Inspection on 29/11/07 for Glebe Lodge

This inspection was carried out on 29th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 Lodge 25/11/08

Glebe Lodge 27/06/06

Glebe Lodge 01/11/05

Glebe Lodge 12/06/05

Glebe Lodge 10/11/04

Glebe Lodge 12/05/04

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

CARE HOMES FOR OLDER PEOPLE Glebe Lodge 2 Hall Street Offerton Stockport Cheshire SK1 4DA Lead Inspector Michelle Haller Unannounced Inspection 29th November 2007 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 Lodge DS0000008601.V350940.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 Lodge DS0000008601.V350940.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glebe Lodge Address 2 Hall Street Offerton Stockport Cheshire SK1 4DA 0161-480 2025 0161 480 2025 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) Care UK Mental Health Partnership Limited (Arc Healthcare Limited) Mrs Susan Nixon Care Home 17 Category(ies) of Dementia (2), Mental disorder, excluding registration, with number learning disability or dementia (15) of places Glebe Lodge DS0000008601.V350940.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service is registered for a maximum of 17 service users to include: *up to 2 service users in the category of DE (Dementia over 50 years of age). *up to 15 service users in the category of MD (Mental disorder excluding learning disability or dementia over 50 years of age). 27th June 2006 Date of last inspection Brief Description of the Service: Glebe Lodge is a residential care home that is registered to provide care for up to 17 residents whose primary care needs are due to them having a diagnosed mental illness; three of whom are aged between 50 years and 65 years of age. The registered manager is Mrs Susan Nixon. Glebe Lodge is one of 75 care homes owned by the Care UK group who focus on providing rehabilitation services for residents with mental health difficulties. Glebe Lodge is a listed building; it is a large, detached house set in its own grounds. All bedrooms are single person occupancy spread over three floors. There are no en-suite facilities at the home, however all bedrooms have a vanity unit. The home has three bathrooms, one of which is fitted with an assisted bath and one is a shower room. The home has two lounges, one of which remains a smoking lounge, and a dining room. There is a large car park to the rear of the house with gardens to the side and front. There is a four-person passenger lift to assist residents around the home. There are a number of steep steps to the front of the property and ramp access is available to the rear of the home. Glebe Lodge is situated close to the town centre with good access to cinemas, local shops, library and park. Stockport town centre, motorway network and public transport are easily accessible. Glebe Lodge DS0000008601.V350940.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process involved interviews with two people individually. One care assistant was also interviewed and in depth discussions with the manager and deputy manager took place. Five care files and other records and reports pertaining to these people were inspected. Other documents concerning the running of the home were also examined. The Commission for Social Care Inspection (CSCI) ‘Annual Quality Assurance Assessment’ which was completed by the manager also provided information that influenced the outcome of the inspection. Three resident CSCI surveys were returned and in the main these people were very positive about the care and support they received in the home. A tour of the communal areas of the home was also undertaken and during the course of the inspection the interactions between people in the home were observed. The home charges £391-68 for people aged over 65 years and £358.02 for people under 65 years old. The latest Commission for Social Care Inspection report is available on request. What the service does well: Over all the outcomes for people living in the home are positive and people are happy to be living at Glebe Lodge, people said ‘I like living here (at Glebe Lodge) the garden is nice- everything.’ And ‘I can’t think of a word high enough to praise them.’ The manager ensures that needs are fully assessed before people move into the home. The manager promotes good health and wellbeing by developing comprehensive and informative care plans that relate directly to needs. People are encouraged to be involved in developing and updating their plans. There is effective contact and access to health and social care professionals. Staff at Glebe Lodge are friendly and caring. The manager makes sure that they fully understand their responsibilities in promoting people’s independence Glebe Lodge DS0000008601.V350940.R01.S.doc Version 5.2 Page 6 and right to respect, dignity and choice. The manager ensures that good relationships are promoted between all who are involved in the home. People are encouraged to maintain self-help and domestic skills and continue to access the local and wider community. The ethos of the home is open. There are successful systems in place that enable residents and staff to have their concerns, complaints and opinions heard, and it is clear that these are given credence. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Glebe Lodge DS0000008601.V350940.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 Lodge DS0000008601.V350940.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (standard 6 is not applicable.) Quality in this outcome area is Excellent. People who use the service have their needs fully assessed prior to moving into the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five care files were examined; four belonged to established residents and one for a person about to commence living at Glebe Lodge. Each file contained a detailed and comprehensive needs assessment. These provided detailed and individualised information about peoples needs including night care assessments, nutritional assessment, lifestyle preferences and social history. Glebe Lodge DS0000008601.V350940.R01.S.doc Version 5.2 Page 9 In respect of the pending admission a pre - admission assessment had been completed providing basic information concerning psychological and health needs and highlighting risk areas including communication and dietary concerns. Records and reports also confirmed that people were able to spend periods of time in the home, including mealtimes and over night stays, to assist with the decision about the home’s ability to meet individuals needs. Contracts and terms and condition of residency were on each file of the people residing in the home. People who returned CSCI surveys felt that they had been provided with sufficient information about the home before moving in. And staff who were interviewed assessed that they were provided with sufficient information to meet the needs of people. One person stated: ‘The manager discusses the needs of service users to check that we can deal with service users and different situations.’ On the day of the inspection the manager and deputy reassessed a person who was in hospital to ensure, before they returned, that their needs could still be met at Glebe Lodge. Signatures also confirmed that people were encouraged to participate in the assessment process. Glebe Lodge DS0000008601.V350940.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in this outcome area is good. The manager promotes physical and emotional well being by ensuring that health and personal care provided is based on individual needs and that the principles of respect, dignity and privacy are put into practice at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans related closely to needs assessment and provided detailed information about the actions staff were to take to ensure that health and other needs were fully met. Care plans had been regularly reviewed and updated and signatures confirmed that people receiving support had been involved in the process. Care plans were individualised and highlighted specialist care required for example, community psychiatric input, files and daily records. Correspondence, reports and other records confirmed that people received medical attention, monitoring and routine and specialist health Glebe Lodge DS0000008601.V350940.R01.S.doc Version 5.2 Page 11 checks in keeping with their needs. It was clear that people had access to full health and social care specialists including chiropodists, general practitioners, dentists, dieticians, psychiatrists and psychiatric nurses, social workers, optician and continence services. People said that staff supported them when attending outpatient hospital appointments. In respect of monitoring, this area could be improved if staff recorded weights either using imperial or metric measure and not both. This will reduce the risk of confusion in relation to whether people have gained or lost weight over a period of time. Medication record sheets were examined and no unaccounted for gaps were seen. This area could be improved further if all medication was signed in when received. Records confirmed that the effectiveness of medication was assessed and consultation with the psychiatrist or general practitioner initiated if there were concerns. Daily records, in the main, contained information that was pertinent to the individual and linked directly to care plans, providing a good picture of peoples response to the care and support offered. These were written respectfully. Observation and interaction between staff and people living in the home indicated that people were relaxed and spontaneous in their relationships and staff treated people with respect and consideration. Certificates confirmed that some staff have received medication training and the notes from staff meetings indicated these were used as a training and updating opportunity in relation to the safe administration, storing and recording of medication. Staff meeting records also confirmed that the importance of working in line with the homes philosophy of care concerning respect, dignity and choice was discussed with staff and reiterated. People were keen to say that their health needs were fully met and that they were treated with dignity and respect at all times. Comments included: ‘Staff – yes I like the people- they are very obliging.’ ‘I can’t think of a word high enough to describe them.’ And -‘ I need(ed) help with body cleansing i.e. hygiene; the staff are very tactful and never too busy to help me.’ Glebe Lodge DS0000008601.V350940.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. 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. People benefit from a service that promotes choice and individuality in respect of social, educational and recreational activities. EVIDENCE: Social histories were detailed and this information should help to devise varied activities that will assist with the maintenance of old skills and interests and provide opportunities for people to try new activities. Records indicated that people had enjoyed a variety of group and individual activities including a visit to Blackpool lights, theatre trips, shopping at a local retail park, games and bingo with prizes. This area could be improved if there was evidence that the activities on offer linked in with the interests that people had identified. People are encouraged to use local facilities such as shops, hairdressers, pubs and restaurants. Care plans and assessments indicated that people’s individual routines and habits were fully catered for and that the routines in the home were flexible. There were no restrictions in relation to visitors, going to bed, getting up, bathing or other lifestyle choices. Two of the three people who returned surveys assessed that activities always met their needs and those who were Glebe Lodge DS0000008601.V350940.R01.S.doc Version 5.2 Page 13 interviewed were content with activities and community contact facilitated by the home, saying ‘my daughters visit every day- visitors can come when they are ready-I use the phone. I do some jobs, cleaning, washing up and set the tables- putting the cutlery out. I’ve been to Blackpool recently.’ ‘I go out, I have a radio that I listen to, we play bingo- I think the activities are brilliant.’ The manager has also ensured that people have been able to maintain contact with friends and family that have been unwell. Care staff prepare breakfast, afternoon meals and supper. The lunchtime meal is provided by an outside catering service. The meal on the day of inspection was not examined. People who were interviewed and who returned CSCI surveys commented that the meals were always sufficient and generally enjoyed, with two people being very positive about the food and one person observing that ‘There are some meals I don’t like.’ This person was also interviewed and she felt that potatoes, in different forms, were repeated, however she also observed that she was always offered an alternative if she did not want what was provided and that she had put on weight since moving into Glebe House and that food was in plentiful supply. People’s comments during the inspection about the food included ’I’m never hungry.’ ‘We get a lot of food and it’s good- there’s always extra available if wanted.’ ‘I like all the meals.’ The menu that was posted for the day was beef and onion pie or roast lamb or cheese omelette. The contents of the fridge and larder were examined to assess the food available to people. The larder was well stocked with fresh fruit, vegetables and salads, eggs, cheese, ham, bacon, cereal, milk, bread cakes, biscuits and tinned produce including baked beans and tomatoes. The manager said that some items such as fruit were purchased twice a week to ensure freshness. Food appears to be an important event in the lives of people living in the home and the residents meetings highlighted that people enjoy a weekly theme night that includes a special menu of for example, Thai, Chinese or Indian food and people were also encouraged to make suggestions for additional items. During the inspection people were observed freely helping themselves to drinks and snacks available in a small kitchen area. Nutritional assessments are in place for people who are vulnerable to weight loss however these would be of more use if a detailed record of the food and drink consumed were maintained and if weights were recorded consistently in a single format. Glebe Lodge DS0000008601.V350940.R01.S.doc Version 5.2 Page 14 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. People at Glebe Lodge are able to express their concerns, and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. EVIDENCE: People who commented during interview or via CSCI surveys felt that they knew how to complain and that any concerns would be listened to and treated with fairness. Comments included ‘I would talk to the manager or deputy- but I’ve never made a complaint.’ The notes from the most recent residents’ meetings also demonstrated that this forum was used to remind people of their the right to complain and to remind them and answer questions about the home’s complaints procedure. The majority of staff have completed adult protection training that has been provided mostly internally. However this training also includes an element of assessment concerning the effectiveness of the training and the knowledge gained. The complaints and incidents records in the home were examined. In the past year CSCI had received one notification concerning a safeguarding adults issue. This had been dealt with openly and effectively, involving the relatives, Glebe Lodge DS0000008601.V350940.R01.S.doc Version 5.2 Page 15 social workers and senior managers of the organisation. The investigation was carried out under the guidance of the Stockport all agency safeguarding policy. A copy of this policy was readily available in the office and the manager acknowledged that lessons had been learned in relation to who needed to be notified in the event of such incidents. The member of staff who was interviewed was clear about the conduct and behaviours that could be considered abuse, she stated that if there were altercations between people living the home this would be recorded and discussed with the manager. She felt that the action taken would include writing everything down speaking to the people concerned and involving others such as their social worker in trying to solve any problems. Glebe Lodge DS0000008601.V350940.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical design and layout of Glebe Lodge enables residents to live in a safe, well-maintained and comfortable environment and promotes independence in some areas. EVIDENCE: During the tour of Glebe Lodge it was noted that communal areas were clean, comfortably furnished and homely. There is a programme of refurbishment in progress, a wet room has been installed, vanity units fitted and two bedrooms completely redecorated. The manager reported that some shoddy and broken furniture had been replaced. The manager stated in the AQAA that is was necessary to have an ‘Ongoing decorating programme to improve the environment ‘ Glebe Lodge DS0000008601.V350940.R01.S.doc Version 5.2 Page 17 In the main furniture, fixtures and fittings that were seen were clean, free from unsightly stains and in reasonable repair. Some domestic kitchen equipment was in place and used by people living in the home. People were pleased with their bedrooms and those that were entered had been personalised and people had keys to their bedrooms. The manager has reported that since the previous key inspection the garden areas have been landscaped and made more pleasant and safe to use. Notes from the most recent residents meeting confirmed that this area was being improved at it was recorded that people had requested the installation of a bird table. The philosophy of the service is to maintain independence and people who are physically able to do so are encouraged to take some responsibility for the general tidiness of their rooms. The communal areas, except for the smoking lounge, and the majority of private rooms that were entered were free from unpleasant odours. Glebe Lodge DS0000008601.V350940.