Inspection on 07/09/06 for Glebe House

This inspection was carried out on 7th September 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 29/11/05

Glebe House 13/07/05

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

CARE HOMES FOR OLDER PEOPLE Glebe House Stein Road Southborne West Sussex PO10 8LB Lead Inspector Mrs G Davis Unannounced Inspection 7th September 2006 10:00 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 DS0000052212.V293990.R01.S.doc Version 5.1 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 DS0000052212.V293990.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Glebe House Address Stein Road Southborne West Sussex PO10 8LB 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) 01243 375198 01243 375198 Shaw healthcare Ltd Ms Ida Kristina Bostrom Care Home 34 Category(ies) of Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (27) of places Glebe House DS0000052212.V293990.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of service users should not exceed 34 at any one time. 29th November 2005 Date of last inspection Brief Description of the Service: Glebe House is registered for thirty-four older people (over the age of 65), eight of who have dementia. Owned by Shaw Health Care, Mr Jeremy Nixey is the Responsible Individual. Mrs Carol Parsons has recently been appointed as the Registered Manager In May the residential home transferred to a new purpose built establishment. Built on two floors served by a vertical lift; the home consists of four residential units each accessed from the main atrium though a secure front door. On each floor two units adjoin and are separated by folding doors to each lounge area. Each unit contains ten single bedrooms with bathrooms ensuite and mirror each other. They containing identical facilities, which include a separate bathroom with adjustable height wash hand basin and assisted bath and a lounge/diner containing a kitchen area, one of which is larger and intended to provide opportunities for the more able resident to retain their independence. In addition a smoking lounge has been provided, a visitors room that offers over night accommodation and a garden room. The whole building is suitable for wheelchair users. Fees vary between £427.74 - £527.18 Glebe House DS0000052212.V293990.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out the unannounced inspection during the course of a day in September. The Manager was present at the inspection and provided the information required. All the key standards were assessed on this occasion. A tour of the premises took place and all areas were seen including the resident’s accommodation and staff facilities. Resident’s care plans and needs assessments; the accident and complaint logs, staff files, medication and maintenance records were examined. A meal was taken with the residents to experience what it was like to eat at the home. Residents and their relatives and staff were spoken with to find out their views of the home and their opinions of the services it provides. “It’s all right here – I like it. Food’s lovely.” Three requirements and one recommendation were made as a result of this inspection. What the service does well: The home was purpose built and has been attractively and comfortably furbished. Most of the resident’s bedrooms contained their own small items of furniture and personal possessions making their rooms personal for their needs. Residents confirmed that they were enjoying the use of their own bathroom and for some it had increased their independence. All residents receive comprehensive pre-admission assessments and these inform the care plans that are in place. They have been reviewed on a regular basis. All specialist equipment and fixtures and fittings have been provided with disability in mind and provide the maximum opportunities for residents to maintain their independence and daily living skills. There was a high standard of hygiene throughout the building. Glebe House DS0000052212.V293990.R01.S.doc Version 5.1 Page 6 Residents were seen to enjoy the day as they wished and were either in their own rooms, the lounges or the garden. Observations of staff and residents showed the staff members were courteous and caring. “I think they go the extra mile”. What has improved since the last inspection? What they could do better: The staffing numbers appear to be too low to provide a service that is responsive to resident need at all times. This could be the result of the way staff members deploy themselves whilst on duty - daily routines should reflect the residents’ preferences rather than those of the staff members.’ . Provision should be made to allow residents to be able to keep their bedroom doors open if they wish, without contravening the Fire Safety Regulations, either to prevent themselves from feeling isolated or to provide better ventilation to their rooms. More opportunities to undergo NVQ training and other in-house training should be provided. Attention should be paid to the security arrangements of the building and a better awareness of the potential for security breaches to occur. Consideration should be given to the affect of excessive heat on staff members working in the home. Glebe House DS0000052212.V293990.R01.S.doc Version 5.1 Page 7 Suitable accommodation should be provided for meetings of a large number of people – staff members’, residents or relatives - so that all can be accommodated without discomfort. 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 DS0000052212.V293990.R01.S.doc Version 5.1 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 DS0000052212.V293990.R01.S.doc Version 5.1 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): 1.3.4.5.6. Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. Intermediate Care is not provided. EVIDENCE: All prospective residents, or their representatives, have a number of opportunities to make an informed choice about whether Glebe House can provide the care they need. All residents in the original building were assessed as to their suitability to move into the new building and those that required a higher degree of care than Glebe House could provide were found alternative and more suitable accommodation where their needs would be fully met. Prior to admission a senior member of staff undertakes an assessment of need on the prospective resident. A random selection of three care plans identified that preadmission assessments had been undertaken and the information gathered had informed the care plans. Glebe House DS0000052212.V293990.R01.S.doc Version 5.1 Page 10 There was a Draft Statement of Purpose and Service User Guide re-written to encompass the changes brought about by the move into the new building and it was confirmed that all prospective residents, their families and their Care Managers would be given a copy at the time of enquiry. When the final version has been produced the Manager intends to give each resident and the Commission for Social Care Inspection a copy. A copy of the draft statement of purpose was available for visitors to read at the front entrance Everybody concerned with the prospective resident is encouraged to visit the home as often as they like and a four-week trial period is used to allow the new resident to settle in and make sure that they are happy with the situation. Intermediate care is not provided Glebe House DS0000052212.V293990.R01.S.doc Version 5.1 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 is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Thee care plans were selected at random and were examined as part of the case tracking of 3 residents. The care plans selected gave enough information to provide guidance to staff members re the actions needed by the staff to meet all the resident’s needs. All contained individual risk assessments including one for the use of cot sides where appropriate. They had been regularly reviewed and alterations made to them as required. From discussion with the staff members; observation of staff carrying out their duties and on talking to the residents it was clear that the residents needs are understood and are met. When looking around the home the inspector noticed staff knocking before entering rooms. Residents were called by their chosen name. Glebe House DS0000052212.V293990.R01.S.doc Version 5.1 Page 12 Arrangements are made for the residents to attend any specialist clinics or any health services that are required, and are registered with a local GP. District nurses visit the home when requested. Records are kept of all such visits. Discussion with one Community Nurse revealed that she considered that the staff group were well informed and always referred to the GP or Nursing Services appropriately and in a timely manner. Medication was safely stored and records were well kept in regard to the administering and disposal of unwanted drugs. The medication administration records were examined and were generally well completed, and no gaps were noted in the recording of medicines. Handwritten entries on the MAR charts were signed and dated. Staff members have received medication training. The home has the appropriate equipment for the residents accommodated, with assisted baths, lifting hoists and each room evidenced that individuals were provided with other appropriate equipment as required. All baths and wash hand basins in the communal bathrooms were adjustable so that a person in a wheelchair could use the basin or the height of the bath could be altered to make the task of assisting someone to bath easier for the carer. Information from previous inspections and observation of the interaction between the staff members and the residents showed that the residents’ privacy and dignity is respected at all times by the staff. Personal care is provided in the privacy of the resident’s bedroom or a bathroom. Glebe House DS0000052212.V293990.R01.S.doc Version 5.1 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 is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Care plans were noted to contain information regarding the past interests of the residents. Residents confirmed that they had the opportunity to join in with various activities on a daily basis and these had been recorded in the care plan. An Activities Co-ordinator works with each individual and also organizes other activities such as a weekly Music and Movement session, Bowls, Bingo, Quizzes, Videos and Outings. A visit to a butterfly farm had been enjoyed the week previous to the inspection visit. On the day of inspection residents were seated in lounges, others were enjoying quiet pursuits in their own rooms and one person had taken advantage of the door in his room to the garden and was enjoying the sunshine. It was clear on talking to the residents that they felt free to lead the lifestyle of their choice. Glebe House DS0000052212.V293990.R01.S.doc Version 5.1 Page 14 Residents meetings will be held and residents encouraged to give their views on all aspects of living at the home. A sample no of residents were spoken to at the time of the Registered Provider’s Reg 26 visits and their views published in the report. The home had an open visiting policy and visitors were welcome to sit in the communal areas or in the residents’ own bedrooms if preferred. There was also a dedicated room for visitors to use and this had been equipped to provide accommodation should relatives need to stay overnight. Some concern was expressed by a visiting social worker regarding the ease at which anyone could walk into the building; this was discussed with the manager who informed that there was a security lock on the front door and an electronic device that could be used by the manager on duty to answer the doorbell. The kitchen was visited during the course of the inspection and was found to be clean, well ordered and appropriately equipped. Recent changes to the menus by the Company’s Catering Adviser had provided a varied and interesting range of well-balanced meals giving a wide choice. The cook had commenced using them the week of the inspection and it was too soon for residents to comment on the differences. The inspector ate lunch with the residents, which proved to be tasty and well cooked. There were several choices of dishes available and residents chose according to their preferences or needs. The meal service took a long time due to the fact that the support workers from each unit combined to serve the meal, thus the residents in the unit served second had to wait until all the residents in the first unit