Inspection on 08/01/08 for Glen Lee

This inspection was carried out on 8th January 2008.

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

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

Glen Lee 12/07/07

Glen Lee 13/02/07

Glen Lee 05/09/06

Glen Lee 14/10/05

Glen Lee 05/05/05

Glen Lee 18/10/04

Glen Lee 21/06/04

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

CARE HOMES FOR OLDER PEOPLE Glen Lee Wavell Road Bitterne Southampton Hampshire SO18 4SB Lead Inspector Michael Gough Unannounced Inspection 8th January 2008 10:30 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 Glen Lee DS0000039231.V356896.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. Glen Lee DS0000039231.V356896.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glen Lee Address Wavell Road Bitterne Southampton Hampshire SO18 4SB 023 80473696 023 80476734 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) Southampton City Council Theresa Ann Marie Dyer Care Home 34 Category(ies) of Dementia (0) registration, with number of places Glen Lee DS0000039231.V356896.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home - to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Dementia (DE) The maximum number of service users to be accommodated is 34. Date of last inspection 12th July 2007 Brief Description of the Service: Glen Lee is a purpose built local authority home managed by Southampton City Council and is located in the residential area of Bitterne, a suburb to the east of Southampton city. The home is designed over two storeys, was built in 1964 and offers accommodation in 34 single bedrooms with a lift access to the first floor. Glen Lee provides care and support for people over the age of 65 years with dementia. A community day centre operates from an area of the home that also offers respite services and is run by Southampton Care Association. The building is detached in its own grounds and gardens with a housing estate surrounding the property. Garden furniture is placed in a covered patio area, which is used as the residents smoking area but can also enable other residents to enjoy the grounds and gardens. Fees at the home are currently £447 02 per week. Residents are responsible for paying for their own toiletries, hairdressing, chiropody and items of a personal or luxury nature. Glen Lee DS0000039231.V356896.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience Adequate quality outcomes This report details the evaluation of the quality of the service provided at Glen Lee takes into account the accumulated evidence of the activity at the home since the last inspection, which was carried out in July 2007. The inspection took into account the homes Annual Quality Assurance Assessment (AQAA), which was returned in June 2007 and also an improvement plan forwarded by the home in response to the inspection report dated 12 July 2007. Included in this inspection was an unannounced site visit to the home, which took place on the 8 January 2008 Evidence for this report was obtained from reading and inspecting records, touring the home and from observing the interaction between staff and residents. It was not always o possible to gain the views of people living at the home due to their dementia, however we (the Commission for Social Care Inspection) had the opportunity to speak with 2 visitors to the home, 8 service users, 4 members of staff and by speaking with the homes manager, who assisted the inspector throughout the visit. The home is registered to provide support for 34 people and at the time of the inspection there were 33 residents accommodated in the home. What the service does well: Glen Lee provides care and support in a pleasant environment and residents spoken to were happy with the home. Care is provided flexibly and there was good interaction between residents and staff and there was a relaxed and friendly atmosphere in the home. Residents at the home are treated with dignity and respect and there right to privacy is upheld. There is a range of varied activities and staff offers support to enable residents to take part if they wish Visitors to the home are made welcome and there is a flexible visiting routine. Residents are offered choice as much as possible and are encouraged to make their own decisions about how they spend their time. Glen Lee DS0000039231.V356896.R01.S.doc Version 5.2 Page 6 The home was commended for supporting staff to obtain recognised qualifications and over 80 of the care staff employed by the home have either achieved or are working towards National Vocational Qualifications. They are committed to their role and work well together as a team. What has improved since the last inspection? Since the last inspection a number of improvements have been made and the following improvements were noted: • The needs assessments of all residents have been reviewed to ensure that the home is able to meet their needs and there is an ongoing review process in place. Risk assessments for residents have been put in place and these provide staff with information on any identified risks. Emergency lighting has been put in place adjacent to emergency exits as requested by Hampshire fire and rescue service The fire risk assessment for the building has been reviewed and updated. Copies of all recruitment records are now available for inspection at the home. All of the bedrooms on the ground floor have had new furniture and a shower room and bathroom has been refurbished. • • • • • What they could do better: There were 2 requirements made as a result of this visit and other points, which need to be addressed to help improve the service provided for residents are contained within the main body of the report. General observations were: Care plans were reviewed monthly but the reviews did not give an evaluation on how the care plan was working, therefore improvements are needed so that reviews show how the care plan was working for the individual and this would also give information on residents progress or lack of it as the case may be. Generally medication procedures at the home are satisfactory, however there was some confusion for staff with regard to “when required” (PRN) medication. Southampton City Council has updated its medication policies and procedures but the home needs to produce a clear “in house” policy with regard to PRN medication so that staff are fully aware of the procedures in the home. Quality assurance questionnaires are sent out to residents and relatives, however any information that is received back is not always passed down to Glen Lee DS0000039231.V356896.R01.S.doc Version 5.2 Page 7 the homes manager and this makes it difficult for her to take positive action on any comments that may have been made. 