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People at Glebe Lodge benefit from staff in the home that are trained, skilled and in sufficient numbers to meet their needs, however more must be done to demonstrate that the homes recruitment and employment policies are robustly followed, and reviewed in relation to employing suitable people. EVIDENCE: On the day of inspection Glebe Lodge appeared adequately staffed, there were 15 people registered in the home and the staff complement for the early shift was five people including the manager and deputy. Three staff files were fully examined, and these included established staff and a recent recruit to the bank. The records held for each person included a copy of their application forms, some interview notes, at least two references, medical questionnaire and copies of proof of identification, Criminal Record Bureau checks and confirmation of POVA first checks. It was noted that the homes employment policy did not include renewal or repeats of CRB checks. Furthermore staff did not consistently sign the declaration concerning rehabilitation of offenders. This is required to assist with ongoing supervision needs and monitoring of staff conduct in relation to adult protection. Glebe Lodge DS0000008601.V350940.R01.S.doc Version 5.2 Page 19 The induction process was discussed with the manager; she stated that an ‘Induction Checklist’ was in place. This process was in keeping with Glebe Lodge’s management company Care Uk’s induction guidance. It covered topics such as understanding the role of a care worker, responsibilities of care work, reading through manuals and policies, introduction to the philosophy of care and the residents’ charter. The manager must ensure that she can demonstrate that staff have access to an induction programme that provides them with training and experiences in line with the recommendations from the Skills for Care Council Records and certificates indicated that staff had access to outside training and training provided by the manager. External training courses have included Control of Substances Hazardous to Health (CoSHH). Training provided in house included moving and handling, health and safety, food hygiene and fire safety. Supervision and other records demonstrated that the effectiveness of training was monitored and taken into consideration, and additional training and clarification provided when needed. The manager also recorded ongoing guidance and training provided to staff in the form of discussions concerning patient care, personal care, risk assessment, care planning, reviews and recording activities and interests. The manager stated that in the coming year the training calendar would include specialist subjects such as the effect of current mental health legislation on rights of people and how support can be offered. People who returned CSCI surveys felt that staff were readily available and comments included ‘Day or night staff always available.’ Glebe Lodge DS0000008601.V350940.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35, 36 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People at Glebe Lodge benefit as the management and administration of the service is professional and competent, based on openness and respect and quality assurance systems are in place. EVIDENCE: The manager Sue Nixon has successfully completed the CSCI registered managers process and is about to commence NVQ level 4 in management qualification. Staff and people living at Glebe Lodge felt that she was open to suggestions and approachable. People felt that there was a response to any consultation and that this was an improvement since the previous inspection. People said: Glebe Lodge DS0000008601.V350940.R01.S.doc Version 5.2 Page 21 ‘the place has changed for the best-and we have been asked our opinion on the manager.’ And ‘We are asked for feed back- it’s open.’ In the past year anonymous staff and residents’ satisfaction surveys have been completed and analysed. This process identified that, of the residents who returned the surveys, the majority felt that activities were ‘Good’, and felt the level of care was excellent. Areas that needed to be developed were identified and there was indication- such as the introduction of themed meal nights – that when the areas for improvement were identified changes were quickly made. Separate and joined staff and residents meetings are also used as a means of quality monitoring in the home and supports an open, transparent and responsive way of managing the home. There appeared to be adequate recording and accounting of people’s money in the home. The accounts for four people were checked and these balanced. Staff supervision records were examined and this provided evidence that the manager spent time with staff, individually, in groups, directly as they go about their work and in private. In doing this she has identified, confirmed and built on strengths and areas of good practice. She has also identified solutions for areas of weakness including, general guidance, training including direct intervention such as shadowing, demonstration and modelling in order to improve work performance and the outcomes for residents at Glebe Lodge. The manager completed the AQAA confirming that all appliances and safety checks had been carried out within the 2007 as recommended by the manufactures or regulatory body such as the fire service. As identified previously staff have received COSH, health and safety first aid, food hygiene and first aid training. The manager should ensure that all inhouse training provided is regularly up-dated with current best practice. Glebe Lodge DS0000008601.V350940.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 4 X X 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 3 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 3 X 3 Glebe Lodge DS0000008601.V350940.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP38 Good Practice Recommendations The registered person should ensure that in-house training including induction, is up-to date with the latest ideas in the areas that are taught, this will ensure that the best care is offered because it will be supported by the most recent and up to date research and guidelines. The registered person should ensure that there is a mechanism in place for recording the actual food intake of people. The registered person should ensure that weights are recorded in a manner that makes it easy for staff to immediately identify weight gain or loss, which will mean that steps to implement the best intervention will be taken quickly. The registered person should have a mechanism in place that will alert her to staff conduct that may have a bearing on their supervision needs. 2 3 OP15 OP15 4 OP29 Glebe Lodge DS0000008601.V350940.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Glebe Lodge DS0000008601.V350940.R01.S.doc Version 5.2 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!