had been served. Many of the residents spoken to confirmed that they enjoyed their meals. All required records regarding fridge temperatures etc were available and had been recorded in a logbook. On observation the staff members were seen to be discreet with any help that was required and appropriately deferential to any wishes that the residents expressed Glebe House DS0000052212.V293990.R01.S.doc Version 5.1 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 is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: On checking the complaints log it was noted that there had been two complaints recorded since the last inspection in November 2005 both regarding the move to the new home and resolved satisfactorily. The home has a complaints procedure in place that states that complaints will be responded to within a maximum of 28 days. It was seen that the registered person had responded to any complaint made appropriately within the timescale and actions recorded. There have been no complaints made to the Commission for Social Care Inspection. Residents spoken to confirmed that they knew how to complain and who to. Training records showed that not all staff had attended training on adult abuse. Discussion with the staff group on duty at the time of the inspection identified that there was a good level of awareness of the issues regarding the protection of vulnerable people and what to do if they suspected that abuse had taken place. The manager is currently undertaking an audit of training needs and will ensure that all gaps in training are addressed. Staff recruitment records were seen to contain all security information required. Glebe House DS0000052212.V293990.R01.S.doc Version 5.1 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): 19.20.21.22.23.24.25.26. Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The move to the new building was made in May. The old building had been razed and the contractors were currently constructing more garden areas to surround the home. Soon after the move a major water leak caused a great deal of damage to the fabric of the home but the staff team were able to continue providing support and care to the residents despite the inconvenience. Repair to the fabric was ongoing. The home had been purpose built on two floors serviced by a vertical lift; it consisted of four residential units each accessed from the main atrium though a front door with touch pad security locks. On each floor two units adjoined and were separated by folding doors at each lounge area. Each unit mirrored each other; had ten single bedrooms with bathrooms ensuite and with identical Glebe House DS0000052212.V293990.R01.S.doc Version 5.1 Page 17 communal facilities, which included a lounge/diner and bathroom with adjustable height wash hand basin and assisted bath. In the units the lounge/diner areas contained a small kitchenette and in the unit on the ground floor adjacent to the office the kitchen had been designed to provide an area for the more able residents to retain their independence as far as possible or for residents who were having respite to try out their daily living skills before returning home. During the inspection the residents were seen to help themselves to drinks from the fridge. Other communal facilities included a smoking room for residents, a guest room with possible overnight accommodation for relatives and a garden room. The dividing doors between units were drawn back at the time of inspection. Apart from the areas that had been damaged by the flooding all areas in the home were attractively decorated in bright colours; comfortable furniture of good quality had been provided throughout. All doorways were wide enough to negotiate a wheelchair through easily. The home was clean and fresh in all areas. The laundry was provided with hand washing facilities and all washing was handled following the correct infection control procedures. The room was seen to be clean and tidy. Both laundresses commented on the problem of the room being too hot and that they required more shelf room for folding linen. A separate sluice was clean and in good order Staff members and residents commented on how hot they found the building. Particularly the Kitchen and Laundry. There did not appear to be any magnetic door catches fitted to any doors and some resident bedroom doors were kept open by means of a wedge. The inspector pointed this out as being an unacceptable practice. The kitchen was unacceptably hot. This would seem to be a serious omission on the planners’ and architect’s part. Residents must be provided with the means to maintain a reasonable temperature in their room, as this is likely to be an ongoing problem given the fact of global warming and the dangers of dehydration in the older person. The Atrium roof had windows automatically controlled by thermostatic triggers however this did not affect the bedrooms, kitchen or laundry room areas. To the north of the building there was a secluded garden for residents to sit out in fine weather and other garden areas are in the throes of being constructed. Glebe House DS0000052212.V293990.R01.S.doc Version 5.1 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 is adequate. This judgement has been made using available evidence including a visit to the service. EVIDENCE: On the day of inspection there were five carers on duty in the morning excluding the Manager, team leader and administrator. The cook and kitchen domestic and house domestic completed the staff compliment for the morning. There was a written rota that showed which staff members were on duty at any time of the day or night and that accurately identified those on duty at the time of inspection. The manager informed that she considered that the staffing was generous; usually one carer to each unit and one person acting as a float helping out where it was most needed. It appeared that the support workers on the two adjoining units preferred to join forces - this did mean that on occasions residents had to wait for fairly long periods of time for attention as witnessed by the inspector at lunch time and discussed by residents. An examination of staff files and conversation with the care staff team revealed that there was a good skill mix and level of knowledge of