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. Glen Lee DS0000039231.V356896.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 Glen Lee DS0000039231.V356896.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&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Potential new residents have a needs assessment undertaken prior to moving into the home and this allows the home, the resident and their relatives to see if the home can meet the resident’s needs. The home does not provide intermediate care. EVIDENCE: The home carries out an individual needs assessment prior to residents moving into the home and there is a clear admission process and assessments were on file at the home and were looked at for the 3 residents case tracked. There was information on mobility, mental state, diet Continence, dressing and undressing, nutrition, washing, personal hygiene, social interaction, sight and hearing, communication, sleep pattern and religious needs. Assessments were made using a needs assessment form and therefore covered the same issues for everyone with a separate section for any additional information. Residents are initially visited by a care manager and social service assessments are carried out. Once this information is forwarded to the home a care coGlen Lee DS0000039231.V356896.R01.S.doc Version 5.2 Page 10 ordinator from the home carries out a pre admission assessment to ensure that the home can meet the assessed needs, potential new residents are visited before they moved into the home, this was confirmed by a residents relative who we spoke to on the day of the inspection. Intermediate care is not provided at the home. Glen Lee DS0000039231.V356896.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 & 10 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The health, personal and social care needs of residents are contained in an individual plan of care, which gives information on what care is needed, however the recording of monthly reviews could be improved to provide clear evidence on how the plan is meeting residents needs. The health care needs of residents are met by the home and the home has medication policies and procedures in place to help protect residents, however improvements are needed with regard to “when required” medication. EVIDENCE: Care plans were inspected for 3 residents and these were clearly written and they provided information for staff on the support that residents needed and also gave staff information on how residents would like their care to be given. Staff members spoken with said that the care plans provided them with good information to enable them to give the right type of support at the right time. Residents said that staff were always very helpful and one commented “ I am well looked after here” and another said “they help me whenever I ask”. We spoke to 2 visitors who said that they felt that their relatives care needs were met by the home. There was information in one care plan that the resident Glen Lee DS0000039231.V356896.R01.S.doc Version 5.2 Page 12 was at a high risk of falls and there was a risk assessment in place for this. We discussed the risk assessments with the manager and she said that she was attending a meeting in the next few days to review the risk assessment procedures and we pointed out the need to ensure that any identified risks were assessed and that the assessment gave clear information to help minimise any identified risks. Daily recording in care plans took place at the end of each shift and there was a detailed handover to oncoming staff. Care plans were reviewed monthly, but this was mainly a small box, which indicated if there had been any change to the plan, if there was a change there was a space where this change could be recorded. We pointed out to the manager the need to expand on the recording of reviews to provide some evaluation on how the care plan was working for the individual and this would also give information on resident’s progress or lack of it as the case may be. Residents are registered with a number of different GP surgeries and district nurse visits are arranged though a local team of nurses. We saw evidence of visits by a range of health care professionals and arrangements are made for dental checks to be carried out in the local community and a visiting optician calls at the home and a visiting chiropodist visits the home on a regular basis. Residents and visitors spoken with all felt that their health care needs are met by the home. The home has a policy for the receipt, storage, return and administration of medication and all staff at the home who are authorised to administer medication have undertaken training and there is a list of these staff in the front of the medication folder along with signatures, we pointed out the need to have specimen initials recorded to provide a clear audit trail. The home uses a monitored dose system from a local pharmacy and the medication administration records sheets (MARS) were inspected and found to be up to