Inspection on 17/04/07 for Glebe, The Care Home

This inspection was carried out on 17th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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, The Care Home 06/06/06

Glebe, The Care Home 14/11/05

Glebe, The Care Home 19/04/05

Glebe, The Care Home 19/10/04

Glebe, The Care Home 21/04/04

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

CARE HOMES FOR OLDER PEOPLE Glebe, The Care Home Church Street Alfreton Derbyshire DE55 7AH Lead Inspector Denise Bate Key Unannounced Inspection 17th April 2007 09:15 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, The Care Home DS0000035739.V335960.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, The Care Home DS0000035739.V335960.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glebe, The Care Home Address Church Street Alfreton Derbyshire DE55 7AH 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) 01773 728347 www.derbyshire.gov.uk Derbyshire County Council Ms Gladys Maureen Cope Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Glebe, The Care Home DS0000035739.V335960.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION 33 1. Conditions of registration: Derbyshire County Council is registered to provide personal care and accommodation at Glebe Care Home for service users whose primary care needs fall within the following category: Old age, not falling within any other category (OP) 32 The maximum number of persons to be accommodated at Glebe Care Home is 32 6th June 2006 2. Date of last inspection Brief Description of the Service: The Glebe is situated in the centre of the busy market town of Alfreton, close to local shops, facilities and public transport. The Glebe is owned by Derbyshire County Council and provides 24 hour personal care and accommodation for 32 older people. All accommodation for residents is in ground floor, single rooms. There are no en-suite facilities. There is a large garden accessible to residents. Fees are £381.84 per week for permanent service users, but a range of prices for short term care service users. Additional charges, e.g. hairdressing, chiropody, are clearly identified in the home’s Statement of Purpose and Service User Guide. Glebe, The Care Home DS0000035739.V335960.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over seven hours. During the inspection seven residents, three relatives, and four staff members were spoken with. The manager and a deputy manager were present during the inspection and provided assistance and information. On 18 December 2006 a random inspection was carried out to assess actions taken with respect to requirements listed on the report from the visit undertaken on 6th June 2006. Reference to this visit is contained within this inspection report. A number of records were examined, including care planning documentation, minutes of meetings, regulation 26 visit records, staff files and medication records. Three residents were case tracked and care planning documentation and files for other residents were seen. A tour of the building and the grounds took place. What the service does well: The Glebe provides a comfortable, homely, relaxed environment for residents. Residents and relatives spoken with made positive comments about the home and staff; ‘the staff are very, very good’; ‘they know my wants and meet them to the best of their ability’; ‘I like it here’, ‘people are nice, very obliging’. The management team were seen to be approachable and responsive. Staff were observed taking every opportunity to react positively with residents while carrying out routine tasks. Communal areas of the home are comfortable and provide a range of areas for service users to use. The home was found to be generally reasonably maintained and clean throughout. The food was said to be ‘very good’ and quality and presentation was praised by all residents and relatives spoken with. Staff spoken to were experienced, enthusiastic and knowledgeable. There is a stable staff group who are very close knit and supportive. They felt well supported by the management who provided practical support during busy periods. Staff supervision is up to date and training is given a high priority. All care staff, except one, are trained to NVQ level 2. Deputy managers are going to undertake the registered managers award. There is a robust system for recruiting and training new staff and appropriate checks are carried out. Glebe, The Care Home DS0000035739.V335960.R01.S.doc Version 5.2 Page 6 There is a corporate complaints procedure, although most day to day difficulties are dealt with on an informal basis. There is a clear safeguarding adults procedure and staff have received appropriate training. 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 Glebe, The Care Home DS0000035739.V335960.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Glebe, The Care Home DS0000035739.V335960.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, The Care Home DS0000035739.V335960.