Inspection on 27/06/07 for Gledhow Christian Care Home

This inspection was carried out on 27th June 2007.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Gledhow Christian Care Home 23/02/06

Gledhow Christian Care Home 16/08/05

Gledhow Christian Care Home 22/02/05

Gledhow Christian Care Home 13/07/04

Gledhow Christian Care Home 23/03/04

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

CARE HOMES FOR OLDER PEOPLE Gledhow Christian Care Home 145 & 147 Brackenwood Drive Leeds Yorkshire LS8 1SF Lead Inspector Carol Haj-Najafi Key Unannounced Inspection 27th June 2007 9:45 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 Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gledhow Christian Care Home Address 145 & 147 Brackenwood Drive Leeds Yorkshire LS8 1SF 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) 0113 2888805 0113 2888816 gledhow@trinitycare.co.uk Trinity Care Ltd Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50), Physical disability (2) of places Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The places for PD are specifically for named service users Date of last inspection 23rd February 2006 Brief Description of the Service: Gledhow Christian Care Home is a purpose built property. The home is located in a residential area close to local amenities and public transport routes. There are car parking facilities. There are gardens surrounding the home that are accessible to the people who live there. The accommodation is on two floors with a passenger lift connecting the two. There are fifty single en suite bedrooms. There are several lounge and dining rooms located throughout the home. There are sufficient communal bathrooms and toilets. Information provided in February 2007 stated the weekly cost of the placement for each person ranged between £393- £645. Information is available about the service in the form of a statement of purpose and service user guide. Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk. The last key inspection was carried out in February 2006. A pre-inspection questionnaire was completed by the home and this information was used as part of the inspection process. Surveys were sent to people who live at the home and their relatives; seventeen surveys were returned and responses have been included in the inspection report. Thirteen surveys were received from people who live at the home, eleven of which were completed with help from staff. One inspector carried out a site visit that started at 9.45am and finished at 6.00pm. Feedback was given to the manager at the end of the visit. During the visit the inspector looked around the home, spoke to people who live at the home, a relative, two healthcare professionals, staff and the manager. Care plans, risk assessments, healthcare records, meeting minutes, and staff recruitment and training records were looked at. What the service does well: People said they were happy living at the home and the nurses and carers were nice. They also said they enjoyed the activities. The programme of activities is very good and it makes a big difference to the quality of life of people living at the home. Surveys from relatives were generally positive and the following are a sample of responses and comments: • • • • We always receive enough information including a regular newsletter. Every response felt the care home usually met people’s needs. Three surveys stated they were always kept up to date with important issues. The care service supports people to live the life they choose. DS0000001341.V336286.R01.S.doc Version 5.2 Page 6 Gledhow Christian Care Home • They are very welcoming and kind. People’s needs are properly assessed before they move in to make sure the home is suitable. Systems are in place to make sure people receive the right support from healthcare professionals. The home is clean and tidy and there are no odours. The gardens are very attractive. What has improved since the last inspection? What they could do better: Care plans contain too much information about care practices and give guidance on how to care for people generally rather than providing specific details about how people’s individual needs should be met. For example care plans stated ‘liaise with GP if needed’, ‘arrange hairdresser if needed’, ‘ensure clothing is suitable for temperature’, ‘if incontinent wash and dry thoroughly’ and ‘ensure privacy and dignity’. People who live at the home said staff were kind and treated them with respect but they also said they were very busy. There are times when people cannot go to the toilet when they need to or they have to wait to get off the toilet when they have finished. Staff and management said there had been staffing difficulties at the home and this had caused some tensions amongst the staff team. Some people thought the problems had affected the quality of care and some thought there were insufficient staff to meet the needs of people who were living at the home. Staff have not received enough training to help them carry out their duties properly or understand the different needs of people who live at the home. They should have attended fire safety and basic food hygiene adults training to make sure people who live at the home are safe. Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 7 People who live at the home are not protected by the home’s recruitment process because some staff had started work at the home even though essential employment checks had not been completed. Requirements and recommendations to address the shortfalls have been made and appear at the end of the report. 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. Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The admission process is good. People’s needs are appropriately assessed before they move into the home so they can be sure that they can be met. EVIDENCE: Admission records were looked at for two people who had recently moved into the home. Pre admission assessments had been completed and these identified the main care needs and the type of support they required. The manager and deputy are responsible for co-ordinating admissions and completing assessments. The manager said a visit and an assessment would be completed before someone could move into the home. One person, who moved in two weeks before the inspection, talked about their admission to the home. They said they were satisfied with the admission Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 10 process and they were happy living at the home. They confirmed that a relative had looked around the home but they had not seen the home because they were in hospital. They also confirmed that the manager had visited them in hospital and completed an assessment. Surveys from people who live at the home stated they had received contracts. The home does not provide intermediate care. Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The individual and personal needs of people who live at the home are not always met because their needs have not been properly identified and they do not always get support at the time they need it. EVIDENCE: Surveys from people who live at the home had mixed responses in relation to the care they received. • • Four people stated they always receive the care and support they need, seven stated usually and two stated sometimes. Six stated staff listen and act on what they say, one stated no. Several written comments were also made under this section, including usually, DS0000001341.V336286.R01.S.doc Version 5.2 Page 12 Gledhow Christian Care Home • mostly, not always, sometimes, carers are too busy doing something else, some do-some don’t. Six stated they always receive the medical support they need, five stated usually, one stated sometimes. Five people’s care records were looked at. Two care records were for people who had recently moved into the home. The care plans followed on from the pre-admission information and all the important information had been included in the care plans. Some information in the care plans was good and gave sufficient information about how individual needs should be met, for example ‘use a straw when drinking’ and ‘take daily newspaper and mail to their room’. But most of the information was general for example ‘liaise with GP if needed’, ‘arrange hairdresser if needed’, ‘ensure clothing is suitable for temperature’, ‘if incontinent wash and dry thoroughly’ and ‘ensure privacy and dignity’. These details are about basic care practices that should always be applied to everyone who receives care therefore it should not be necessary to write it in individual care plans. The manager had identified that some of the care plans were generic and was starting to address this but acknowledged that there was still work to do before the care plans identified how individual needs should be met. Staff talked about how they supported people who live at the home and they appeared to have good information about how their care needs should be met. The staff spoken to had all worked at the home for some considerable time. One staff said they knew how to care for people because they had worked at the home for a long time but they thought it would be hard for new staff. Because there was insufficient information recorded it was not possible to establish if everyone was receiving the right care or that staff were providing consistent care. People who live at the home talked about healthcare and said they see different healthcare professionals, including GPs, chiropodists and opticians. One person said they always tell the carers if they are unwell and they talk to the nurses. Healthcare records confirmed that people had received regular visits from healthcare professionals. During the inspection a healthcare professional visited the home. They asked a care worker for some written information about their patient but because the qualified staff and the manager were having their lunch, the healthcare worker was told they would have to wait twenty minutes or come back later. The healthcare professional said this had not happened before. This is unacceptable practice and could result in a person’s healthcare needs not being met. Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 13 Another healthcare professional also visited. They said they were happy with what they had been involved in and thought the home responded to advice from GPs and specialists and carried out everything that had been asked of them. People who live at the home said staff were kind and treated them with respect but they also said they were very busy. One person said they could not go to the toilet when they wanted and often had to urinate in their pad because staff were too busy. One survey from a person who lives at the home stated there was a problem arranging a bath time. Another survey stated they didn’t like being left on their own whilst toileting. Another stated staff usually leave me too long. Staff also said they were busy and confirmed that often people had to wait to go to the toilet. One person said they often had a ‘queue’ and had to tell people that they had to wait. Another staff said people were sometimes left on the toilet longer than necessary. Generally staff did not think they got opportunities to spend quality time with people who live at the home. The home’s medication system is a Monitored Dosage System. The administration of medication was observed, it was administered appropriately and the staff member explained to people what she was doing. Medication records were looked at and they had been completed correctly. Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The programme of activities is very good and it makes a big difference to the quality of life of people living at the home. The food is good. EVIDENCE: People said they were happy living at the home. They also said they enjoyed the activities. Staff were also very positive about the quality and range of activities that are provided. There is a daily programme, which includes one to one activities and group activities. On the day of the inspection the inspector joined an armchair exercise group. People were clearly enjoying the activity and benefiting from the stimulation. A bible study group was also held earlier in the day. Surveys from people who live at the home were generally positive about daily life. • Ten surveys stated there were always activities arranged by the home, two stated usually, one stated sometimes. DS0000001341.V336286.R01.S.doc Version 5.2 Page 15 Gledhow Christian Care Home • Four stated they liked the meals, three stated usually, six stated sometimes. Several written comments were also made under this section, including teas could be better, portions are too large. Surveys from relatives were generally positive and the following are a sample of responses and comments: • • • • • • • • We always receive enough information including a regular newsletter. Every response felt the care home usually met people’s needs. Three surveys stated they were