for their time, assistance and hospitality during this inspection. What the service does well: What has improved since the last inspection? What they could do better: The homes Statement of Purpose and the Service Users Guide need to be updated to ensure that prospective residents have an informed choice whether they would like to live in the home based on the information available to them. The registered person must ensure that each resident has a copy of their contract/ terms and conditions regarding their stay in the home. Glebe House DS0000049209.V314405.R01.S.doc Version 5.2 Page 6 Improvements need to be made regarding reviewing residents risk assessments, dining arrangements for the residents and privacy for residents and visitors in the home. The registered person must make arrangements for the recording, handling, safekeeping, safe administration and safe disposal of medicines received into the home. Urgent attention must be paid to this matter in order to ensure the safety and welfare of residents The homes complaint procedure needs to be updated and appropriate to the needs of the residents in order that any complaints can be dealt with promptly and efficiently. It is required that the home must make arrangements 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. The home must ensure that the new bathroom is appropriately assessed and re designed in order that there are sufficient bathing facilities for the residents. The registered person must ensure that adequate arrangements are in place to ensure a competent and skilled staff team are caring for residents. All staff must receive training for the work they are to perform for example food hygiene, first aid, moving and lifting, health and safety and fire training to ensure the safety and well being of residents. It was immediately required that the home must ensure that all persons working in the care home have adequate pre employment checks for example CRB disclosures or POVA first checks in order to protect the service users from harm. The kitchen must be risk assessed, deep cleaned, and the kitchen area managed more appropriately in order to ensure the safety of staff working in the kitchen and for the safe preparation of food, including the level of training for all kitchen staff in order to ensure the safety and welfare of residents. 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 DS0000049209.V314405.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.V314405.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents moving to the home do not have sufficient information available to them in order to ensure that the home would meet their needs. The homes admission and assessment procedures ensure that resident’s needs are appropriately identified and met. EVIDENCE: The inspector sampled the homes Statement of Purpose, which was dated 2003. The document was out of date for example reference was made to the National Care Standards Commission, the previous manager, and it was noted to be a complex documents with no page numbers. It is required that the Statement of Purpose and the Service Users Guide are updated to ensure that prospective residents have an informed choice whether they would like to live in the home based ion the information available to them. Glebe House DS0000049209.V314405.R01.S.doc Version 5.2 Page 9 The service manager advised the inspector that all resident’s contracts and statements of terms and conditions are held at Head Office in Weybridge. One resident file contained a copy of the documents. It is required that copies of the contracts and statements of terms and conditions are stored within each resident’s individual file. The home has a documented pre assessment process and several resident care plans evidenced that the pre assessment records were well documented in order to ensure that the home could meet the needs of the prospective resident. The manager demonstrated knowledge and understanding for the assessments for residents prior to admission. The home accepts emergency admissions with a documented pre needs assessment yet do not offer intermediate care. Glebe House DS0000049209.V314405.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The resident’s individual plans of care are comprehensive and demonstrate that their health and personal care needs are met however further development is required regarding the completion and review of residents risk assessments. Medication was not administered to all residents in a safe and appropriate way. EVIDENCE: The inspector sampled several residents care plans and each contained full pre assessment records. The care plans sampled were well documented and included a recent photo of the resident, details of the persons next of kin including friends, GP, Care Manager, religion, medical history, weight charts, abilities regarding mobility and daily records regarding the care that the resident had received. It was noted that the standard of documentation was good and reflected the resident’s rights to dignity and respect. Glebe House DS0000049209.V314405.R01.S.doc Version 5.2 Page 11 One area was noted to need further improvement in respect of the care plans, for example the lack of resident’s personal history. The service manager explained that new care plans were being implemented within the next three months to all the homes and this section would be included. One care plan sampled of a resident newly admitted to the home evidenced that a falls risk assessment was in place yet not fully completed by the staff. It is required that all risk assessments must be fully completed and updated in order to ensure that all activities in which the resident participates are so far as possible free from avoidable risks. Health records in the residents care plans evidenced that the home has contact with the GP, District nurses, specialist nurses, dentists, opticians and other health care professionals. There was some evidence to support that care managers had undertaken care plan reviews in the home to ensure that resident’s current needs were reviewed and met. The inspector observed the medication procedures in the home. The home has a medication policy and procedure, which, the inspector was told, was being updated. Staff who administer medication have received medication training from an accredited facilitator. The inspector sampled the medication administration charts and noted that there were no gaps and where necessary consent from the residents GP had been sought regarding administering homely remedies. The medication profiles contained individual photos of each resident’s