Inspection on 02/02/07 for Gledhow Wood Road

This inspection was carried out on 2nd February 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gledhow Wood Road 22/01/09

Gledhow Wood Road 17/01/06

Gledhow Wood Road 03/10/05

Gledhow Wood Road 08/02/05

Gledhow Wood Road 29/06/04

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

CARE HOME ADULTS 18-65 Gledhow Wood Road 68 Gledhow Wood Road Leeds West Yorkshire LS8 4DH Lead Inspector Dawn Navesey Key Unannounced Inspection 2nd February 2007 09:30 Gledhow Wood Road DS0000001455.V328952.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 Gledhow Wood Road DS0000001455.V328952.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. Gledhow Wood Road DS0000001455.V328952.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gledhow Wood Road Address 68 Gledhow Wood Road Leeds West Yorkshire LS8 4DH 0113 2179500 0113 2179500 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) TACT UK Ltd Mr Patrick Cassidy Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Gledhow Wood Road DS0000001455.V328952.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2006 Brief Description of the Service: The home is located in a residential area of Oakwood, north of Leeds. It is a detached building and does not look any different to the other houses within the road. The service users’ bedrooms are on the ground and first floor, with office space and the staff bedroom on the top floor. There are large attractive gardens to the rear of the building. Personal care is provided for five service users who all have a learning disability. The local healthcare team offer good support to the service users. The home is within walking distance of a supermarket, shops, bank and a post office and the service users are able to make use of these facilities. There is a car at the home to make sure the service users are able to attend any appointments they have and to take them on trips out. A regular bus service to the city centre is available. The current scale of charges at the home is £962.29 per week. Additional charges are made for hairdressing, toiletries, and holidays. Gledhow Wood Road DS0000001455.V328952.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 One inspector between 9-30am and 4-15pm carried out this unannounced inspection. The purpose of this key inspection was to monitor progress in meeting the recommendations made at the last inspection and to make sure the home was providing a good standard of care for the people living there. The methods used at this inspection included a tour of the home, looking at care records, observing working practices and talking to service users and staff. There were no visitors to the home on the day of the visit. Information gained from a pre inspection questionnaire and the home’s service history records was also used. Surveys and comment cards were sent to service users, their relatives and visiting professionals to the home, asking for their views about the home. Four of these have been returned. This information has also been used in the preparation of this report. Feedback was given to the senior support worker at the end of the day. The manager was not on duty on the day of the visit. Requirements and recommendations made during this visit can be found at the end of the report. Thank you to everyone for the pre-inspection information and for the hospitality and assistance on the day of the visit. What the service does well: Gledhow Wood Road DS0000001455.V328952.R01.S.doc Version 5.2 Page 6 Staff have a good knowledge of each service user’s individual needs and many of the staff have worked with the service users for many years. Service users speak highly of the staff and manager. The atmosphere in the home is friendly and relaxed. Staff interact well with service users and assist them with their independence; making sure they are treated with dignity and respect. Staff are good at making sure that service users can make choices and live their lives as they want to. Comments received from relatives who returned comment cards, included, “We are extremely pleased with the care and attention my relative receives” and “They cater for each individual residents personal needs to the best of their ability.” Staff make sure that service users have regular and varied activity that suits them as individuals. Staff are also good at encouraging family involvement and supporting service users to keep in touch with family and friends. They are also good at making sure the service users are part of the community in which they live. Service users receive a good standard of health care. The staff team work well with the health professionals involved with service users. What has improved since the last inspection? What they could do better: Gledhow Wood Road DS0000001455.V328952.R01.S.doc Version 5.2 Page 7 The homes Statement of Purpose which, is the document that describes what the home’s philosophy is and what it provides, needs to be updated with current information. Some work is needed on the service users care plans and risk assessments. This will make sure they are detailed, specific and give staff the direction that is needed to meet service users’ needs in full. Staff need to follow good food hygiene procedures and make sure they label foods with the dates of when they were opened. More thorough cleaning is needed in the home. Particular attention needs to be paid to the paintwork and dusting. Staff’s files need to hold all the required recruitment documentation to show all the background checks have been done. Staff’s mandatory training needs to be brought up to date. The manager also needs to complete the Registered Managers Award. Staff need to be aware of the procedure for reporting accidents. Maintenance records such as gas and electrical safety certificates must be held at the home so any renewals that are due can be monitored by the manager. 