always kept up to date with important issues. One survey stated that staff were good at recognising any changes in health/needs, another survey stated this was an area that could be developed. The care service supports people to live the life they choose. They are very welcoming and kind. Three of the four surveys made reference to the very good range of activities that are offered. They respond positively to suggestions. The inspector joined people who live at the home for lunch. The meal was two courses, well organised and everyone enjoyed the food. Juice was provided and people were offered a hot drink after the meal. People said the food was good and they thought there was a good choice. The menus have been reviewed and a new system has been introduced that is based on providing a good balanced and nutritional diet. People who live at the home said the menu was better. Staff said there was a better choice, including vegetarian dishes. They also said the introduction of a more substantial supper menu was also an improvement. Menus were received with the pre inspection material. The meals were varied and nutritious. Vegetarian options were available. They had also identified which meals were suitable for diabetics and soft diets. People said they thought they had plenty to eat and drink. One person said they had used the call bell at 5.30am that morning and asked staff for a cup of tea and staff brought it straight away. Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Safeguarding and complaints procedures are in place and most people know who to talk to if they are unhappy. EVIDENCE: People who live at the home said they talk to staff if they are unhappy. Some said they would talk to carers, others said they would talk to nurses. A relative said they would feel comfortable talking to the manager or staff if they had any concerns. Seven surveys from people who live at the home stated they always knew who to speak to if they are not happy, three stated they usually knew. Eight stated they know how to make a complaint, two stated no, three stated not sure. Surveys from relatives stated that they always know how to make a complaint and the care service had responded satisfactorily to any concerns raised. The pre inspection questionnaire stated the home had received three complaints since the last inspection. A record of the complaints was maintained. The complaints procedure was displayed near the entrance of the home. Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 17 Southern Cross confirmed that 60 of care staff have completed NVQ level 2 and the training involves a module on protection of vulnerable adults. The manager had completed adult protection training and was aware of safeguarding procedures. Nine out of fifty staff have attended specific adult protection training. The organisation confirmed that all staff would undertake specific training by 30th September 2007. Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The environment was clean and tidy but was in need of some maintenance and redecoration to make sure that people live in a pleasant and safe environment. EVIDENCE: A tour of the building was carried out. Communal areas and bathrooms were visited and a number of bedrooms were seen. The home was clean and tidy and there were no odours. Furniture and furnishings were of a reasonable standard. The home was being redecorated although the decorators had been transferred to another job. Areas that had been decorated were of a good standard; other areas were in need of decoration. Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 19 The grounds were well maintained and looked very attractive as you approached the home. A new decking area has recently been built; this again was an attractive feature. Several bedrooms had furniture and various items that people had brought with them when they moved in. One person that recently moved in had brought their own curtains, bedding and had a new carpet fitted. This is good practice and demonstrates that everyone is encouraged to make their room homely and more comfortable. The call system was checked during the tour and this was working satisfactorily. A lot of different equipment was available throughout the home to aid moving and handling and help people maintain independence. Nine surveys from people who live at the home stated it was always clean and tidy, three stated it was usually clean and tidy. People who live at the home said the home was always clean and tidy. One person said it was good because there were no smells. The organisation confirmed that all regulatory health and safety monitoring checks were up to date at the time of the inspection. Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience poor quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. There are not always enough staff to make sure that the care needs of people are satisfactorily met. The recruitment practices place people living at the home at potential risk. EVIDENCE: People who live at the home said the nurses and carers were nice. Surveys from people who live at the home had mixed responses in relation to staffing. One survey stated staff are always available when you need them, five stated usually, six stated sometimes. One commented under this section staff usually leave me too long. Surveys from relatives were positive about staff. One survey stated they were very careful, another survey stated that overall staff are caring, patient and try hard to meet needs. Another survey stated that most staff were exceptional in their care and commitment to the quality of life. Staff and management said there had been difficulties at the home and this had caused some tensions amongst the staff team. Some people thought the problems had affected the quality of care and some thought there were insufficient staff to meet the needs of people who were living at the home. Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 21 Some staff said they thought team morale was low. Some staff said they thought staff were generally tired because they had worked extra because of the staffing levels. The manager said staffing had been a problem and on occasions it had been difficult to cover shifts. The Pre Inspection Questionnaire provided a list of staff training that had been provided in the past twelve months, which included mandatory and additional training. It also stated 61 of staff had a qualification in care. The manager said they had identified that staff training was not up to date and this was a major problem. A training matrix was looked at and this confirmed that there were significant gaps. For example staff had not received dementia training even though they are working on a day to day basis with people who have dementia. Other examples of training shortfalls have been highlighted under the management section of this report. Records for the last two people recruited to work at the home were looked at. They had both started working the previous week but were not spoken to during the inspection. Application forms were available but these were not satisfactory. One did not have a full employment history and had not provided reference details for their most recent employer. The other applicant was working for an employment agency but had not included this in their employment history or provided these details as a reference. An employment reference had been applied for from an address next to where a candidate lived although this had not been received. Only one reference was available for both employees and neither had an employment reference. A protection of vulnerable adults first check had been completed for both candidates but a full criminals check had not been obtained. Both staff should not have started work at the home because essential employment checks had not been completed. Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 & 38 People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. Some management systems have not been as effective as they should be and this has resulted in some practices that do not promote the health, safety and well being of the people living at the home. EVIDENCE: The manager had only been in post for five months and said she was still getting to grips with many things. The manager had previously managed residential homes. At the time of the inspection, the Commission had not received an application for the manager to be registered. The manager said Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 23 she had completed the relevant form and had forwarded it to her line manager. The home has gone through a period of change in the past few months and this has resulted in some tensions amongst the staff team. Staff had not received formal staff supervision, which would have been an ideal opportunity for staff to air their views and talk through their concerns with management, and to have general discussions about care practices and the philosophy of the home. The organisation wrote to the Commission confirming that people who live at the home and their relatives are invited to six monthly reviews of their care packages. Should relatives be unable to attend, copies of the records are forwarded to the relative. They said the manager holds a weekly relatives surgery, which takes place early evening, and resident and relative meetings are held every three months. A relative/resident meeting was held in February 2007. One person who lives at the home said they don’t get chance to see the manager. Satisfaction questionnaires are sent out once a year. These had been completed last September and results were published and available in the home. Financial records for three people were looked at. Personal monies were recorded on a computerised system. Every transaction had been recorded and balances corresponded with the monies held. Receipts for hairdressing, chiropody and clothing parties were available but one person had gone shopping with a staff member and had withdrawn £100. Receipts were not available from this shopping trip and no money had been returned. To make sure all monies are accounted for it is important to obtain receipts for any purchases made on behalf of or with any people living at the home. The administrator said it was general practice to obtain receipts. Accident and incident records were looked at. Forms had sufficient details of incidents that had taken place. The manager had completed monthly audits to identify any patterns. This is good practice and demonstrates that management are monitoring accidents and incidents. A training matrix was looked at. This identified that there were gaps in staff training. Moving and handling training was up to date. Only eighteen out of fifty staff had up to date fire training and twenty-six out of fifty staff had up to date food hygiene training. The pre inspection questionnaire stated that policies and procedures were available and regular maintenance and health and safety checks by external agencies were completed at the home. Portable appliance tests had been completed in May 2007. Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 1 28 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 1 X 2 Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15 (1) Requirement All people that live at the home must have a detailed care plan. This will ensure they receive person centred support that meets their needs. People who live at the home must be able to see healthcare visitors when they arrive to make sure their healthcare needs are met. People who live at the home must be able to have their personal needs met at appropriate times. This is to ensure their dignity is maintained. There must be sufficient staff working at the home to meet people’s assessed needs. A robust recruitment process must be completed to make sure people who live at the home are protected All staff must be appropriately trained to make sure they can meet the needs of the people who live at the home. Receipts must be obtained for all purchases that are made on DS0000001341.V336286.R01.S.doc Timescale for action 31/08/07 2 OP8 12 (1) 31/07/07 3 OP10 12 (4) 31/07/07 4 5 OP27 OP29 18 (1) 19 (1) 31/07/07 31/07/07 6 OP30 18 (1) 31/08/07 7 OP35 17 (1) 31/07/07 Gledhow Christian Care Home Version 5.2 Page 26 8 OP38 18 13 23 behalf or with people who live at the home to make sure their personal monies are safeguarded. All staff must be appropriately trained in safe working practices to make sure the health and safety of people who live and work at the home is protected. 31/08/07 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 OP36 Good Practice Recommendations Staff should be appropriately supervised and have opportunities to talk about care practice and the philosophy of the home. Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Gledhow Christian Care Home DS0000001341.V336286.R01.S.doc Version 5.2 Page 28 - 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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