and documented side effects of their medication. The inspector checked the Schedule 2 medication with the senior staff member and the accounting and documentation was correct. It was noted that the medication cupboards needed to be cleaned as they were soiled. The senior staff member advised that she would clean the cabinets as soon as possible. It was noted that before the senior staff member administered the medication she signed the administration sheet to indicate that the resident had already been administered their medication. When questioned by the inspector she advised that she would change the details afterwards if the resident had not taken their medication. The staff member was also observed to take medication from the blister packs using her hands and also was seen to check the numbers of Schedule 2 medication using her hands. During the inspection the inspector discussed the procedures of returning medication to the dispensing chemist and has recommended that a sealed bag from the chemist be purchased in order to ensure that returned medications are securely and appropriately handled. It has been immediately required that the registered person must make arrangements for the recording, handling, safekeeping, safe administration and safe disposal of medicines received into the home. Urgent attention must be paid to this matter in order to ensure the safety and welfare of residents. Glebe House DS0000049209.V314405.R01.S.doc Version 5.2 Page 12 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 adequate. This judgement has been made using available evidence including a visit to this service. A variety of activities take place both inside and outside of the home. Visitors are welcomed to the home to maintain contact with their family members. The food at the home was of a good standard. Further improvements regarding skills and practice of staff supporting residents at mealtimes is needed. EVIDENCE: The inspector noted that, where able residents moved freely around the home. One resident who had recently moved to the home was unsettled and told the inspector that they didn’t want to stay in the home. The daily records of the resident showed that staff had given the resident reassurance and there had been contact with their family who were visitors to the home. Other residents spoken with during the inspection appeared happy to be resident and spoke highly of the home and the staff. One comment card out of ten stated that the resident sometimes did not like living in the home. The inspector was told that the activities in the home included Bingo, which the residents said they enjoyed playing and also winning!. Other stimulating activities included sing songs, and reminiscence, darts, quizzes, discussions of Glebe House DS0000049209.V314405.R01.S.doc Version 5.2 Page 13 family trees and social history, crafts, card making and manicures. A dance session was held in the afternoon with staff and residents. One resident said that they used to be a professional dancer and it was apparent that the activity brought back happy memories. Residents were also engaged in playing indoor bowls. An audit had been carried out in the home, which indicated that not all residents enjoyed the activities on offer and had requested some more sit down exercises. Following lunch several of the residents chose to go to the privacy of their rooms either for a rest or to watch television or read the paper, it was apparent that the residents felt comfortable and able to exercise this choice in their lives. The home has also employed an aroma therapist and hairdresser, which the residents told the inspector they liked this service coming to the house. Issues concerning vetting of staff will be documented more fully in the forthcoming section on Page 18 of the report. A comment card received from a visitor to the home stated that there were no outings arranged for the residents. The inspector asked the manager who explained that the home does not currently have a service vehicle and are considering fund raising to obtain funds for a house vehicle in order that residents would be able to get out and about a bit more in their local community. The manager explained that she was also trying to organise a trip for residents who wish to go Christmas shopping. The home is able to arrange visits to the home by various clergy to provide residents with pastoral and spiritual care. Comment cards received from visitors to the home stated ‘nothing is too much trouble’, ‘ the staff are very friendly towards myself and my family and always make us very welcome’. One comment card indicated that a visitor to the home was not given the opportunity to meet with their friend in private and it is required that adequate private accommodation is provided for residents in order that they may receive their visitors and friends individually in private. Five resident comment cards out of ten stated that they sometimes did not like the meals served in the home. The inspector sampled the midday meal served to resident’s and noted that the resident needing additional staff support were offered their meals prior to the other residents coming into the dining area. The meal served was wholesome and in the main enjoyed by the residents. The inspector observed that some staff stood beside residents whilst the staff member cut up the resident’s meal or offered encouragement to the resident to eat their meal. It was also noted that staff brought a large trolley into the dining area and scraped plates of unwanted food into a plastic container in the Glebe House DS0000049209.V314405.R01.S.doc Version 5.2 Page 14 dining area in front of the residents who were still eating their meals. It has been required that the dining arrangements for the residents are revised in order that they are conducted in manner which promotes respect and dignity for residents. The inspector has recommended improvements in the dining area, which could include making the dining tables more stimulating to include condiments; central displays for example silk flowers, coloured napkins and attractive place settings. Glebe House DS0000049209.V314405.