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 Wood Road DS0000001455.V328952.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 Gledhow Wood Road DS0000001455.V328952.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): 1, 2, 3 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are given reasonably sufficient information to enable them to make a choice about the home. Service users were assessed before they moved into the home. The home is not registered to meet the needs of a service user who is over 65. The home is however meeting his needs well. EVIDENCE: The Service User Guide has been produced in an easy read format, using large print and photographs. The Statement of Purpose, however, has not been updated since 2003 and had some out of date information in. Service users have a contract with the organisation. One service user did not have a contract on file. Staff said they would look for it and thought it may have been put somewhere else. The contracts have all costs listed in them and are signed by service users who are able to do this. It would be good Gledhow Wood Road DS0000001455.V328952.R01.S.doc Version 5.2 Page 10 practice to ask service users’ representatives to sign for those who can’t sign to show they are in agreement with the costs. Service users’ needs have been assessed to make sure the home could meet their needs, however this was some time ago as all the service users have lived at the home for many years. One service user said, “It’s good living here.” Another said, “I like it here, it’s better than the hospital.” The organisation needs to apply for a variation in the conditions of registration at the home for a service user who is over 65. Gledhow Wood Road DS0000001455.V328952.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, 8 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Despite the gaps in documented care planning and risk assessment, service users’ needs are met and they are supported properly. Service users are involved in the day-to-day running of the home and can influence what happens there. EVIDENCE: Care plans have not been developed from an assessment of service users’ current needs. Staff said they are aware of service users’ needs based on their knowledge of them. Some staff at the home have worked with the service users for many years and pass this knowledge on to newer staff by word of mouth. This could lead to important needs and strengths being overlooked. Gledhow Wood Road DS0000001455.V328952.R01.S.doc Version 5.2 Page 12 Some of the care plans are detailed and give staff specific instruction on care and support needs. However one service user had no care plans on personal care needs. It was not clear what tasks he needed help with and what he could do independently. Another service user had no detailed care plan for the use of as and when required medication. Some of the care plans would benefit from a more person centred approach. For example, more information on likes and dislikes and daily routines such as what time service users like to go to bed or get up. Most of the care plans are linked with a risk assessment and risk management plan. Some of the risk strategies need more explanation of when a restriction is placed on a service user. It was not always clear why a restriction had been imposed. This would be useful information for staff and the service user. Care plans and risk assessments are reviewed monthly through staff meetings and key worker meetings. Any changes are made and the plans are signed to show they have been reviewed. It would be good practice for service users or their relatives or representatives to sign their care plans and risk assessments. This would show their involvement in drawing them up. Despite the gaps in documented care planning, staff showed they had good knowledge of service users’ needs. Staff are able to accurately describe the care and support they give to service users. In a returned comment card a relative said, “ they cater for each individual residents personal needs to the best of their ability.” Another said, “we are extremely pleased with the care and attention my relative receives.” Service users have a regular meeting. The minutes of these meetings could not be located on the day of the visit. One of the service users said, “We talk about all sorts.” Staff said that topics at the meeting include any forthcoming events, food choices, likes and dislikes, shopping, activities and holidays. Service users were also offered choices throughout the day; what to do, where to go and what to eat. They were also encouraged to take responsibility such as assisting in the kitchen if they wanted to. All staff said they respected the service users choices on what to do and how to live their lives. The staff make a note of choices that service users have made on a daily basis in the service users’ daily journals. This also includes when choices have been refused. Gledhow Wood Road DS0000001455.V328952.