Inspection on 14/12/05 for Glebefields Resource Centre

This inspection was carried out on 14th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 but made no statutory requirements on the home.

Other inspections for this house

Glebefields Resource Centre 04/08/07

Glebefields Resource Centre 19/09/06

Glebefields Resource Centre 14/12/04

Glebefields Resource Centre 06/07/04

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

CARE HOMES FOR OLDER PEOPLE Glebefields Resource Centre Strathmore Road Tipton West Midlands DY4 OTT Lead Inspector Mrs Cathy Moore Unannounced Inspection 14th December 2005 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 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. Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Glebefields Resource Centre Address Strathmore Road Tipton West Midlands DY4 OTT 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) 0121 569 5940 0121 557 7438 Sandwell Metropolitan Borough Council Ms Avril Nott Care Home 19 Category(ies) of Dementia - over 65 years of age (19) registration, with number of places Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. All requirements contained within the registration report of 22 January 2003 are met within the timescales contained within the action plan agreed between Sandwell Metropolitan Borough Council and the National Care Standards Day care provision must not encroach on the facilities, staffing and services provided to residential service users. 08/08/05 2. Date of last inspection Brief Description of the Service: Glebefields is owned and managed by Sandwell Council. It is registered to provide care to a maximum of nineteen older people who have been diagnosed as having dementia. Glebefields is located in a residential area of Tipton. Local amenities are close by which include a fish and chip shop, small shops and a library. Adjacent to the home are playing fields. The home has gardens to the front and the rear. The back garden is attractive, safe and appropriate to the needs of the residents’. Car parking space is available at the front of the home. The home comprises of two floors. Both floors are accessible via stairs or the passenger lift. Communal areas, offices, the laundry, kitchen, and toilets are located on the ground floor. All bedrooms are situated on the first floor. All are single occupancy. The home is maintained to a good standard overall. The lounges are of a very high standard. Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by one inspector between 09.00 and 15.30 hours. The inspection was carried out as the second of the home’s two routine inspections for this year. During the inspection three visitors and five residents’ were spoken to. One staff member was involved in the inspection process another staff member was spoken to. The manager was present for the feedback part of the inspection. Three residents’ files were examined as were two staff files. Records looked at included; assessment of need processes, care planning, daily records, financial processes, staff training and recruitment and selection. The premises were partly assessed to include garden areas, the dining room, lounges, bathrooms, toilets and two bedrooms. Not all standards were assessed during this inspection. For a full overview of service delivery this report should be read together with the previous report dated 8 August 2005. What the service does well: The layout of the home and garden gives the residents’ freedom to wander in an environment which is safe. The provision of four lounges and a dining room on the ground floor offers a variety of communal space promoting privacy for those residents’ who want this and choice to residents’ where they spend their time. One relative commented; “The lounge areas are second to none. The day space offered is of a high standard”. The rear garden is attractive with its established trees, shrubs and raised flowerbeds. The garden has ramped access. It has adequate fencing at all boundaries to enhance safety. It is private as it is not directly overlooked. A relative said;” The garden is beautiful, in the better weather residents’ can go outside when they want to, it is safe and secure”. The atmosphere of the home is warm, welcoming and positive. Visiting times are open and flexible, the staff encourage residents’ to maintain contact with family and friends. The management team and staff are committed to providing a high standard of care to the residents’. Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 6 Residents’ spoken to were happy and content. One resident said; ”The home is very, very nice. I never thought I would have to come into a home. I have no regrets at all. The food is beautiful, I never leave a thing”. One relative commented;” The home seems pretty good- she seems to be happy”. Staff comments received included; “ This is a nice place to work in”, and 2 The residents’ are well cared for we get used to their individual preferences and patterns and are able to monitor their well being”. The home has a high N.V.Q attainment level. The home was nicely decorated for Christmas. A number of residents’ proudly showed off the Christmas trees. Monitoring processes are in place to assess staff conformance with policy, practice and procedures. What has improved since the last inspection? What they could do better: The home has a number of requirements outstanding from previous inspections which include the following; adult protection processes, production of complaints procedures which are appropriate to all, infection control auditing and management, care planning and evidencing of daily personal care delivery. Record keeping in areas such as care planning and daily care delivery need further development. Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 7 The home is in need of redecoration externally. Replacement of the dining room windows has been needed for some time. The dining room needs to be redecorated. Processes as required in accordance with the Care Standards Act 2000 need to be complied with in relation to incidents regarding a staff member. Medication systems require some ‘fine tuning’ to ensure that they are adequate and safe. Quality assurance processes require further development particularly for residents who access the home for short term care. Health and safety requires development and diligence to ensure regular servicing of the hoisting equipment. A number of requirements remain outstanding in respect of fire safety. 