Inspection on 28/03/07 for Glebe House Nursing Home

This inspection was carried out on 28th March 2007.

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 Nursing Home 09/12/05

Glebe House Nursing Home 02/06/05

Glebe House Nursing Home 10/08/04

Glebe House Nursing Home 14/04/04

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

CARE HOMES FOR OLDER PEOPLE Glebe House (Chaldon) Church Lane Chaldon Surrey CR3 5AL Lead Inspector Sandra Holland Unannounced Inspection 28th March 2007 09:55 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 (Chaldon) DS0000013324.V331307.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 (Chaldon) DS0000013324.V331307.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glebe House (Chaldon) Address Church Lane Chaldon Surrey CR3 5AL 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) 01883 344434 01883 341504 Glebe Care Limited Mrs Sarah Elizabeth Vincent Care Home 43 Category(ies) of Physical disability (6), Physical disability over 65 registration, with number years of age (43) of places Glebe House (Chaldon) DS0000013324.V331307.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 4 (four) beds may be used for Palliative Care. Date of last inspection 5th September 2006 Brief Description of the Service: Glebe House is a well- established home providing care and nursing for up to forty- three older people who have a physical disability. The home can also provide accommodation for up to four people who are terminally ill and require palliative care. Accommodation is provided in single or double bedrooms spread over three floors and there is a shaft lift and platform lift to provide access to all areas of the home. There is ample communal space including a large lounge, dining room, and conservatory, which has ramp access to a well-maintained garden. The fees at this home range from £550.00 to £1051.12 per week. Glebe House (Chaldon) DS0000013324.V331307.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection site visit was carried out by the Commission for Social Care Inspection (CSCI) under the “Inspecting for Better Lives” process. Mrs Sandra Holland, Regulation Inspector carried out the inspection over six and a half hours. Mrs Sarah Vincent, Registered Provider and Registered Manager was present representing the service. Although Mrs Vincent is known as the Matron within the home, for clarity Mrs Vincent will be referred to as the manager throughout this report. The people living at the home prefer to be known as residents and that is the term that will be used throughout this report. A full assessment was carried out of all information held about the home, prior to the visit. A pre-inspection questionnaire was supplied to the home and this was completed and returned. Some of the information supplied will be referred to in this report. During the visit to the home, a number of records and documents were sampled including residents’ individual care plans, medication administration record (MAR) charts and staff files. A tour of the premises was undertaken and twelve residents and ten members of staff were spoken with. A number of CSCI feedback forms were supplied for distribution to residents, healthcare professionals, relatives and visitors. What the service does well: The home is very well decorated and comfortably furnished to meet the needs of residents, with a regular programme of refurbishment and improvement. The premises, both in and outside the home are colourful, homely and attractive. Well-balanced and appetising meals are served and staff provide sensitive and discreet assistance to residents who require it. Residents are supported by a well-trained team of staff. The home has achieved the target of 50 of care staff trained to at least National Vocational Glebe House (Chaldon) DS0000013324.V331307.R01.S.doc Version 5.2 Page 6 Qualification (NVQ) level 2. Compliments received by the home and independent feedback to CSCI, commented on the high standard of care provided by the staff. The home is effectively managed in an open manner and the manager, who is also the provider, is in day-to-day control of the home and is freely accessible to residents, staff and visitors. What has improved since the last inspection? What they could do better: A statement of the terms and conditions of residence must be supplied on or before admission. For those residents purchasing their care privately a contract must be supplied on or before admission. Assessments must be carried out of any risks to residents. The stock of medication held in the home must accurately match the record held, all administration of medication must be recorded and residents must not be left without a supply of their prescribed medication. Medication prescribed for a resident must not be administered to any other resident. When medication record charts are written by hand, these should be signed by the person writing them and should be checked and countersigned by another member of staff who is appropriately trained. The social and recreational activities in the home should be reviewed in consultation with residents to ensure they meet the residents’ needs and choices. An updated copy of the Surrey Multi-Agency procedure for safeguarding adults should be obtained. The home’s own procedure regarding abuse should be reviewed and revised. Glebe House (Chaldon) DS0000013324.V331307.R01.S.doc Version 5.2 Page 7 For all applicants to work at the home, the entitlement to work in the UK and confirmation of their identity must be obtained and retained, gaps in employment history must not be permitted and a recent photograph of staff must be kept. 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 (Chaldon) DS0000013324.V331307.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glebe House (Chaldon) DS0000013324.V331307.