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 poor. This judgement has been made using available evidence including a visit to this service. The residents are not currently protected by the homes complaints and safeguarding adults procedures. EVIDENCE: No complaints have been received into the home since the previous inspection. The home has a complaints procedure, which requires updating in order that any person wishing to make a complaint is able to do so using the home complaints procedures. The inspector sampled a log kept in the home of complaints and actions taken to address the concerns or complaints. The home has a copy of the Surrey Safeguarding Vulnerable Adults multi agency policies and procedures 2005. Records indicated that not all staff had attended the Safeguarding adults training yet the manager explained this had been booked for October 2006. It is required that the home must make arrangements 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. Glebe House DS0000049209.V314405.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): 19,21,23,24,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a clean and hygienic environment. Resident’s bedrooms were well decorated and personalised. Improvements are required in respect of bathing facilities to ensure that residents have sufficient facilities available to meet their needs. EVIDENCE: The indoor communal areas of the home were observed to be well decorated, sufficiently bright and pleasant however some improvements to the decoration of the dining area could be considered. The bathrooms and toilets throughout the home were clean. Following previous inspection requirements the home have installed a bath/shower room however the managers explained that the bath was not currently used by residents as it does not meet their needs due to moving and handling concerns and the current site of the bath. It has been required that the home ensures Glebe House DS0000049209.V314405.R01.S.doc Version 5.2 Page 17 the bathroom is appropriately assessed and re designed in order that there are sufficient bathing facilities for the residents. During the tour of the premises the inspector noted that portable hoists had been recently serviced. It was noted that a resident’s wardrobe was in a state of disrepair and a resident’s bedroom door was not closing properly. These defects were immediately remedied by the homes maintenance person and checked by the inspector in order to ensure the safety and wellbeing of the residents. All resident’s bedrooms were well decorated, reflected individuality and contained personal items for example some furniture, radios, television and other personal items. Residents told the inspector that their rooms were comfortable. Glebe House DS0000049209.V314405.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): 27,28,29,30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staffing levels of the home were evidenced as adequate to meet the current needs of residents. The residents were not fully protected by the homes staff training and recruitment policy and procedures. EVIDENCE: The staff levels at the home during the inspection were adequate for the needs of the residents. Several staff recruitment records sampled were well managed and evidenced that the home had undertaken safe recruitment practice of care staff in order to safeguard residents. The inspector was informed that the visiting hairdresser and an aroma therapist had not had been subject to CRB or POVA first checks. There were no details of qualifications, work history, training, or registration with, or membership of, any professional body within the home. It was immediately required that the home must ensure that all persons working in the care home have adequate pre employment checks for example CRB disclosures or POVA first checks in order to protect the service users from harm. Glebe House DS0000049209.V314405.R01.S.doc Version 5.2 Page 19 The manager spoke with the hairdresser on the telephone during the inspection and advised that the documents need to be attained as soon as possible. The inspector was advised that hairdresser would be speaking with the Head Office regarding the arrangements for the home to ascertain issues of insurance and apply for Pova first checks. Whilst sampling some training records the inspector noted that there were gaps in staff training records. It has been required that all staff must receive training for the work they are to perform for example food hygiene, first aid, moving and lifting, health and safety and fire training. It is recommended that a clear documented system is developed which assists the manager to clearly identify gaps in staff training. The service manager explained that the home would be implementing the Common Induction Standards and have recently purchased training videos. Five members of staff are waiting to be registered for their National Vocational Qualification (NVQ) Level 2. Glebe House DS0000049209.V314405.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): 31,33,35,37,38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The day to day management of the home is adequate to ensure the safety and wellbeing of residents. Policies and procedures with regard to the safekeeping of resident’s valuables and money are robust. Requirements have been made that the home review the current standard of management in the kitchen with regard to staff training, food storage and hygiene in order to ensure that safety of residents and staff working in the kitchen. EVIDENCE: The current manager of the home has completed her application of registered manager with the Commission for Social Care Inspection (CSCI) and the inspector has advised that she must submit the completed CRB into the local CSCI office. The manager has been in post since last September 2005 and advised the inspector that she has achieved Level 2 National Vocational Glebe House DS0000049209.V314405.R01.S.doc Version 5.2 Page 21 Qualification (NVQ). At the conclusion of the inspection the inspector was advised that the manager would be resigning from her position in the home in the forthcoming months. In general the homes staff spoke favourably of the management of the home yet one comment card stated that the manager lacked experience. In discussion with the manager it is strongly recommended that the home obtain an updated copy of the Care Homes Regulations 2004 (as amended 2006). The atmosphere in the home during the day was calm and orderly and staff were observed to know and understand the routines of the home and conduct themselves appropriately. Quality Assurance has been achieved in August 2006, which included feedback from the relatives and residents regarding the home. As a result the manager explained that the home have altered some activities as a result of the relatives feedback. The inspector sampled several residents records regarding safekeeping of their money and noted that all transactions were clearly documented, receipts obtained, weekly accounting checks were made and