Inspection on 22/06/07 for Glebe Villa

This inspection was carried out on 22nd June 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glebe Villa 24/06/08

Glebe Villa 09/06/06

Glebe Villa 27/01/06

Glebe Villa 02/08/05

Glebe Villa 26/01/05

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

CARE HOME ADULTS 18-65 Glebe Villa 26 Glebe Road St George Bristol BS5 8JH Lead Inspector Jacqueline Sullivan Key Unannounced Inspection 22nd June 2007 10:00 Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 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 Villa DS0000061212.V341155.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 Adults 18-65. 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 Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glebe Villa Address 26 Glebe Road St George Bristol BS5 8JH 0117 9541353 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) Aston Care Homes Mrs Etylin Astbury Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Date of last inspection 9th June 2006 Brief Description of the Service: Glebe Villa is registered to provide accommodation and personal care to six adults with learning disabilities. It is located in the St George area of Bristol close to shops, amenities and bus routes. The property has the appearance of a domestic dwelling, blending well with its local residential environment. It is arranged over three floors with shared space on the ground floor and bedrooms on the first and second floor. An application to extend the property has been received and it is the provider’s intention to increase the numbers from six to seven people and relocate the dining room and kitchen, thereby being able to offer accommodation on the ground floor. Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was conducted over one day in June 2006 as an unannounced visit. This visit focused on the requirements and recommendations of the last inspection through an evaluation of records and discussions with staff and residents. Resident surveys were sent to the home in advance of the inspection and full responses were received. Two members of staff and three residents were spoken with during the inspection. The Provider was present at the latter end of the inspection and there was opportunity the feedback the findings of the inspection. A tour of the premises was conducted and samples of resident’s files were seen. What the service does well: What has improved since the last inspection? The Deputy has almost completed her registered managers award and has shown a strong commitment to working towards meeting the requirements of the last report. The organisation has a strong commitment to developing the house to ensure that it is a homely and comfortable environment for the residents. Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 6 What they could do better: The statement of purpose must be updated to reflect the increase in number of residents that can be accommodated at the home. This will ensure that the residents and their representatives are clear about the changes. To ensure clarity for both the residents and the Commission of the day-to-day arrangements at the home, the acting manager must complete the registration process with the Commission if she is to be the manager of the home. Repeat requirements arising from this inspection are based on the further development of care planning and risk assessments. The frequencies to complete tasks must be incorporated onto action plans. Risk assessments must include the options available to demonstrate that the level of risk reflects the actions to be taken. The frequency of staff supervision must be improved to enable staff to work consistently to meet the needs of the residents. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Quality in this Outcome area is good. The statement of purpose must be updated. This will ensure that the residents and their representatives are clear about the changes. Each prospective service user has their needs assessed to ensure the home can provide the correct levels of support. Service users have the opportunity to visit the home prior to moving in. Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 9 EVIDENCE: Since the last inspection there has been a successful application for an increase in the number of people that can be accommodated. The new room is now complete although the bathroom is awaiting a decision by the new prospective resident about installing a bath or a shower. The Deputy said that this will be their choice and the Provider is happy to do either. The statement of purpose was seen and it was noted that it has not been updated to reflect the change in numbers. A requirement has been made that this is completed and a copy sent to the Commission. Residents spoken with confirmed that service users guide was given to them. The residents who spoke with the Inspector said that they were offered a visit to the home before they made the decision to live there. Information in their files confirmed this to be the case. A sample of residents files seen showed that Initial assessments and appropriate information is in place. Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s need’s are continuously assessed and monitored within their care plans and monthly reports. However these need to be further developed to include more detail of the support given to residents. Risk assessments are completed for activities that may contain an element of risk. They have recently been reviewed but still require some work. Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 11 EVIDENCE: At the last inspection it was noted that a person centred format was recently introduced to prepare individual care plans. Essential Life Plans (ELP) are prepared by the staff at the home. The identified needs are detailed in the plans along with a description of how the identified needs are to be met. The name of the person responsible for the task is listed for each need. However, the frequency of support was not detailed in the plans. A requirement was made that the times and frequency for staff to undertake tasks must be recorded in the individuals action plans. At this inspection it was noted the Deputy had reviewed the plans but the information about the support given to the residents was not detailed enough. The information was very general for example the plans listed “staff” and not the individual member of staff to complete the task. Or the section named ”person responsible” for the task was left blank. Whilst recognising the work completed to meet this requirement it will be a repeat requirement in this report. Since the last inspection one resident has been diagnosed with dementia. Staff training has taken place and the residents care plan is in the process of being updated. The residents file showed that a lot of thought and work has taken place to ensure that this residents needs are being met. The ability of the staff team to meet the needs of this resident and those of the other residents will be a focus of the next inspection. Three residents giving feedback, during the inspection, confirmed that regular meetings take pace between themselves; their relatives and the staff team took place to discuss the care planning. Discussions with the residents and evidence recorded in the residents meeting books confirmed that the residents have an opportunity to express their opinions about the care they receive. Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 12 At the last inspection it was noted that risk assessments are completed for any activity that may involve an element of risk. Within the care plans, the individual’s personal safety, mobility needs are described which relate to road safety, fire evacuation and personal needs. A requirement was made that risk assessments must detail the options available to evidence that actions reflect the level of risk. At this inspection it was noted that the Deputy has reviewed these assessments but they are not yet complete. In that, they do not fully detail the level of risk and the format needs further development. For example there is a risk assessment about the risk resident developing a smokers cough. This is a risk but so also are many associated illnesses. A cough is one risk associated with smoking. The Inspector discussed this with the Deputy who noted the points and said shed go through them again. The requirement will therefore remain and will be removed once the work is complete. Care plans include the actions to be taken to diffuse and divert the behaviours. One resident uses a combination of Makaton and symbols to communicate and the care plan lists the person’s ability to communicate. The Deputy said that a residents will at times exhibit inappropriate behaviours and was able to describe the strategies the team have in place to diffuse the situation. Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. The staff support the residents maintain links with family and friends. Meals provided at the home are nutritious and well balanced. Residents participate in a variety of structured daytime activities. Residents are able to make use of activities in the community and are encouraged to be independent. Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 14 EVIDENCE: Essential Life Plans (ELP) meetings are in place. These include an action plan to meet the agreed residents goals and aspirations. The care plan is then established from this information. Independence skills are detailed in one resident’s plans. There is a programme of shopping, activities in the home, visiting parks and restaurants. The acting manager has developed a recording system with plans and targets to ensure that the activities are regularly reviewed to ensure that they are meaningful for the residents. There is an expectation detailed in the care plans that the residents participate in household chores in the home. Residents who were spoken with during the inspection were able to describe the activities they did during the day. Overall they felt they had enough time for both structured and relaxing time. One resident said “I went out to Weston all day on Sunday” and said that it was enjoyable. The residents have a variety of activities including attendance at day care services and employment. Two attend structured day care services each day and one attends twice weekly with one person undertaking daily activities. One person is currently at home twice weekly. Bedrooms are lockable and residents are provided with room keys and house keys. Information about the residents right to privacy is contained in the Service User Guide. Residents who were spoken with confirmed that the staff knock before entering their rooms. The residents said that they sometimes help prepare the meals and they decide the menus. Menus are prepared with residents and where necessary alternatives are provided. There is a record of alternatives prepared kept at the home. Al the residents spoken with said they liked the food. Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team ensure that the resident’s personal and health care needs are met. To maintain safe handling of medications, a running balance of paracetamol administered to residents, when required, must be maintained. Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 16 EVIDENCE: The house has been adapted for adults with limited mobility so the stairs has two handrails to assist the residents. Residents who spoke with inspector and responded to questionnaires were happy with the health care support provided by the staff. Some residents visit their GP and other NHS facilities without staff support. On the day of inspection a resident was observed explained the outcome of a recent visit to her G.P Other residents stated that staff members accompany them on all health care appointments. The acting manager is a nurse and said that the systems they use are similar to those she was taught. The records of medication indicate that staff sign the records immediately after administering medications. There is a record of medications received at the home. Paracetamols are administered from a stock supply when required. At the last inspection it was required that the record of administration for paracetamol include a running balance. This has been reviewed but still needs some adjustments so the staff team can ensure they have a record of the balance of these tablets to compare with the number held. Residents spoken with and evidence in their files confirmed resident’s access local NHS facilities and regular visits are arranged to the dentist, optician and dentist. Details of these visits and their health needs were seen to be recorded in their individual care plans. Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected from abuse and feel that their views are listened to. EVIDENCE: The staff files showed that two members of staff have attended external POVA training and the acting manager stated that she is arranging for the other staff to attend. She was able to demonstrate a sound knowledge of POVA (Protection of Vulnerable Adults) training, policies and procedures. The Pova policy was seen to be detailed included financial abuse the misuse of money and exploitation and gave examples of changes of behaviour that might indicate abuse. At the inspection three residents were asked if they felt safe and they all said they did. One said “I would talk to staff if I had any problems they were sure staff would help them. Two said they had someone outside the staff team they could talk to if they needed to. Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 18 The complaints/comments/suggestions is in a user-friendly format. There were no complaints received at the home from residents or their relatives since the last inspection. Residents confirmed that they know how to complain. One resident said” I’m happy here if I was unhappy I would tell the staff.” The resident’s meetings book showed that complaints is a regular item on the agenda. The home maintains records of all accidents and incidents. It has also provided relevant reports to the Commission of significant events in accordance with Regulation 37. Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 30. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The house is a homely environment for the residents. EVIDENCE: The house has recently undergone some changes. At the last inspection it was noted that the kitchen is in part of the new extension and what was the laundry, the laundry is now adjacent to the kitchen and dining room was resited to where the kitchen was previously. The dining room has been divided into an en-suite and a shared toilet. At that point the bedroom and toilet were not usable. They are now complete apart from the bathroom in the new bedroom discussed in the first section. The garden area is on the business plan to be developed and both the acting manager and the provider said this was going to be developed as soon as possible. In the light that there is a plan for this to be completed a recommendation has been made rather than a requirement. This will be a focus of the next inspection. Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 20 The provider was very clear that he wants a homely environment for the residents and has a plan to ensure this takes place. All the residents who spoke with inspector were happy with accommodation. With the exception of one double room, all bedrooms are single occupancy. In bedrooms there is a combination of the home’s furniture and residents’ personal belongings. Each bedroom is decorated to the individuals taste and reflects their individuality. The bedroom that has been registered is an en-suite. The double room and the room on the top floor are full en-suite with shower, toilet and wash hand basins. There is on full bathroom on the first floor and a separate toilet. Now the toilet downstairs is in use there is now a ratio of bathrooms to residents. As noted at the last inspection the laundry is adjacent to the kitchen. The flooring is laminate and the walls are painted for easy cleaning. Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 34, 35, 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has an effective staff team which support the service users needs at all times. The training programmes ensure that all staff are provided with the guidance and skills to provide support to each service user. All staff must be supervised on a regular basis, to ensure they are supported to provide appropriate support to service users. EVIDENCE: There is a core of well-established staff with varying skills and abilities who meet the needs of each individual who uses the service. There are four members of staff working at the home including the acting manager. A bank member of staff from another home within the organisation works at the home. The personnel files of the staff working at the home were examined. Completed application forms are in place for all staff, with written references and CRB disclosures for two staff, National Bureau of Investigation (NBI) disclosures for two staff and work permits for overseas staff. Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 22 Staff told the inspector they are provided with lots of training opportunities. These include mandatory health and safety training together with more specialist training. Training in relation to dementia has taken place although certificates were not on file. There was supporting evidence to show attendance. A staff member said they enjoy working in the home and feel the staff team works well together. Staff morale is said to be good as is communication between members of the team. The team meets on a regular basis, normally once a month. All meetings are recorded and appropriate subjects are discussed in order to guide and direct staff practice. The Deputy told the inspector these meetings were useful and that anyone could put an item on the agenda for discussion. Attendance at these meetings was good. Staff members are provided with formal supervision by the Deputy. The minutes of these meetings showed that although staff supervision takes place the frequency must be improved. The last dates recorded were 21.2.07 and 11.3.07. All staff must be provided with regular supervision, in accordance with the home’s policy and a clear record maintained. Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 41, 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although service users are benefiting from a person centred approach a manager for day-to-day operations must be appointed to take forward the running of the home. The views of service users are actively being sought in relation to the quality of the service. Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 24 EVIDENCE: At the last inspection it was required that the service must provide an action plan on the day-to-day management of the home and the systems in place to monitor consistency. At this inspection it was noted that the rota provides evidence of the manager being at the home intermittently but the deputy is still in reality the manager at the home. The Deputy stated that the manager acts as a resource to her to ensure consistency but the rotas show that this support is infrequent. The Deputy said that, due to illness it is now unlikely that the manager will be returning. The Deputy has now nearly completed her RMA in anticipation of this post. Discussion with the Provider confirmed they are in a clearer poison since the last inspection and they want the Deputy to become manager. There were requirements made at the last two inspections regarding the management of the home have not been met. On the 26/06/ 07 a letter was received at the Commission explaining the organisations intention for the Deputy to become manager as soon as practical. To ensure that this arrangement is resolved quickly a requirement has been made that the deputy completes the registration process with the Commission. At the inspection the Deputy was able to demonstrate a good knowledge of the homes policies and procedures and the residents needs. She has attempted to meet all the requirements set at the last inspection. The ethos of the service is person centred. A member of staff stated their views are listened to, and that they are well supported by the manager. Through discussion with residents it was evident there continues to be an inclusive atmosphere within the home. The residents remain the focus of the service and the Deputy is clearly leading and developing the person centred approaches. Information in the resident’s surveys and discussions with three residents in the home confirmed that they are happy with the management of the home. The record keeping is of a good standard. Files and documentation are wellorganised and easy to access. The records that relate to fire safety checks and practices were examined during the inspection and were seen to meet the required standard. Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 25 A comprehensive quality assurance system is in place within the home covering many aspects of the service. Monthly visits are carried out and are duly sent to the Commission. The views of residents are actively being sought in relation to the quality of the service. The quality assurance document seen was in an easy read format. There are recording systems in place to support Health and Safety within the home, which are being used consistently. Records examined included fire drills, fire alarm system checks, fire fighting equipment checks, COSHH products, Gas Safety and fridge/freezer temperature recording. All of these records were in order and checks were up to date. Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 2 3 3 3 4 3 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 3 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 x 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 1 3 x x x 3 x Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 27 Yes Are there any outstanding requirements from the last inspection? 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 YA1 Regulation 4 Requirement The statement of purpose must be updated to reflect the increase in number of residents that can be accommodated at the home. This will ensure that the residents and their representatives are clear about the changes. Timescale for action 30/09/07 2 YA6 15 The times and frequency for staff 30/09/07 to undertake tasks must be recorded in the individuals action plans. Second requirement but substantive work in place to try and meet this requirement. The running balance of medications administered from a stock supply when required must be maintained. Second requirement but substantive work in place to try and meet this requirement. 30/09/07 3. YA20 13 Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 28 4. YA9 13(4) Risk assessments must be further developed so that they include the options available to minimise the level of risks. This will ensure that the residents are safer when taking risks. Second requirement but substantive work in place to try and meet this requirement. 30/09/07 5. YA37 10(1) The acting manager must 23/07/07 complete the registration process with the Commission if she is to be the manager of the home. This will ensure clarity for both the residents and the Commission of the day-to-day arrangements at the home. 6. YA36 18(2) Ensure all staff are supervised on a regular basis and maintain a 30/08/07 clear record of each meeting. 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 YA24 Good Practice Recommendations The garden is landscaped. Glebe Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Bristol West Regional Office 4th floor Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0117 9307110 Textphone: 0845 015 2255 Email: enquiries.bristol@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 Villa DS0000061212.V341155.R01.S.doc Version 5.2 Page 30 - 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. 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