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): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users lead interesting lives and have the opportunity to be involved in a variety of activities. Service users receive a nutritious and balanced diet of their choosing. EVIDENCE: Service users are involved in various activities each week. This ranges from day centres, an activity and leisure service, meals out, shopping, drives out, going to the pub or cafe, bike riding and walks. Staff make sure that service users go out individually which seems to meet their needs better. During the visit, staff worked hard to make sure that service users each got an outing of Gledhow Wood Road DS0000001455.V328952.R01.S.doc Version 5.2 Page 14 their choice. One service user said how much he enjoyed his daily trip to a café where everyone knows him and he has made friends. Throughout the day service users were listening to music or radio, watching TV, assisting with household chores or interacting with staff. The radio station was chosen by the service user and played the sort of music he liked. Service users are encouraged to meet up with friends and to keep in contact with their families. Care plans have been written to support service users in keeping in contact with their families. This is good practice. The diverse needs of the service users are met and they enjoy the lifestyle they want. One service user had chosen to have a day off the day centre and enjoy a good lie in, as it was his birthday. Holidays are arranged for service users who enjoy them. Alternative plans are made for those who don’t. One service user has had a summerhouse built in the garden instead of taking a holiday. He said he prefers to stay at home. Another service user enjoys walking holidays and goes on these with staff who share his interest. Staff were seen to support people with courtesy and thought for their dignity. Staff said it was important to make sure service users are as independent as possible. They said they are encouraged to get involved in household tasks and to make drinks and snacks for themselves. They also said they encourage service users to be independent when they go out too. One staff said, “This is important to keep service users’ minds and mobility going.” Another said, “It is so we don’t introduce what we want them to do and take away their choices.” There was plenty of social interaction between the staff and service users. The atmosphere was relaxed. Menus appear to be well balanced and nutritious. A good variety of food is available and staff try to make sure there is a good selection of fresh produce available. Food choices are made on the day and recorded in a diary. This suits the needs of the service users. Some of the service users get involved in doing the weekly shopping. One of the service users said, “It’s lovely food here.” Another said, “I like the food here, no problems.” Service users chose what they wanted for breakfast. One service user chose to have kippers and brown bread another chose cereal. The lunchtime meal was a sandwich followed by fruit. The evening meal was pizza, chips and salad. A service user who was celebrating his birthday chose this. A number of foodstuffs had been opened and put in the fridge without a note of the date it had been opened. This means that staff are not always aware of when food is past its use by date. Gledhow Wood Road DS0000001455.V328952.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported properly with their personal care needs. Health care support is, in the main, provided in a way that meets service users’ individual needs. Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Staff supported service users with their personal care needs in private and with dignity. Staff have good knowledge of their needs even if they are not fully documented in the care plans. The care plans have details of any health professionals that service users see. These included, GP, dentist, specialist nurse and psychologist. Staff always Gledhow Wood Road DS0000001455.V328952.R01.S.doc Version 5.2 Page 16 accompany service users on their appointments. Staff were seen to offer reassurance to a service user about a health appointment that day. Records are kept of any health appointments and their outcome. Records are mainly made in service users’ daily journals. However some health record forms are also used for some appointments. This system could be confusing. Some service users have specialist health needs, for example, epilepsy but have no support plans in place for this. Staff said this service user has not had a fit for some years and if he did they would ring an ambulance. A service user who has been putting on weight recently is being encouraged to eat sensibly and follow a healthy eating plan. He was served food that matched the suggestions in his care plan. His facial expression and gestures showed he clearly enjoyed this. The home uses a monitored dosage pre-packed system for medicines. All staff take responsibility for the administration of medication and have been trained to do so. There are good ordering and checking systems in place, with a clear audit trail for any unused medication returned to the pharmacy. The medication administration record (MAR) sheets were checked and showed no errors in administration. Gledhow Wood Road DS0000001455.V328952.