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some residents but not all, have been supplied with a contract. The needs of prospective residents are assessed except when they are admitted in an emergency. EVIDENCE: The files of a number of recently admitted residents were sampled at random. The manager stated that as two of the residents selected had been admitted in emergency situations, it had not been possible to carry out a pre-admission assessment. It was noted that for these two residents, contracts had not been supplied, to detail the terms and conditions under which the residents were living at the home, even though they had been admitted for at least six months, or more. Contracts were not available for two other residents, including a resident who had lived at the home for more than two years. The manager stated that a number of residents are supported financially by local authorities and there is Glebe House (Chaldon) DS0000013324.V331307.R01.S.doc Version 5.2 Page 10 often a delay in the supply of the contract by the local authority department, after the placement of the resident. During the course of the inspection visit, the manager obtained copies of local authority contracts for two residents, although these had yet to be provided to residents and signed by all parties. The majority of residents who completed and returned a CSCI feedback form indicated that they had received a contract. Where residents are supported by a local authority and admission is planned, an assessment of the resident’s needs had been carried out under the care management process and copy of the care management assessment had been obtained. The manager stated that she uses the same form of assessment to assess the needs of residents who are funding their own admission to the home. Intermediate care is not provided at the home the manager advised. A requirement has been made regarding Standard 2. Glebe House (Chaldon) DS0000013324.V331307.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A detailed plan of the care needs of each resident is available to guide staff and residents’ healthcare needs are well met. The management of medication must be more robust to fully safeguard residents. EVIDENCE: A comprehensive plan of the care needs of each resident has been drawn up, to guide staff to meet those needs. The plans detail the support required by residents in most areas of their daily lives, including their personal care, mobility, continence, dietary needs, night-time needs and activities and interests. A review of the plans had been carried out on a regular basis and they had been updated as required to reflect changes in residents’ needs. Assessments of risks to residents were included within the care plans. Risks assessed included the risks of falling, of developing pressure sores and those resulting from a reduced sense of danger. It was noted that for some residents, not all risks had been assessed, such as the use of electrically operated beds or the risk of choking. Glebe House (Chaldon) DS0000013324.V331307.R01.S.doc Version 5.2 Page 12 It was clear from the records and documents sampled, that residents’ healthcare needs are well met. A number of healthcare professionals are involved in the support of residents, including a general practitioner (G. P.), optician, physiotherapist and dietician. Medication is supplied to the home in original packets and containers by a local pharmacy, the manager stated. The administration of medication is recorded on a medication administration record (MAR) chart that covers a period of three months. The MAR chart entries are hand-written, but had not been signed by the person making the entries, nor checked and countersigned by another member of appropriately trained staff. It is recommended that this is carried out as advised by the Royal Pharmaceutical Society guidelines. A number of shortfalls were noted in the administration of medication. The amounts of medication held in the home on behalf of residents were checked against the records held, and for a number of residents these did not accurately match. It was also noted that one resident had been left without a stock of a prescribed medication for a long period, but had been administered the same medication at the same dose, from the stock prescribed to another resident. A small number of gaps were noted on the MAR chart, so it was not possible to know whether the medication had been administered as prescribed. Staff were observed to speak to residents in a friendly but appropriate manner and to promote and protect residents’ privacy. Staff were noted to knock before entering residents’ bedrooms or bathrooms, and personal care was offered and provided discreetly. An immediate requirement has been made regarding Standard 9 and a requirement has been made regarding Standard 7. Glebe House (Chaldon) DS0000013324.V331307.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A small range of activities are available, but these need to be reviewed in consultation with residents. Residents are supported to maintain contact with their families and friends. A well-balanced diet is provided to suit the needs of residents. EVIDENCE: From the information supplied with the pre-inspection questionnaire and from speaking to residents, it was clear that a range of activities are arranged. A monthly list of events is displayed in the entrance hall and this included music and movement sessions, sing-a-longs, celebrations of residents’ birthdays, as well as visits by the GP, hairdresser, physiotherapist and chiropodist. There was a mixed response on the CSCI feedback forms regarding activities, with some residents indicating there were activities to join in with if they wished, whilst other residents indicated they would enjoy other activities, such as quizzes or bingo, which are not currently arranged. Other residents indicated that they had enjoyed activities in the past but were no longer able to take part or that they did not enjoy group activities. Glebe House (Chaldon) DS0000013324.V331307.R01.S.doc Version 5.2 Page 14 The manager stated that a visiting activities organiser had previously been employed, but had left the home three months ago. As the response from residents about activities was so varied, it is recommended that the activities programme is reviewed and revised. This should be carried out in consultation with residents, to ensure that it is fully meeting their social and recreational needs and to reduce the emphasis in the home, on the care and nursing aspects of residents’ lives. As many residents are very disabled, elderly or frail and find it difficult to go out, the manager advised that the home tries to bring the community in and a monthly communion service is held at the home by a visiting priest, for example. It was clear that visitors are welcomed in the home and a number of