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): 1, 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available to ensure residents can make an informed choice about where they live. EVIDENCE: A requirement was made at the last key inspection to update information in the statement of purpose and service user guide. This had been carried out by 18.12.06. Copies of the updated statement of purpose, service user guide, and other information are made available to current and potential residents. Copies are kept in each resident’s bedroom and in the lounges. A copy of the most recent inspection report is kept on the notice board in the foyer together with other relevant information. In practice quite a few residents know the home Glebe, The Care Home DS0000035739.V335960.R01.S.doc Version 5.2 Page 10 through short term care or day care, so some prospective long term residents are already familiar with the service provided. Others have decided to become residents through the home’s local reputation or personal recommendation. The manager visits prospective residents at home or in hospital as part of the assessment process. Prospective residents or their advocates are encouraged to visit prior to making a decision. Copies of assessments carried out by social services staff were seen on care planning documentation of case tracked residents. The home does not provide formal intermediate care and therefore standard 6 does not apply. Glebe, The Care Home DS0000035739.V335960.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, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are completed in detail and are individualised to demonstrate that residents’ health, personal and social care needs are being fully met. EVIDENCE: Three sets of care planning documents were seen at the 16.12.06 visit. These had been substantially improved and included a personal profile, logs, a detailed and informative personal service plan signed by the resident, review meeting minutes, monthly written reviews, and a monthly monitoring check list as well as records of health professionals visits. The improvements to care planning documentation have continued to be maintained. Three case tracked residents had clearly arranged care planning documentation covering all aspects of care. Items in files included copies of Glebe, The Care Home DS0000035739.V335960.R01.S.doc Version 5.2 Page 12 reviews, personal service plans, risk assessments (moving and handling, falls prevention, nutrition), weight monitoring, health care professional visits, reviews and detailed day to day logs. Personal service plans were clearly written and resident focussed and individualised e.g. including food preferences, private hairdressing arrangements. There was some out of date information on one resident’s current file that could be archived to prevent confusion, e.g. self medication form. One risk assessment seen relating to falls could have been completed in more detail. Personal service plans had been signed by residents, indicating that they had been discussed and agreed with them and/or their advocates. The personal service plans are used as a working tool, well presented, written in clear language, and could be used in an emergency by people who are not familiar with their contents. The home are in the process of introducing a computer based care recording system, which was shown to the inspector. For each resident a second care file contains financial information and background details and copies of assessments and care plans that have been superseded. There were copies of contracts available for some residents, but copies for other residents had been archived. At previous inspections it has been noted that when resident dependency was very high staff were very busy which could possibly lead to insufficient staff being on duty to meet all residents needs. As part of monitoring this situation the home are undertaking dependency assessments. Staff were observed supporting and reassuring residents. There was a good deal of good natured ‘banter’ between staff and residents. Staff described the ‘family atmosphere’ in the home and said they had close relationships with many residents. Staff take every opportunity to interact sensitively with service users. Residents said staff are ‘very patient’, ‘they don’t get ratty with you’, ‘they come when you ring the bell’. Staff look after residents ‘as I would like my own parent to be looked after’. Staff said the home have an efficient system of communication between staff shifts, which contributes towards consistency of care. Staff spoken to emphasised the importance of keeping daily logs up to date and these are used as a major channel of communication. All aspects of residents health needs and medication were clearly presented, although care will be needed to ensure both paper and electronic records are kept up to date simultaneously. Residents and relatives spoke extremely highly of the excellent quality of care provided; ‘the staff are very kind and patient’; ‘they always take their time when they give me a bath’. There is a key worker system that operates effectively. As mentioned elsewhere in this report, the quality assurance exercise found that the overall quality of care was rated as ‘good’ or ‘excellent’. Glebe, The Care Home DS0000035739.V335960.R01.S.doc Version 5.2 Page 13 The home uses the monitored dosage system for medication and there is a separate medication room. The medication records of some case tracked residents were seen and found to have been recorded correctly. The date of opening had been recorded on eye drops and creams. The fridge temperatures were being monitored. The home have access to medication reference books to provide information about particular drugs and their uses and side effects. The home have obtained a copy of The British Pharmaceutical Society Guidance. Three deputy managers have undertaken medication training and one deputy is taking over responsibility for medication issues to ensure all aspects of the home’s practice is in line with current Derbyshire County Council guidelines. A record is kept of staff signatures but some signatures on the MARs sheets were difficult to identify. The manager reports a good