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. Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 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 Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 No standards in this section were assessed during this inspection. EVIDENCE: No standards in this section were assessed during this inspection. Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9,10 Medication systems require ‘fine tuning’ to ensure that they are adequate and safe. Generally residents’ feel that they are treated with respect. EVIDENCE: Good practice in terms of medication systems and administration was observed. Where handwritten medication records are used two staff are verifying that the information transferred from bottles and containers is correct. Residents’ were asked by the person administering the medication if they required their prescribed’ as needed’ medication. Where a choice of dosage for example; ‘ one or two tablets’ is prescribed the staff document how many tablets they actually administer. The person administering the medications ensured that measuring utensils and drinks were available before she started. A contract is in place between the homes providing pharmacist and the home. The providing pharmacist carries out regular audits of the homes medication systems. It is positive that the home is in the process of securing input to ensure that each residents’ medication is reviewed regularly. Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 11 A number of shortfalls were identified; certificates to evidence staff medication training were not available for examination. The home was not able to provide a pharmaceutical guide no older than 12 months. The homes medication policy has not been revised for some time. Not all medication records detail the required information. Staff observed during the inspection were respectful towards residents’. Staff are aware and use the preferred form of address for each resident. A public payphone is available in the entrance space. All doctors and nurse assessments are carried out in the privacy of the residents’ own bedroom (all bedrooms are single occupancy). Toilet and bathroom doors were seen to be closed when in use. Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 Residents’ are helped to exercise choice and control over their lives. EVIDENCE: Bedrooms viewed held a number of residents’ personal effects examples being; ornaments and photographs. Residents are registered with the local council to give them the opportunity to vote if they wish. Information pertaining to external advocacy services is available within the home. Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 13 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Residents’ are not fully being protected from abuse. EVIDENCE: Concern was raised in that there was no information on site relating to disciplinary work or referral to the Protection of Vulnerable Adults list in respect one staff member who was moved to none care duties after an incident occurred. Policies and procedures in respect of adult protection do not all comply with Sandwell Councils Adult Protection Procedures and Department of Health guidance. Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 No standards in this section were assessed during this inspection. EVIDENCE: No standards in this section were assessed during this inspection. Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,29,30 Residents’ are in safe hands. Residents’ are not supported and protected by the homes’ recruitment practices. Better evidence must be available at all times to demonstrate that staff are trained and competent to do their jobs. EVIDENCE: The home must be congratulated in that only 3 of the 21 care staff to date have not achieved N.V.Q level 2 or above. A number have attained level 3. Domestic and laundry staff have achieved N.V.Q level 1 in housekeeping. Well done to all. The home’s recruitment processes and retaining of required records on site, continues to breach of Care Home Regulations and be of a concern. Two files were examined pertaining to two new starters; written references and sources of identity were once again lacking. Additionally, there was no firm evidence of CRB/POVA list checks or health declarations. The organisation provides its own in-house induction/foundation training. There is however, no certified evidence of what this training consists of or to confirm attendance dates. Training plans were available on staff files perused. There was however, a lack of certificates on these files to confirm training undertaken by individuals. Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38. Residents’ live in a home which is run and managed by a person who is fit to be in charge. Further developments are needed in relation to the homes ethos and satisfaction measuring tools. Residents’ financial interests are safeguarded. Further developments are required to ensure that all staff are adequately supervised. Improvements are needed in terms of record keeping. Work is needed to ensure that the health, safety and welfare of residents’ is promoted and protected. EVIDENCE: The manager has recently been approved and registered by the commission for Social Care Inspection as a fit person to be in charge of the home. The Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 17 manager keeps herself updated regarding knowledge and practice. She has attained the required qualifications for her job role. A relative commented that at times;” Communication between her and the home is inadequate. This person alleged that a couple of situations had arisen whereby staff had not addressed her requests or staff had not communicated where they should have done. The home does have quality procedures and processes in place. Policies and procedures however, are not readily available to staff other than via information technology. It was identified that there is a lack of quality/satisfaction measures