visitors were attending on the day of inspection to celebrate a resident’s birthday. One resident regularly attends a local day centre, which enables them to maintain contact with their friends and to meet new people. A two-week menu was supplied with the pre-inspection questionnaire and from this, it is clear that a well balanced diet is offered. The lunch-time meal on the day of inspection appeared appetising and corresponded with the menu displayed. A copy of the weekly menu is provided to residents who are cared for in bed so that they can anticipate their meals and request an alternative if they do not wish to have the meal that is planned. Comments regarding meals from residents’ feedback forms ranged from “very good food” to “can be a little repetitive, especially the evening meal”, and the majority of residents indicated that they usually enjoy their meals. A number of residents required a soft or liquidised diet and this was presented attractively, with each item of food liquidised separately. Staff were seen to assist residents who required assistance in a sensitive way, making conversation and giving residents time to enjoy their meal. Glebe House (Chaldon) DS0000013324.V331307.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The few complaints that are received are appropriately managed. Staff are aware of their responsibilities in the safeguarding of residents. EVIDENCE: The manager stated that the complaints procedure is displayed in the entrance hall, although few complaints are received and any dissatisfaction would usually be advised verbally to the manager or nurse in charge and would be dealt with immediately. The pre-inspection questionnaire recorded that only one complaint had been made during the last twelve months and the manager was able to advise of this and the outcome. The majority of residents who completed and returned CSCI feedback forms, indicated that they knew who to speak to if they were unhappy and knew how to make a complaint. Copies of six recent letters of compliment which had been received at the home were provided by the manager, and all commented positively on the kindness and standard of care that had been received. It was clear from speaking to staff that they have received training in the safeguarding of vulnerable people and were aware of the differing types of abuse. Staff stated that they would report any incidents or suspicions of abuse Glebe House (Chaldon) DS0000013324.V331307.R01.S.doc Version 5.2 Page 16 to the manager of nurse in charge and would not hesitate to do so. Staff advised that they felt confident that appropriate action would be taken, but were aware that they could raise concerns outside the home if needed. A number of policies and procedures are available to guide staff, including a Whistle-blowing policy and an abuse policy. It was noted that the home’s abuse policy needs to be updated as it refers to the National Care Standards Commission (NCSC) not CSCI, and does not refer to the Surrey Multi-Agency procedure for safeguarding adults. The manager stated that in the event of an allegation or incident of abuse, the home would follow the Surrey Multi-Agency procedure, a copy of which is held in the home. It was noted that the copy held in the home was outdated and it is recommended that the most recent version is obtained. Recommendations have been made regarding Standard 18. Glebe House (Chaldon) DS0000013324.V331307.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home presents as a safe, well-maintained and comfortable place in which to live. All areas of the home were freshly aired and appeared hygienic. EVIDENCE: The home is very well decorated and furnished to a high standard and presents as an attractive and comfortable place to live. Two lifts ensure that residents can access all areas of the building, as the home is set over three floors. Spacious communal areas are available, including a lounge, dining room and conservatory. Corridors are wide enough to allow for the passage of wheelchairs and large well-equipped bathrooms are available and easily accessible on each floor. The manager stated that it is planned to replace one of the easy access baths with Glebe House (Chaldon) DS0000013324.V331307.R01.S.doc Version 5.2 Page 18 a more modern version, with improved facilities, as already carried out on another floor. Residents’ bedrooms were of varying sizes and many were equipped with an en-suite toilet or toilet and basin, and all bedrooms had fitted wash-hand basins. There are a small number of double bedrooms and moveable screens are provided to ensure each resident’s privacy. A number of resident bedrooms have doors opening onto patios and many overlook the well-kept garden or surrounding countryside. The home was very well maintained, with a number of recently refurbished resident bedrooms. The home has two cats, two budgerigars and the manager advised that residents are welcome to bring their pets into the home with them. All areas of the home were clean, freshly aired and appeared hygienic. Hand– washing facilities with liquid soap and paper towels were available in all appropriate places and a sluice room is available on each floor. Staff were observed to use personal protective equipment, including gloves and aprons, to prevent the spread of infection and the home has a contract for the removal of clinical waste. A laundry is sited away from the kitchen and food-handling or storage areas and is well equipped with washing and drying machines with appropriate settings. Staff were observed to move soiled laundry items in appropriately coloured plastic bags. Glebe House (Chaldon) DS0000013324.V331307.