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users or their representative’s concerns are listened to and acted upon. Service users are protected from abuse by the home’s policies and procedures on adult protection. EVIDENCE: The home has a complaints procedure, which forms part of the Service User Guide. This has been produced in an easy words and pictorial format to make it more accessible to all. The organisation also has a comprehensive complaints procedure. In a returned comment card a relative said they did not know how to complain. It would be good practice to make all relatives aware of the complaints procedure. The home keeps a complaints and compliments book. There were no complaints recorded. A service user said he would tell the manager if he had any complaints. Staff know what to do if they receive any complaints. Staff have received training on the protection of vulnerable adults. They were able to say what action they would take if they suspected abuse or had an allegation of abuse made to them. They were also able to describe the different types of abuse and the whistle-blowing procedure. Gledhow Wood Road DS0000001455.V328952.R01.S.doc Version 5.2 Page 18 The staff said that the organisation has a detailed policy on the protection of vulnerable adults. However, this could not be located at the time of the visit. The senior support worker said she thought a member of staff had borrowed it for some NVQ (National Vocational Qualification) work. She said she would make sure another copy was obtained. Records are kept of service users’ finances and their monies are kept in a locked safe. However, handovers of the monies do not take place at each shift change, which means the service users’ money is not properly protected. The manager checks the finance records and receipts are kept. Gledhow Wood Road DS0000001455.V328952.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment in the home is, in the main, clean, safe and hygienic. Staff’s practices control the spread of infection. EVIDENCE: A tour of the home was carried out, accompanied by a staff member. The home is welcoming, spacious and well laid out, providing sufficient room for all service users. Service users’ bedrooms have been decorated and furnished, to a high standard, suiting them as individuals. One service user said, “I like my bedroom.” The styles of the rooms show their interests and personality. The kitchen has just been re-fitted and staff have decorated it to a good standard. The lounge and hall carpet is due for replacement and is booked for the week following this visit. It is to be replaced with a wooden floor. The stairs and Gledhow Wood Road DS0000001455.V328952.R01.S.doc Version 5.2 Page 20 landing carpet is stained and worn looking. This also needs to be replaced. The senior support worker said that this is the next thing to be done. Much of the paintwork throughout the house needs attention. It is looking shabby and in need of either re-doing or a thorough cleaning. The dining room chairs are also in need of a thorough cleaning and the settee in the lounge is very dirty under the cushions. The upstairs office and staff sleep-in room is dusty. Many of the files containing the records for the home had a thick layer of dust on them. This room looked like it hadn’t been cleaned for some time. There are three bathrooms in the home. One of them has recently been refurbished to a high standard. There is a choice of bath or shower for service users. None of the present service users need any specialist equipment. The bathrooms did not have any liquid soap for hand washing in them. The senior support worker ordered new soap dispensers during the visit. The home has a large well-kept garden. Service users said they make use of it in the better weather. Staff have received training in infection control and were able to say what infection control measures are in place. They wore protective clothing when attending to service users’ personal care needs. Gledhow Wood Road DS0000001455.V328952.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff are competent to meet the needs of service users, but they are not always properly supported and supervised. Service users are protected by the home’s recruitment procedures, however some records are not available. EVIDENCE: There are staff on duty throughout the day and night. There are usually two or three staff on the morning and afternoon shifts. At night there is one staff member sleeping in, who can be called upon in emergency. The manager works alongside staff and is part of the numbers on the rota. Staff said there is always enough staff on duty and the rota works well. The manager makes sure there is a driver on duty at all times so service users can get out and about. Gledhow Wood Road DS0000001455.V328952.R01.S.doc Version 5.2 Page 22 Recruitment records were inspected. Staff said CRB (Criminal Records Bureau) checks are carried out by the organisation. However these records were not on staff’s files and the senior support worker was unable to locate them. Most other records such as references and interview notes were on file. Staff did not have a clear photograph for identification purposes on their file. Training, such as first aid, fire and food hygiene, is not up to date for many of the staff, including the manager. Records are kept of staff’s training and when their updates are due. However, this does not always match up with what is on the staff’s file. The staff files would benefit from some re-organisation as it is difficult to find some records. The manager is aware of the training updates that are needed and has nominated staff for training courses in the near future. 