the resident group within that team although the staff on duty said that staff shortages made it difficult as often the agency workers were inexperienced. It was seen that the registered person operates a thorough and robust recruitment procedure. Glebe House DS0000052212.V293990.R01.S.doc Version 5.1 Page 19 The files of the staff members that had been recruited since the last key inspection were examined and seen to contain all information required by the National Minimum Standards. New staff members were only confirmed in post following the completion of a satisfactory Police and POVA Check. Training files were examined for four members of staff and it was seen that a number of in-house training sessions on relevant service related subjects had been undertaken including Moving and Handling, Fire Safety, and First Aid. Although it was noted that not all staff members had received training in POVA, it was evidenced that new members were given a comprehensive induction that included the Principles of Care and the Protection of Vulnerable People. The staff on duty confirmed this at the time of inspection. There appeared to be a commitment from the staff team to continue training and learning, which was supported by the manager as far as the staffing constraints would allow. 15 of staff had NVQ level II and above with four more candidates starting NVQ II in September. It is intended to address the relatively low percentage of trained staff in the coming year. There has been a period of instability of Senior Staff that has coincided with the move into the new building. Since Mrs Parsons has taken over work has been undertaken to introduce structure and administrative systems. The Team Leader on duty informed the inspector that the Manager had given good and supportive help. Supervision systems and rota have been devised and are now in place and supervision of support staff is due to be carried out in the immediate future. There is not a room of sufficient size to accommodate a full staff meeting; this has resulted in the manager having to use the Garden Room for meetings with the overspill encroaching into the garden. This would not be acceptable in the winter months or on wet days and Mrs Parsons has broached the issue with her line managers with a view to being able to use the guest room on occasion by combining it with the manager’s office through the use of folding doors as used on the units. Staff members have been provided with excellent facilities including a smoking and non smoking room and a shower. Glebe House DS0000052212.V293990.R01.S.doc Version 5.1 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): 31.33.35.38 Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The registered manager was available on the day of inspection. The Registered Manager, Mrs Carol Parsons, has recently transferred from another Shaw home. Prior to Mrs Parsons’ appointment Glebe House had a succession of managers causing instability at a time of lengthy and intense change, this had ultimately caused disruption to the usual routines such as supervision of staff members, training etc. In response to this Mrs Parsons was currently undertaking a period of assessment of all aspects of the management of the service. This would involve the identification of weaknesses and strengths and the production of a business plan to address any identified issues. New daily work Glebe House DS0000052212.V293990.R01.S.doc Version 5.1 Page 21 procedures been devised and introduced and these were still in the process of being tried and tested – adjustments were being made on a daily basis. Through discussion with the manager it became apparent that the needs of the residents were paramount and that all actions undertaken were intended for their benefit. The staff on duty spoke very highly of the manager and stated that she was very supportive. The registered provider carries out a regulation 26 visit and report on a monthly basis and these indicate thorough monitoring of the service. Any complaint feedback would be used constructively to improve the performance of the home. Shaw Healthcare has a robust approach to quality assurance and will be using all audit outcomes to inform a business plan and will be publishing the results when completed. Verbal comments from both residents and their relatives indicated a good level of satisfaction with the service provided. The policy of the home is not to manage the financial affairs or handle large sums of money for the residents and any expenditure on the residents’ behalf is billed to their representative to manage for them A system of formal supervision had been devised and would be put in place for all care staff within the next week. The manager had drawn up a rota of supervision dates. Staff members confirmed that they found their manager fair and supportive. Glebe House DS0000052212.V293990.R01.S.doc Version 5.1 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 3 X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 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 3 17 X 18 3 4 4 4 4 3 3 4 4 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Glebe House DS0000052212.V293990.R01.S.doc Version 5.1 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. 1 Standard OP27 Regulation 18 Requirement Timescale for action 30/11/06 2 OP25 23.2.(p) 3 OP28 18 The registered provider must ensure that the staffing numbers are appropriate for the health and welfare of service users. The registered person must 01/01/07 ensure that the heating lighting, water supply and ventilation of the service users accommodation meets relevant environmental health and fire safety requirements and the needs of the individual service user. The registered person should 06/06/07 ensure that a minimum of 5o of staff have a qualification to the equivalent of NVQ II or above 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 OP12 Good Practice Recommendations The daily routines of the home should reflect the needs of the residents and not the preferences of the staff. Glebe House DS0000052212.V293990.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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 DS0000052212.V293990.R01.S.doc Version 5.1 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!