relationship with local GPs and District Nurses. Staff said that doctors ‘are always called straight away’ when there are any health issues relating to residents. Glebe, The Care Home DS0000035739.V335960.R01.S.doc Version 5.2 Page 14 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, 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is committed to improving the quality and recording of activities taking place and the quality of catering is good which contributes to a pleasant atmosphere and the overall levels of satisfaction for residents. EVIDENCE: At the 18.12.06 visit the inspector was shown records of activities that were taking place at the home. It was acknowledged that sometimes activities had had less priority because of meeting residents care needs, but staff spoken to felt that their capacity to organise activities had improved. At the 18.12.06 visit it was noted that the home had been beautifully decorated for Christmas, and residents spoken to felt that staff had made a real effort to ensure their surroundings reflected the seasonal celebrations. Glebe, The Care Home DS0000035739.V335960.R01.S.doc Version 5.2 Page 15 On this occasion residents and staff confirmed that some activities and entertainment took place, although not all residents spoken to wanted to take part. A student social worker was doing a placement at the home and planning a reminiscence group. She has been doing a considerable amount of work,e.g. collecting information about past hobbies and interests, but this was not reflected in the home’s records. Bingo was a favourite pastime, and a small group of residents use one of the lounges to play dominoes in the afternoon, and were doing so on the day of inspection. There are a number of religious groups who visit on a regular basis. The home is near Alfreton, and staff said that they sometimes took residents out shopping. An days outing was planned for Thursday, and it is hoped that more will take place over the summer. The records for activities had not been kept up to date in recent weeks, nor were forthcoming events publicised on the weekly calendar. A consultation with residents had taken place regarding spending money on a patio, but this was not recorded anywhere. The need to develop activities was identified in the last quality assurance exercise. The manager said that they have not been able to interest current residents in forming a residents group. Considerable discussion took place on this issue and the home have been advised to consult colleagues in other homes where there are active residents groups and activities are provided by some outside agencies. In addition other methods of obtaining feedback from residents could be developed and recorded. Most residents have contact with family and friends, and three relatives were seen on the day of inspection. They confirmed that they are made welcome at the home, think highly of the service provided and the staff, and are always informed of any significant developments regarding their relative or friend. All residents spoke highly of the quality of catering and the standard of menus, which are wholesome and offer choice. The dining room is pleasant and spacious and allows for the pleasing presentation of meals. Glebe, The Care Home DS0000035739.V335960.R01.S.doc Version 5.2 Page 16 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, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Clear and accessible complaints and safeguarding adults procedures are in place to ensure residents can be confident that any issues raised would be acted on effectively and promptly. EVIDENCE: There is a corporate complaints procedure, although most relatives and residents prefer to raise issues on a more informal basis. There have been no ‘formal’ complaints, and one minor complaint had been recorded in the complaints book since the last inspection. No complaints have been made to CSCI, indeed a letter has been received from relatives praising the very high standard of care provided by the home. Residents and relatives said if they were worried about anything they would talk to one of the managers or the staff. Comments from relatives and residents included: ‘if I wasn’t happy about something I would tell them, I don’t believe in hiding things’; ‘I have no complaints’. Glebe, The Care Home DS0000035739.V335960.R01.S.doc Version 5.2 Page 17 Derbyshire County Council has clear procedures for dealing with the safety of residents and safeguarding them from harm. Staff spoken to showed an awareness of safeguarding adults issues, were clear about their responsibilities and would pass any concerns on to their line manager. Training in safeguarding adults has been provided for staff. Glebe, The Care Home DS0000035739.V335960.R01.S.doc Version 5.2 Page 18 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, 20, 21, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides residents with an attractive and homely place to live, although maintenance of the garden could be improved to enhance residents safety and enjoyment. EVIDENCE: The home provides a range of communal lounges for residents which are homely and comfortable and generally well maintained. There is a spacious dining room where residents can take their meals in comfort. There are a range of bathrooms and toilets and a shower room. Several residents showed the inspector their bedrooms, which were individualised according to their Glebe, The Care Home DS0000035739.V335960.R01.S.doc Version 5.2 Page 19 interests and preferences. Residents were satisfied with their rooms; ‘I like my room’. ‘I am happy with