33 of the staff team have achieved an NVQ (National Vocational Qualification) in level 2 or above. Another two staff are currently working on this qualification. All staff said they felt they have a good team and the manager is very supportive. Staff said they felt communication and teamwork within the home is good. They said they have regular staff meetings. However, the minutes of these meetings could not be found. Staff said they receive supervision. However, the records showed that no staff have received supervision since May 2006. Staff said that the deputy manager usually organises supervision but has been off sick for some time. The manager has not made alternative arrangements for supervision to be continued. The organisation operates an appraisal system. All staff spoken to said it had been some time since they had received one. The staff records looked at showed the last appraisal had taken place in 2003. Gledhow Wood Road DS0000001455.V328952.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is, in the main, well managed, the interests of the service users are seen as important to the manager and staff and are safeguarded at all times. EVIDENCE: The home has an experienced manager who is undertaking the Registered Managers Award. However, this has come to a standstill, as the manager has no assessor for his work. This has been outstanding since it was highlighted in an inspection in October 2005. The manager works on the rota and does not have any supernumerary time. All staff said the manager is a good leader and role model. Service users said he is a good manager. One said, “He is a good Gledhow Wood Road DS0000001455.V328952.R01.S.doc Version 5.2 Page 24 lad, he sorts things out for us.” Another said, “He’s a nice man.” A relative who returned a comment card said, “Things run and smoothly and all residents are happy here.” The operations manager visits the home on a monthly basis to carry out regulation 26 visits. This involves talking to service users and staff about the home. A report of these visits is made showing details of any action to be taken to improve the service. In addition to this, the organisation carries out a quarterly service review, as part of its quality assurance programme. This also includes service users, relatives and staff. Staff carry out weekly or monthly health and safety checks around the home such as fire alarms, emergency lighting, water temperatures and checks on the house vehicle. These maintenance records are well kept. Environmental risk assessments are completed and are up to date. The senior support worker could not locate a current certificate for gas safety or electrical wiring in the home. It was therefore unclear if these safety checks had been carried out. Staff were unable to locate the current accident records. Some staff did not seem to know the correct procedure for accident reporting and the procedure for this was missing from the home’s policies and procedures manual. The senior support worker said she would get another copy. Gledhow Wood Road DS0000001455.V328952.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 3 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 3 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 3 3 X X 2 X Gledhow Wood Road DS0000001455.V328952.R01.S.doc Version 5.2 Page 26 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 RQN Regulation Care Standards Act 2000 Section 15 4 15 Requirement The organisation must apply for a variation to the conditions of registration for the service user who is over 65. The manager must make sure there is an up to date Statement of Purpose for the home. The manager must make sure that each service user has a clear and detailed care plan, which identifies all their needs, including health needs and how they will be met. The manager must make sure that risk assessments are clear and give an explanation when restrictions are imposed on service users. The manager must make sure there are systems are in place so that staff are aware of when foodstuffs are past their use by date. The manager must make sure that all parts of the home are thoroughly cleaned on a regular basis. The manager must ensure that staff’s records hold all the required recruitment records. DS0000001455.V328952.R01.S.doc Timescale for action 30/04/07 2 3 YA1 YA6 YA19 31/03/07 30/04/07 4 YA9 13 30/04/07 5 YA17 16 31/03/07 6 YA30 16 31/03/07 7 YA34 19 31/03/07 Gledhow Wood Road Version 5.2 Page 27 8 9 10 11 12 YA32 YA35 YA36 YA37 YA42 18 18 18 9 13 and 23 The manager must make sure that 50 of the staff achieve an NVQ level 2 in care. The manager must make sure that staff’s and his own training is kept up to date. The manager must make sure that staff receive regular supervision. The manager must make sure that they complete the Registered Managers Award. The manager must make sure the gas safety test and electrical wiring test is up to date. The certificates must be held at the home. The manager must make sure that all staff are aware of the accident reporting procedures. 30/06/07 30/06/07 31/03/07 30/06/07 30/04/07 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 YA23 Good Practice Recommendations Some consideration should be given to the introduction of a handover procedure for the money held on behalf of the service users’. Gledhow Wood Road DS0000001455.V328952.R01.S.doc Version 5.2 Page 28 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. 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