all money was correct at the time of the inspection. The service manager advised the inspector that all the company’s policies and procedures are being updated within the next two weeks. The manager and service manager discussed the homes current Regulation 37 notifications with regard to the un witnessed falls in the home. The forms were discussed and it has been recommended that the time and location of the falls are noted on the forms in order that the home are able to monitor and assess the reasons for the falls. The home currently documents the resident’s night time reports and in discussion with the managers it was agreed that the home in order to improve the documentation will be implementing a system whereby residents are checked each hour during the night and any interventions or incidents are recorded. The kitchen of the home was noted as disorganised and in need of a review with regard to safe storage of boxes, utensils and various foodstuffs for example it was observed that boxes of biscuits, cereals, sugar were stored on high shelves. There was general clutter for example bin liners in jugs and the cooks uniform hanging in the kitchen and several areas in the kitchen for example under the shelves and floor areas needed deep cleaning. The kitchen staff member identified that pate and ham were not labelled in the fridge, as she could not find the labels. Immediate action was taken to remedy this shortfall and the staff member labelled the food in keeping with the current legislation of food hygiene standards. Glebe House DS0000049209.V314405.R01.S.doc Version 5.2 Page 22 The inspector was advised that there were several cooks in the home and the manager was unsure regarding their levels of training with regard to food preparation. A requirement has been made that the home must review the level of training for all kitchen staff in order to ensure the safety and welfare of residents. Fridge and freezer temperatures were well documented and temperatures of meals served documented. Due to the hazards identified during the inspection it has been required that the kitchen is risk assessed, deep cleaned, and the kitchen area is managed more appropriately in order to ensure the safety of staff working in the kitchen and for the safe preparation of food. Fire equipment and records of practices and drills were evidenced by the inspector and well documented. Glebe House DS0000049209.V314405.R01.S.doc Version 5.2 Page 23 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 2 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 3 X 2 X 3 3 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 3 X 3 X 3 X 3 2 Glebe House DS0000049209.V314405.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4.(1)(a-c) Schedule 1 5 (1) (a-f) Requirement The registered person must ensure that the home’s Statement of Purpose and Service Users Guide are updated to ensure that prospective residents have an informed choice whether they would like to live in the home based on the information available to them. The registered person must ensure that each resident has a copy of their contract/ terms and conditions regarding their stay in the home. The registered person must ensure that all risk assessments are completed and updated in order to ensure that all activities in which the resident participates are so far as possible free from avoidable risks. The registered person must make arrangements for the recording, handling, safekeeping, safe administration and safe disposal of medicines received into the home. Urgent attention must be paid to this matter in order to ensure the safety and DS0000049209.V314405.R01.S.doc Timescale for action 03/12/06 2 OP2 5a (2,3,4,)(a -b) 13.(4)(ac) 10/10/06 3 OP7 03/11/06 4 OP9 13 (2) 03/10/06 Glebe House Version 5.2 Page 25 5 OP13 6 OP15 7 OP16 8 OP18 9 OP21 10 OP29 11 OP30 welfare of residents. The registered person must ensure that adequate private accommodation is provided for residents in order that they may receive their visitors and friends individually in private. 12.(4)(a) The registered person must ensure that the dining arrangements for the residents are revised in order that they are conducted in manner, which promotes respect and dignity for residents. 22.(1)(2) The registered person must ensure that the homes complaint procedure is updated and appropriate to the needs of the resident in order that any complaints can be dealt with promptly and efficiently. 13.(6) The registered person must make arrangements 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. 23.(2)(j) The registered person must ensure that the newly fitted bathroom is appropriately assessed and re designed in order that the home has sufficient bathing facilities for the residents. 7,9,19 The registered person must Schedule ensure that all persons working 2 in the care home have adequate pre employment checks for example CRB disclosures or POVA first checks in order to protect the service users from harm. 18.(1)c (i) The registered person must ensure that all staff receive training for the work they are to perform for example food hygiene, first aid, moving and 23.(2)(e) DS0000049209.V314405.R01.S.doc 03/11/06 03/12/06 03/12/06 03/12/06 03/12/06 03/10/06 03/12/06 Glebe House Version 5.2 Page 26 12 OP38 23.(2)(d) 13 OP38 18.(1)c (i) lifting, health and safety and fire training to ensure the safety and well being of residents. The registered person must ensure that the kitchen is risk assessed, deep cleaned, and the kitchen area is managed more appropriately in order to ensure the safety of staff working in the kitchen and for the safe preparation of food. The registered person must review the level of training for all kitchen staff in order to ensure the safety and welfare of residents. 17/10/06 17/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP9 OP15 Good Practice Recommendations It is recommended that a sealed bag from the dispensing chemist be purchased in order to ensure that returned medications are securely and appropriately handled. It is recommended that improvements in the dining area, which could include making the dining tables more stimulating to include condiments, central displays for example silk flowers, coloured napkins and attractive place settings. It is recommended that a clear documented system is developed which assists the manager to clearly identify gaps in staff training. 3 OP30 Glebe House DS0000049209.V314405.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 DS0000049209.V314405.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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