my room, it’s big enough for what I need’. At the 18.12.07 visit outstanding requireemnts relating to the environment had been met,apart from the garden. A plan had been drawn up to identify electrical maintenance which had been prioritised and would be carried out in due course. No urgent electrical work remained outstanding. One toilet could not be repaired and has been taken out of service and was being used as a storeroom. The home has eleven toilets and meets minimum standards. Improvements carried out since the last key inspection included the following; one lounge has been refurbished, a small sun lounge made available to residents, four bedrooms have been decorated since Chirstmas, bathrooms have been redecorated, some new bedroom chairs and commodes have been obtained, new lights have been installed in the corridor, the emergency lights have been replaced. During the tour of the building it was noted that the lights in shower room needed cleaning and the doors on boiler room need painting and the inspector was informed that these will be attended to in the near future. Consideration has been given to replacing exterior and wooden windows as recommended at the last inspection. This may be carried out next year and remains a recommendation. Some areas of the garden had recently been planted with attractive flowers and tubs. This had been done by residents relatives, and it is understood that a volunteer is to continue with some planting of flower beds and hanging baskets. Residents do enjoy sitting outside in fine weather and garden furniture was available, although at present the only area currently available is immediately outside the front door. After consultation with the residents it has been decided to build a patio and this will benefit residents by providing a pleasant area for them to enjoy. However, the garden area did not generally present a pleasing appearance; the grass needed cutting, and some areas outside of the building needed tidying as there were bits of rubbish strewn around. Part of the garden is also being dug up to relay gas pipes. Poor maintenance of the garden has been drawn to the attention of the proprietors on several inspections and will remain a recommendation at this inspection. The home have a cleaning programme and areas of the home seen on the day of inspection were generally clean and tidy. Residents said they were satisfied with the standards of cleanliness. Glebe, The Care Home DS0000035739.V335960.R01.S.doc Version 5.2 Page 20 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, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A trained and competent workforce are in place which meet the dependency needs of residents currently accommodated within the home. EVIDENCE: A requirement was made at the last key inspection because there were insufficient staffing levels to meet residents needs at all times. At that time (June 2006) there were several residents who had very high needs and required two people to transfer them, as well as residents who had dementia and/or a mental health problem. By the 18.12.06 visit three residents had been reassessed and moved to other placements. At that inspection staff spoken to, and the manager and deputy manager, all agreed that overall dependency levels had been reduced and that residents needs were being met at that time. At this visit information on staffing levels was provided which indicates that there are continue to be sufficient staff on duty to meet residents current needs. This was confirmed by staff who said that they had recently been very Glebe, The Care Home DS0000035739.V335960.R01.S.doc Version 5.2 Page 21 busy, but that they were able to meet residents needs. Their priority is ensuring that the needs of the residents are met appropriately and the feedback from residents and relatives suggest that this is achieved. Some discussion took place within the staff group and with managers regarding activities and outings, which do depend on staff goodwill and them being prepared to give up free time. There was also discussion about the recording of information and the advice and guidance available to ensure that standards continue to improve and evidence of improvements gathered by the home. As mentioned previously, the home have introduced a system of dependency monitoring which should allow a systematic overview of the dependency levels of residents within the home. This should assist in ascertaining whether staffing levels remain appropriate and will be discussed at a future inspection. The manager now has access to a ‘flexi-pot’ to finance extra staffing when necessary. Discussions with staff indicated that they are well trained, enthusiastic and committed. They work well as a team and ‘support each other’, ‘our colleagues are brilliant’, ‘it’s a pleasure to come to work’. They are willing to give up their own free time to take residents on outings. Managers and staff were committed to supporting residents for as long as possible; ‘the residents are like family’. Where appropriate managers do their best to ensure that further assessments are carried out when residents needs can no longer be met within the home. The inspector was informed that staff training records are now being stored on the computer in the form of a matrix which makes it easier for managers to ascertain when staff need refresher courses. The inspector was informed that all mandatory training was up to date and that all expect one member of care staff have reached NVQ Level 2. Further planned training includes ‘refreshers’ in first aid and basic food hygiene. One of the deputy