in the home for example; questionnaires especially for residents’ who only stay at the home for respite or short term care. It was pleasing that measures are in place to ensure the safekeeping of residents’ money held by the home. The home has a safe. Residents’ money is held separately in a sealed envelope that has been verified by two staff members .At each handover the safe contents are checked by the staff in charge at the time, records of these checks and safe key handovers are made. Three resident monies were checked against balances and were all found to be correct. Two residents’ files viewed held a personal inventory where clothing, valuables and other items had been recorded. It was identified that staff handover notes and ‘bath ’regimes have detailed all residents’ names and applicable information. This practice contradicts Data Protection and Access to records protocols. It is pleasing that evidence was available to demonstrate that staff are receiving one to one supervisions. A supervision matrix was on display on the wall in the office. It was identified however, that the frequency of these supervision sessions does not amount to six per year for each staff member. Documents and certificates pertaining to health and safety, maintenance and servicing of equipment were examined. The fire alarm was serviced in October 2005, emergency lighting December 2005, fire extinguishers in June 2005. A Gas service certificate was available rather than the required gas landlord’s safety certificate. There was evidence of accident reporting whereby a monthly analysis of all accidents is undertaken. The lift was serviced in October 2005. There was however, no certificates to demonstrate that the six monthly servicing of hoisting equipment has been undertaken, the last date was May 2005. Outstanding work remains in respect of West Midlands Fire inspection and a further inspection undertaken by the organisation. Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 18 Staff have been coached about substances which have a potential to harm. Unfortunately an unlabelled container was found on a windowsill which had an unidentified cleaning liquid inside. The front of the home, paths and the car park were covered with leaves. These leaves when wet or frosted could become very slippery and a potential hazard. Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 1 x x x x x x x x STAFFING Standard No Score 27 2 28 4 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 x 3 2 2 2 Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 OP1 Regulation 5(1)(2) 12(4)(b) Requirement The registered person and manager must ensure that the service user guide is produced in an additional format examples being; pictures or symbols which may make it easier to understand by the service user group. ( Timescales of 1.2.05 and 1.10.05 not met). The registered person and manager must ensure that the care plans cover all needs assessed, the diagnosis, the full spectrum of daily living, medications, individual goals and aspirations, risks, aggression, regimes to monitor diabetes, incontinence, continence promotion, preferences, choices etc. (Timescale of 1.9.05 not fully met). Timescale for action 01/02/06 2 OP7 15(1) 01/02/06 Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 21 3 OP7 15(1) The registered person and manager must ensure that care plans clearly state what has to be done, when, how, how often and by whom. ( Timescale of 1.9.05 not fully met). 01/02/06 4 OP8 12(1a) 12(1b) 17(2) The registered person and manager must ensure that daily personal care delivery records(tick charts) are completed diligently and consistently. (Timescale of 9.8.05 not fully met). The registered person and manager must ensure certificates to evidence staff medication training are available on site at all times. (Timescale of 1.9.05 not met). The registered person and manager must ensure that the medication policy is reviewed . The registered person and manager must ensure that medication records clearly state; The name of the residents’ doctor. Any allergies. The residents’ date of birth. This to include medication records that are handwritten. The registered person and manager must ensure that an approved pharmaceutical guide no older than 12 months is available at all times. 01/02/06 5 OP9 13(2) 01/02/06 6 7 OP9 OP9 13(2) 13(2) 01/02/06 05/01/06 8 OP9 13(2) 05/01/06 Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 22 9 OP9 13(2) The registered person and manager must consult with the following residents’ doctors’; AD- regarding his Co-codramol as this is presently prescribed as ‘take two four times a day’, yet it is very infrequent that this medication is required. EH- regarding the prescribed fortisips which are no longer being given. AW- regarding his prescribed Ensure that is no longer being given. 10/01/06 10 OP11 12(4)(b) The registered person and manager must review service users’ files to ensure that an account is made of individual wishes, preferences relating to dying, following death and funeral arrangements. This information must be clearly documented on the service users’ individual personal file. Where possible other relevant people must be secured to obtain this information. (Timescales of 1.2.05 and 1.9.05 not met). 01/02/06 Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 23 11 OP12 12(4)(a) (b) The registered person and manager must ensure that all of the personal needs and preferences of each service user be explored regarding preferred rising and retiring times, meal times, hobbies, activities, and general routines of daily living. These choices and preferences must then be recorded onto and worked into the service users’ individual care plan. (Timescale of 1.9.05 not fully met). The registered person and manager must display a complaints procedure within the home which is large print and a pictorial format. (Timescales of 1.2.05 and 9.9.05 not met). The registered person and manager must provide evidence that the care worker concerned was referred to the Protection of Vulnerable Adults list. 01/02/06 12 OP16 22(2) 01/02/06 13 OP18 13(6) CSA2000 Sec82 28/12/05 14 OP18 13(6) 17(2) A serious concern letter was sent by the CSCI in which this requirement was included. The registered person and 28/12/05 manager must provide to the CSCI all records in relation to the care worker in questions disciplinary hearing. A serious concern letter was sent by the CSCI in which this requirement was included. Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 24 15 OP18 13(6) The registered person and 01/02/06 manager must ensure that the departments policy for “ staff who witness severe bad practice” is read, signed and dated by all staff. This policy must however, be reviewed in accordance with Sandwell MBC adult protection procedures and Department of Health guidance. (Timescales of 1.2.05 and 1.9.05 not met). The registered person and manager must ensure that the exterior of the building is redecorated. Timescales in respect of this requirement have been made in previous reports the work however, to date has not been addressed/completed. The registered person and manager must ensure that the remaining downstairs windows ( dining room) are replaced. 16 OP19 23(2)(b) 23(2)(d) 01/06/06 17 OP19 23(2)(b) 23(2)(d) 01/06/06 18 OP19 23(2)(d) Timescales in respect of this requirement have been made in previous inspection reports the work however, to date has not been addressed/ completed. The registered person and 01/04/06 manager must ensure that bathrooms, toilets and landings are redecorated. Timescales in respect of this requirement have been made in previous inspection reports the work however, to date has not been addressed/ completed. Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 25 19 OP19 23(2)(d) The registered person and manager must ensure that the dining room and ceiling are redecorated. 01/07/06 20 OP21 23(3)(j) 21 OP25 13(4)(a) (c) Timescales in respect of this requirement have been made in previous inspection reports the work however, to date has not been addressed/ completed. The registered person must 01/03/06 provide appropriate showering facilities. (Timescale of 1.10.05 not met). The registered person and 01/02/06 manager must ensure that the radiator in the hairdressing room- first floor- is suitably guarded. ( Timescale of 15.9.05 not met). The registered person and 01/02/06 manager must undertake an infection control audit of the premises, processes, policies and procedures. (Timescales of 25.1.05 and 15.9.05 not met). The registered person and manager must ensure that personal care items are not stored in the bathrooms. Items belonging to individual residents’ must be returned to their rooms after use. (Timescale of 9.8.05 not fully met). 22 OP26 13(3) 23 OP26 13(3) 29/12/05 Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 26 24 OP29 19(2) Sched 2 & 4 The registered person and manager must ensure that the home holds on site all records required as detailed in Schedules 2 and 4. (Timescales of 1.2.05 and 1.9.05 not met). 15/01/06 25 OP30 18(1)(a) 18(1)(c) There has been a repeated breach of Regulations regarding this requirement. Timescales in respect of this requirement have been made in previous inspection reports the records however, to date, are not all available on site. The registered person and 01/02/06 manager must ensure that staff attend the prescribed induction training within six weeks of commencing employment and that certified evidence is issued to confirm the content of the course. (Timescales of 1.2.05 and 1.9.05 not met). The registered person and manager must ensure that documentary evidence of any relevant training/qualifications of each person employed in the home is available for inspection. The registered person and manager must identify and implement systems to determine if communication within the home is effective. The registered person and manager must ensure that all policies and procedures are readily available to staff and that these can be accessed quickly in an emergency. (Timescales of 1.2.05 and 1.9.05 not met). 26 OP30 19 Sched 2 01/02/06 27 OP32 12(5)(a) 15/01/06 28 OP33 24 01/02/05 Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 27 29 OP33 24 30 OP36 18(2) 31 OP37 12(4)(a) 32 OP38 23(4) 33 OP38 23(4) 34 OP38 13(4) 35 OP38 13(4) 23(4) The registered person and manager must ensure that satisfaction surveys/processes are established and used within the home- especially for residents’/relatives accessing respite/short stay care. The registered person and manager must ensure that all staff receive 6 one to one supervision sessions in any 12 month period. The registered person and manager must ensure that all records made in respect of residents’ are documented on individual sheets to comply with the Data Protection Act and access to Records protocols. The registered person and manager must ensure that all requirements made following the last fire inspection are met. (Timescale of 1.9.05 not fully met). The registered person and manager must ensure that all staff receive fire training. Each staff member must receive fire drill training twice in any 12 month period. (Timescale of 1.9.05 not fully met). The registered person and manager must ensure that all staff comply with COSHH requirements and that no solutions are decanted into unsuitable or unlabelled containers. The registered person and manager must provide official documentation to the CSCI to demonstrate that all work highlighted in the last 5 year fixed electrical wiring test report has been addressed. DS0000035175.V272820.R01.S.doc 01/02/06 01/03/06 29/12/05 25/01/06 01/02/06 29/12/05 10/01/06 Glebefields Resource Centre Version 5.0 Page 28 36 OP38 13(4) 37 OP38 13(4) 38 OP38 13(4) The registered person and manager must ensure that a gas landlord’s safety certificate is obtained. The registered person and manager must provide to the CSCI official evidence to demonstrate that all hoisting equipment has been serviced within the last 6 months. The registered person must ensure that the car park and all pathways are clear of leaves at all times. 01/02/06 14/01/06 28/12/05 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 Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 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 Glebefields Resource Centre DS0000035175.V272820.R01.S.doc Version 5.0 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. 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