Inspection on 24/06/08 for Glebe Villa

This inspection was carried out on 24th June 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glebe Villa 22/06/07

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 27/09/2008.

CARE HOME ADULTS 18-65 Glebe Villa 26 Glebe Road St George Bristol BS5 8JH Lead Inspector Sandra Jones Unannounced Inspection 24 and 30th June 2008 02:00 th Glebe Villa DS0000061212.V364504.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.V364504.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.V364504.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) glebe26@tiscali.co.uk Aston Care Homes Mrs Etylin Astbury Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 7 persons with learning disabilities aged 18 64 The Home will not accommodate any individual in the downstairs bedroom until the work in bedroom and en-suite are completed. The preference of the potential person will be sought and installed before their admission to the Home. 22nd June 2007 Date of last inspection Brief Description of the Service: Glebe Villa is registered to provide accommodation and personal care to seven 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 all floors. Fees are paid by direct debit into the homes account and range from £337.00£597.59 per week. The ethos of the home is to promote independence, offer choice and treat people with respect and through encouragement people can develope their full potential. Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This key inspection was conducted unannounced in June 2008 over two days and focused on the assessment of key standards. The main purpose of the visit was to check on the welfare of the people who use the service, ensure the premises are well maintained and to examine health and safety procedures. During the site visit, the records were examined and feedback was sought from individuals and staff. Prior to the visit some time was spent examining documentation accumulated since the previous inspection. This information was used to plan the inspection visit. “Have your say” surveys were sent to the relatives of the people living at the home and health care professionals. Three surveys were received from relatives and two Health Care professionals in advance of the inspection. There are seven individuals living at the home and four were case tracked during the inspection. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. The inspection included looking at records such as care plans and reviews of the care of people using the service and other related documents. The home’s policies and procedures were also used to confirm the findings. The views of the people living at the home and staff were gathered through face-to-face discussions. What the service does well: The people at the home confirmed that they participate in meaningful daytime activities. It was also stated that they knew how to make complaints and indicate that the staff satisfactorily resolved their complaints. Regarding the staff, individuals said that they are treated well by the staff, they know how to meet their needs and felt safe at the home. Relatives made the following comments through surveys “ They look after people in their care extremely well,” “ They put the service users first on all accounts, they always get in touch if anything is wrong and can be discussed” and “ The home is compatible with the people that live there.” Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 6 The Occupational therapist that responded through the survey made the following comment about the home, “Overall they are a good home which cares for the people that live there” What has improved since the last inspection? What they could do better: There are four requirements arising from this inspection and these relate to care planning, safety systems and staffing. Two requirements relate to care planning and are based on further information that must be added to the care plans. The care plans for people with communication needs must incorporate the way the person makes decisions over all aspects of their lives. This will show that people at the home are empowered to make decisions. For people that have dementia their care plans must include their need in terms of safety and security. The manager must seek two written references for new employees, to ensure that the staff working at the home are suitable to work with vulnerable adults. Fire Risk assessments must be completed to ensure that where risks are identified action is taken to minimise the risk. Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 7 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.V364504.R01.S.doc Version 5.2 Page 8 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.V364504.R01.S.doc Version 5.2 Page 9 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): (2) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The admissions procedure is effective and enables people wishing to live at the home to make an informed choice about moving there. They can assured that the home will have the skills and resources to meet their assessed needs. EVIDENCE: The Statement of Purpose and Service User Guide was recently updated to ensure that people wishing to live at the home have up to date and accurate information, so that they can make decisions about living at the home. The Service User Guide is symbolised with pictures and words to ensure that people can make choices about living at the home. Within the Service User Guide, the facilities, expectation of both parties, rules and complaints procedure are included. In terms of the Statement of Purpose the information is detailed and gives a clear account of the approach used at the home. The Admission procedure describes the process that will be followed to ensure appropriate placements and confirms that introductory visits and trial periods are offered. One person was admitted since the last key inspection and a Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 10 social workers assessment’s was provided before admission to the home. This individual’s feedback was sought during the inspection and stated that this home was chosen after visiting other homes, and confirmed that introductory visits took place and a trial period was offered once the decision to move into the home was made. This shows that the home undertakes assessments and places an emphasis on ensuring that the person is suitable to move into the home. Three relatives responded through surveys about the care home. Two said that they were always given enough information about the care home to make decision and one said that this was usual. Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 11 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. There are effective care planning systems in place so that individuals at the home benefit from receiving an individualised and consistent service. They can expect to be involved in making decisions about all aspects of their care EVIDENCE: Each person has a Person Centred Plan (PCP) that specifies preferred routines, important information including relationships, leisure and appearance. Care plans supplement the PCP and action plans guide the staff to consistently meet the assessed need. The manager said that following monthly meetings with the staff, discussions with the person then takes place about the care plan and where necessary the care plan is amended. Individuals sign their care plans to indicate their agreement with the plan of action. The manager also said that Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 12 the care plans would be further developed to provide more comprehensive action plans. The care plans of the two people with communication needs were examined during the inspection. There is a brief statement about the way individuals communicate and make decisions. A care plan that lists communication, as a need, with an action plan on meeting the need must be developed. This will ensure that people at the home are empowered to make choices over all aspects of their lives. Individual’s feedback about the care planning process was sought during the inspection and individuals confirmed that a keyworker system is in operation. The role of their keyworker was described by the individual and included going on trips, providing personal care and assisting with tidying bedrooms. The member of staff on duty confirmed the individual’s description of the keyworker role and added that maintaining care plans was also part of the role. There are two people that were diagnosed with dementia and are exhibiting dementia characteristics. The care plans for these individuals were examined and need to include the way the individual’s dementia manifests itself. For example, safety and security needs. Surveys from three relative states, that the care home always gives the care agreed to their relative at the home. Risk assessments are in place for activities that may involve an element of risk. Risk factors and the triggers and measures to reduce the level of risk are specified within the risk assessments. Glebe Villa DS0000061212.V364504.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 is (good) This judgement has been made using available evidence including a visit to this service. Individuals benefit from good support systems that are in place for people to lead active and interesting lifestyles and to be valued members of the community. EVIDENCE: Individuals at the home participate in daytime activities. Currently one person attends college, two are employed on a part-time basis and four attend day care centres. A rota of the activities undertaken by the person is included in their case file, which supports the comments made, by individuals and the staff. There are Individuals Personal Plan (IPP) meetings for people that attend colleges, employment and day care centres which are convened annually to ensure that the placements are suitable. The manager said that Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 14 the IPP meetings provide an opportunity to, where necessary, inform outside agencies of any changes in the person’s needs. One person is at home twice weekly and the manager said this individual undertakes household chores on one day and on the other day the staff provide 1:1. Two relatives giving feedback through the surveys said that the home always supports their relative at the home, to live the life they choose and one said this was usual. Three people are independent in the community and are able to use public transport without staff support and the staff accompany the other four individuals. People at the home use the local library, park and use local leisure facilities such as bowling and skittles. The weekend routine for individuals at the home is to visit the local library, visit coffee shops, have lunch in a restaurant and then do the weekly shop. On Sundays there are day trips organised to such places as Weston-SuperMare and Bath. A member of staff on duty named the people that participated in the weekend routine and two people were consulted about the weekend arrangement. One person said that generally family visits take place at weekends and another person confirmed the weekend activities. The manager said that the people at the home have relatives and friends that visit. The visitor’s policy upholds the right for people to maintain links and relationships with family and friends. The three relatives giving feedback through surveys said that the home supported their relative at the home to keep in touch. Individuals at the home said that the staff welcome their visitors and bedrooms can be used for additional privacy. The manager was consulted about the way that people at the home are respected as individuals. It was stated that through supervision, feedback from the people at the home and observing practices, staff performance is monitored and standards maintained. Within the home’s Charter of Rights, the approach towards privacy and dignity is described and, endorses that the people at the home have the right to be treated with respect, protected from abuse and have their needs met. Individuals consulted said that knocking on doors before entering, locking doors while personal care is taking place and using the correct form of address are the ways that staff respect their rights. A discussion took place with the manager about the expectation that individuals undertake household chores. The manager said that people at the home are asked to undertake such household chores as laying the table, Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 15 undertaking their laundry and maintain their bedrooms tidy. Individuals confirmed the managers’ statement A good range of fresh, frozen and tinned food is available at the home and corresponds with the meals served at the home. The manager said that individuals are asked for their meal preference before the mealtime. Individuals consulted said that there is always enough to eat and the meals served are good. Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 16 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. People at the home can expect sensitive and prompt support for their personal and health care needs from a skilled staff team. Medication systems are safe. EVIDENCE: Person Centred Plans (PCP) are detailed in respect of the individuals preferred routines and care plans provide action plans for meeting the personal care needs. Two people access Speech and Language therapists through the Community Learning Disability Team (CLDT) and three people have Community Psychiatrist Nurses (CPN) and three have Occupational Therapists (OT) through the CLD team. The records show that people at the home have input from outside agencies. The GP that visits the home gave feedback through a comment card that the home communicates clearly with them. The staff demonstrate a clear Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 17 understanding of their people’ s care needs and where specialist advice is sought it is incorporated into the care plan. Feedback from the Occupational Therapist (OT) and another health care professional, states that the health care needs of the people at the home are always met. The OT stated “They have sought advise from me about dementia, equipment, activities and have acted on this advice.” Relative’s comments about the home keeping them informed about important issues confirm that specialist support is sought for individuals health care and their relatives are kept informed about the outcomes. People at the home visit the GP regularly and with the exception of two people, the staff support people on health care visits. Separate records of the visits undertaken are maintained and confirm that people visit their GP and access NHS facilities such as opticians and dentists. The two individuals consulted said that the staff accompanied them on health care visits and staff confirmed individual’s statements. Grab rails and handrails were installed to assist individuals with mobility impairments and elevated toilet seats and showers support people to maintain their independence. Medication risk assessments are in place to determine the person’s ability to self medicate. Medication profiles are in place for people that have regular prescribed medications and the nature and, purpose of the medication, its side effects and compatibility are detailed in the profiles. Medications administered records checked were signed by the staff and corresponded with the medications held. Staff said that they administer medications and two people confirmed that staff administer their medications. Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 18 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. Individuals at the home can expect their concerns to be listened to and to be protected from abuse. EVIDENCE: The Complaints procedure is sectioned into stages that include raising concerns, unresolved complaints and external agencies that can be contacted. The procedure is available in a format that can be understood by the people for whom it’s intended. For example, the complaints procedure is symbolised with pictures and words. The manager said that during monthly meetings with people at the home, the complaints procedure is discussed to ensure that people know that their feedback is valued. The records of complaints received at the home show that there were no complaints received at the home since 2006. Individuals consulted about making complaints said that they would approach a member of staff with complaints. A member of staff consulted about the way individuals are supported to make complaints said they would guide the person using the home’s complaints procedure. The three relatives giving feedback through the surveys said that they know how to make a complaint. Regarding the home’s response to complaints Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 19 received, one relative said appropriate action was taken, another said it was usual and the third person had no experience of making complaints. Policies that show a commitment to safeguarding people from abuse include the Safeguarding Adults and WhistleBlowing procedures. The home’s Safeguarding Adults policy describes the factors of abuse, however, the actions to be taken where abuse is alleged abuse are not currently stated. The actions to be taken by the staff must be included and must follow “No Secrets” guidance. In terms of the WhistleBlowing policy, members of staff are informed that it’s their duty to report poor practice. The manager said that Safeguarding Adults training forms part of the statutory training for the home. Members of staff consulted were clear about the factors of abuse and the expectation that they report alleged abuse. Individuals consulted said that they felt safe at the home. Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 20 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) & (30) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. The home is well maintained so that individuals benefit from living in a comfortable and clean environment. EVIDENCE: Glebe Villa is a care home in St George. It is located in a residential environment close to shops, bus routes and other amenities. It has the appearance of a residential dwelling arranged over three floors. Shared space is on the ground floor and bedrooms will be on all floors. The house was recently upgraded, it was extended to provide a kitchen, dining room, laundry and downstairs toilet. The original dining room was divided to create a downstairs en-suite bedroom. Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 21 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 individual’s taste and reflects their individuality. Shared space consists of the lounge and dining room. In the lounge there is seating for nine people and in the dining room there is sufficient seating for the residents to sit together. The laundry is adjacent to the kitchen. The flooring is laminate and the walls are painted for easy cleaning. The washing machine is domestic in scale and can reach 95 temperatures. Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 22 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) Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People are supported by a competent, qualified and skilled staff team who are well supervised. EVIDENCE: The personnel files of the people working at the home were examined and completed application forms, Criminal Record Bureau (CRB) disclosures and two written references are held in the file. For one person, the references sought were not available for inspection and, the manager must ensure that two written references are obtained for people working at the home. This ensures that people suitable to work with vulnerable adults are employed. The Occupational Therapist (OT) that responded through the surveys said that the staff usually have the right skills and experience to meet the needs of the people at the home. The OT said that some staff could benefit from improving their English language. The manager was consulted about the comments Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 23 made and said that there are four staff from overseas and two are currently undertaking communication skills courses to assist them with their English language and the other person will be registered on the next available course. The manager said that this training would ensure that staff can communicate effectively with the people at the home. The manager said that statutory training including Learning Disabilities Award Framework (LDAF) for new staff is scheduled and external courses are accessed from recognised training providers. Statutory training provided includes Health & Safety, Manual Handling, First Aid, Food Hygiene, Fire Safety, Safeguarding Adults, LDAF and medication. Dementia training is also provided for the staff from the Community Learning Disabilities Team (CLDT) to ensure that staff have the skills to meet the changing needs of the people at the home. The home’s induction programme follows Skills for Care Common Induction standards and will take three months to complete. The induction programme was available for the most recent employee and shows that the role of the staff, homes policies and procedures and the people of the home form part of the induction. Four of the staff working as care assistants are qualified nurses and the manager said that their qualification is equivalent to NVQ level 3 and the two new staff will be registering on NVQ level2. Two responses from relatives state that the staff always have the right skills and experience and one person said this is usual. The member of staff giving feedback said that training was encouraged at the home. The two people consulted said that the staff knew how to care for them and that they were treated well by the staff. Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 24 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), (39) & (42) Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. Individuals benefit from a well managed home. They can expect to live in a safe environment and can be assured that standards will be the subject of ongoing monitoring, including input from their own views. Fire risk assessments will ensure that where there is a risk of fire, preventative measures can be taken. EVIDENCE: The manager recently completed the NVQ level 4 & RMA and “Fit Persons” process. This means that that the manager is now registered with CSCI and is qualified to manage this care home. Feedback from the manager was sought about the role and the manager said that evaluating the needs of the people Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 25 living at the home, discussing the way the needs are to be met and implementing action plans is part of the role. Monitoring the progress and updating care plans also falls within the remit of the role particularly with the introduction of a person centred planning approach to meeting needs. The leadership skills used to maintain consistency is through supervision, working “hands on”, staff meeting and feedback from people at the home. Staff competency is assessed through appraisals and reviews to ensure that they are skilled to meet the changing needs of the people at the home. The manager said that the Registered Individual visits the home monthly and reports on the conduct of the home. The records in place confirm that the visits take place. Members of staff said that supervision occurs monthly with the manager. The records support their comments that supervision is based on performance, training needs and people living at the home. The home operates a Quality Assurance programme and questionnaires are used to seek feedback about the standards of care from relatives and people living at the home. Questionnaires are symbolised with pictures and words to ensure that the people for whom its intended can understand it, this makes the process meaningful. The manager said that the questionnaires are then analysed and where necessary, action is taken to implement their suggestions. The rota in place shows that one person is on duty with the manager throughout the day and one person sleeps in the premises. When the people at the home are out, the manager is generally left on duty without any other staff. Facilities for the safekeeping of cash and valuables exist and four people currently have money in safekeeping. Records checked correspond with the cash held and receipts support purchases made on behalf of the person. Fees are paid by direct debit into the homes account and range from £337.00£597.59 per week. An accident book is maintained at the home and since the last inspection one accident was recorded. One person lost their balance and staff rendered first aid. The manager ensures that the home complies with associated legislation and includes gas safety and portable equipment annual checks from external contractors. A visit from Environmental Agencies took place in October 2007 and the home was awarded 5 Star. Fire risk assessments were not available at the time of the inspection and while there is evidence that fire alarm systems, other safety checks and consultation with fire officers are taking place, risk assessments must be completed. The Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 26 purpose of fire risk assessments is to considers possible causes of fire and describe measures to reduce these risks. Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 27 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 X 2 3 3 X 4 X 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 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 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 3 X 3 X 3 X X 2 X Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 28 NO 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 YA6 Regulation 17(1)(a) Sch.3(l) Requirement Timescale for action 30/09/08 2. YA6 12 (2) 3. YA34 7,9,19 Sch. 2.3 23 (4) 4 YA42 For the people with communications needs their care plans must include the means by which they are to make decisions over all aspects of their lives. The care plans for people with 30/09/08 dementia must include their safety and security needs and detail the how their dementia manifests itself. Two written references must be 30/07/08 obtained for new employees to ensure that staff are suitable to work with vulnerable adults Fire Risks assessments must be 30/07/08 completed to ensure that where risk are identified action is taken to minimise the risk. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 29 Glebe Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Villa DS0000061212.V364504.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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