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. An effective and well trained team of staff are employed to meet the needs of residents. All recruitment documents and records must be obtained and kept in the home to fully safeguard residents. EVIDENCE: From the information supplied with the pre-inspection questionnaire, it was clear that a full team of staff are employed to meet the needs of residents, including care and nursing staff, housekeeping staff, catering staff and administrative staff. A number of care staff have undertaken and achieved a National Vocational Qualification (NVQ) in care to level two or above and the home has achieved the target of 50 NVQ qualified staff. Qualified nurses are employed day and night and lead the staff team on each shift. The files of a number of staff were sampled and recruitment documents and training records were seen. Most of the appropriate checks had been carried out during the recruitment of staff including references and Criminal Record Bureau (CRB) disclosures. It was noted that confirmation of identity and entitlement to work in the UK, or a photograph had not been obtained or Glebe House (Chaldon) DS0000013324.V331307.R01.S.doc Version 5.2 Page 20 retained for two members of staff. For another member of staff, a full employment history had not been obtained. The manager stated that documents regarding confirmation of identity and entitlement to work in the UK would have been seen to enable applications for CRB’s, but this information had not been retained. It is clear from the information supplied and records seen, that staff have undertaken a wide range of training, some required by law, including fire safety, first aid and food hygiene. Other training has been undertaken to develop knowledge and skills, including mouth-care, infection control, customer care, continence and bereavement. The staff team is predominantly female which is reflected in the resident group. The cultural and racial diversity of the staff group is not reflected in the resident group, with all residents who completed CSCI feedback forms, describing themselves as British. A requirement has been made regarding Standard 29. Glebe House (Chaldon) DS0000013324.V331307.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is effectively managed by a qualified and experienced person and is run in the best interests of the residents. The health and safety of residents and staff are promoted and protected. EVIDENCE: From information supplied with the pre-inspection questionnaire, it was clear that the manager is a qualified nurse, has achieved the NVQ Registered Manager’s Award, has run the home for twenty two years and has the required knowledge and experience for the role. Staff confirmed that the manager is approachable and supportive and the home is run in an open manner. The manager advised that the last survey of the quality of the service provided was carried out a year ago. As the home is a member of the Registered Glebe House (Chaldon) DS0000013324.V331307.R01.S.doc Version 5.2 Page 22 Nursing Homes Association, a quality survey devised by the association has been used in the past. The association are developing a new survey to link with the revised National Minimum Standards (NMS) and the manager stated it is planned to use this format when it is produced. A number of CSCI feedback forms were supplied to the home for distribution to residents, relatives or visitors and healthcare professionals and a good response was obtained. Twenty feedback forms were completed and returned by residents, seventeen by relatives or visitors and seven by healthcare professionals. The majority of responses were positive, although some residents indicated they would like more variety of social activities and some visitors indicated they were not aware of the complaints procedure. A very small number of visitors indicated that they felt there were not enough staff on duty to enable staff to have time to sit and chat or socialise with residents. The manager stated that no monies are held for safekeeping for residents, as any additional expenses, such as for hairdressing or chiropody, are paid for by the home and invoiced to the resident or their representative. It was clear from the information supplied and records seen, that systems and equipment in the home are maintained appropriately and to the required frequency, to safeguard the health and safety of all who live and work at the home. No hazards were noted on the tour of the premises and the health and Safety at Work poster and insurance certificate were displayed as required. Glebe House (Chaldon) DS0000013324.V331307.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 X 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 4 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 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 (Chaldon) DS0000013324.V331307.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 OP2 Regulation 5 (a) Requirement Residents must be provided with a statement of the terms and conditions on, or before the day of admission, or a contract if purchasing their care privately. Any known or identified risks to residents must be assessed and wherever possible minimised. (a) The amount of medication held in the home must accurately match the record held; (b) Residents must not be left without a supply of their prescribed medication; (c) The administration of medication must be accurately recorded and (d) Medication prescribed for a resident must not be administered to any other resident. All the required recruitment documents and information for applicants to work in the home, must be obtained and retained in the home, including confirmation of identity, entitlement to work in the UK, a recent photograph and a full employment history. Timescale for action 27/04/07 2 3 OP7 OP9 13(4) (c ) 13 (2) 28/03/07 28/03/07 4 OP29 19 28/03/07 Glebe House (Chaldon) DS0000013324.V331307.R01.S.doc Version 5.2 Page 25 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 OP9 Good Practice Recommendations It is good practice for any hand-written entries on medication administration record charts, to be signed by the person making the entry and for the entry to be checked and countersigned by an appropriately trained person. It is recommended that the social and recreational activities provided are reviewed and revised, in consultation with residents. It is recommended as good practice that an updated copy of the Surrey Multi-Agency procedure for the safeguarding of adults is obtained and retained in the home. It is recommended that the home’s procedure regarding abuse is reviewed and revised, to include reference to the Surrey Multi-Agency procedure for safeguarding adults and to refer to CSCI (not NCSC). 2 3 4 OP12 OP18 OP18 Glebe House (Chaldon) DS0000013324.V331307.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Burgner House, 4630 Kingsgate Cascade Way 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. 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