managers has recently obtained a qualification in counselling. Although not part of mandatory training, some staff could benefit from training in dementia and mental health needs to enhance their skills to better meet the needs of some residents. This inspector was informed that this is partly being covered for new staff in ‘Skills for Care’ induction training. Two staff files were seen and found to have appropriate records of application forms, references, and evidence of CRB checks having been undertaken. Glebe, The Care Home DS0000035739.V335960.R01.S.doc Version 5.2 Page 22 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, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager is suitably qualified and experienced and staff demonstrate an awareness of their roles and responsibilities, thus ensuring the home is run in the best interests of residents. EVIDENCE: The manager has been registered with the Commission for Social Inspection and is suitably qualified and experienced to carry out her role. The management team consists of the manager and six deputies, three whole time Glebe, The Care Home DS0000035739.V335960.R01.S.doc Version 5.2 Page 23 equivalents. Although one part time manager is currently not at work, all management posts are filled with each manager taking responsibility for an aspect of running the home. The manager is able to go to management meetings with other home managers, and to access training where appropriate. There are plans in place for the deputy managers to undertake their registered managers qualification and risk assessment courses. Discussions took place with the manager regarding the future development of the home, increasing the professionalism of the management team, and changes being introduced by CSCI as part of ‘Inspecting for Better Lives’. As indicated elsewhere in this report; residents benefit from a high level of commitment to meeting their day to day needs. However, in some instances, e.g. social activities, the home could benefit from taking a wider perspective and utilising the experience of other managers of home to provide ideas for development of the service. Staff spoken to said that their supervision was up to date and that they felt very well supported by members of the management team: ‘you can approach them with any problem’, ‘training is always updated’, ‘managers will help with residents if you are very busy’. Managers said they had an excellent staff team. Regulation 26 visit reports were seen which indicated the home is visited regularly by a representative of the registered person and that matters relating to day to day running of the home are dealt with. Residents’ monies are kept in the safe and manual records kept. The inspector was informed that this system is working satisfactorily. A quality assurance exercise has recently taken place and indicated that the overall satisfaction level of the home has improved in the last year, with all residents describing their overall care as ‘good’ or ‘excellent’. A number of suggestions for improvements have been made, including continuing to develop activities. A meeting with the quality assurance manager took place during the first week in the New Year, and a plan of action was drawn up and has now been made available to residents. It is prominently displayed in the main corridor. Some of the benefits identified of living at The Glebe included ‘someone to care for me’, ‘feeling safe’, ‘able to go into town and chat to friends, ‘home is the best I have visited’, ‘convenient for visiting’. The manager informed the inspector that matters relating to health and safety were up to date. On the day of inspection tests were taking place on the emergency lighting, smoke detectors and fire alarms, and records were updated at the end of the tests. Glebe, The Care Home DS0000035739.V335960.R01.S.doc Version 5.2 Page 24 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 X X x 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 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 3 X X 3 X 3 STAFFING Standard No Score 27 3 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, The Care Home DS0000035739.V335960.R01.S.doc Version 5.2 Page 25 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 2 3 4 5 Refer to Standard OP1 OP7 OP9 OP12 OP12 Good Practice Recommendations Copies of contracts should be kept on all residents files to ensure that matters relating to finances are transparent. Consideration should be given to archiving information on the current care plan that is out of date to ensure to avoid confusion about individual resident’s current needs. Signatures on MARs sheets should be the same as on the sample staff signature sheet to ensure that the person administering medication can be easily identified. Records should be kept of activities to provide evidence of the range and type of activities taking place. Consideration should be given to improving methods of communication and empowering residents, e.g. by a residents group, newsletter, small groups; and records kept of consultation with residents. Wooden exterior windows should be repaired and painted to improve the safety and appearance of the environment. 6 OP19 Glebe, The Care Home DS0000035739.V335960.R01.S.doc Version 5.2 Page 26 7 OP19 All areas of the garden should be well maintained and kept clear of debris to enhance the environment for the benefit of residents. Glebe, The Care Home DS0000035739.V335960.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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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