date. Southampton City Council has updated its medication policy and procedures for all of its homes and this includes information about administering “when required medication” (PRN). When inspecting MARS it was found that staff are signing for PRN medication even if it had not been given, they were then completing another sheet stating that the medication had not been given and giving a reason for this. We spoke with the manager and staff that administer medication and it was clear that there was some confusion on what needed to be recorded. We stated that the MARS should only be signed when medication had been given and if it was not required the MARS should be blank. In order to ensure that staff have clear information the manager needs to produce a clear “in house” policy with regard to PRN medication and this should give staff information on the procedures to follow in Glen Lee it should also include information on who makes the decision on when PRN should be given and how this should be recorded. Staff were seen to behave appropriately with residents and we observed staff interacting with residents and using their preferred form of address. Staff were seen to knock on residents doors before entering and residents spoken to confirmed that staff treat them with dignity and respect. Glen Lee DS0000039231.V356896.R01.S.doc Version 5.2 Page 13 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 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a range of activities for residents, which meet their expectations and their religious and recreational needs are met. Residents are able to maintain contact with family and friends and visitors are welcome at any time. Residents are supported to exercise choice and control over their lives as much as possible and they are provided with a balanced diet in pleasant surroundings at time convenient to them. EVIDENCE: Activities at the home are displayed on the notice board and these include: films, visiting entertainers, card games, carpet bowls, musical movement exercise class, hand massage and reminisance, there are also trips to the local pub. The home has an activities co-ordinator and she organises monthly social activities, recently these have included an Xmas bazaar and a resident’s birthday party. Residents spoken with said there was always something going on every afternoon and that there were able to take part if they wanted but could make their own decision on whether they wanted to take part. One resident said that she preferred to watch what was going on rather that getting involver herself. The manager said that they have regular visits from local churches and staff support residents to attend religious services of their choice. Glen Lee DS0000039231.V356896.R01.S.doc Version 5.2 Page 14 The home has a clear visitors policy and there are no set times, visitors sign in at the home and the visitors book is kept in the hallway, residents spoken to said that their visitors were always made welcome and we had the opportunity to speak with 2 visitor to the home who confirmed that visiting times were flexible and they had never experienced any restrictions. We observed staff supporting residents and they were consulted about life in the home, residents spoken to confirmed that they are able to make informed choices and are able to control their own lives as much as possible, they said that they were consulted regularly and that staff at the home respected their views and that if they wanted anything all they had to do was ask. The majority of residents had bought some of their own possessions into the home and rooms had been personalised. The home operates a five-week rolling menu and residents spoken with were happy with the choice of food provided by the home. Comments received were “ the food is very good” “ I always have enough to eat” and “there is nothing to complain about” there is a choice of meals available including a vegetarian option. Residents are supported to make choices with the use of picture card menus, which are displayed on the residents’ notice board. Mealtimes were unhurried and staff provided suitable support for those residents who required it. Residents are able to eat their meals in the dining room or elsewhere if they prefer. Glen Lee DS0000039231.V356896.R01.S.doc Version 5.2 Page 15 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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a simple, clear and accessible complaints procedure, which includes timescales for the process and any complaints are logged and responded to appropriately. The homes policies and procedures protect residents from any form of abuse. EVIDENCE: The home has a clear complaints procedure, which contains all of the required information and residents spoken to said if they had any complaints they would speak to a member of staff. Staff members spoken to were aware of the complaints procedure and said that they would support any resident to make a complaint if they wished to do so. The home keeps a record of all complaints and there have been 4 complaints to the home since the last inspection, these were relatively minor issues but they had been appropriately recorded and responded to. Staff have received training on adult protection and the home has a whistle blowing policy and also a copy of the Hampshire Adult Protection procedure. Staff spoken to were aware of their responsibilities in this area and knew what to do should they suspect any form of abuse had taken place. The manager told us that there had been one adult protection issue since the last inspection and this involved an agency staff member who had spoken to a resident inappropriately. This was not initially reported to social services under the adult protection procedure and the manager had carried out her own investigation. We discussed this issue with the manager who recognised that Glen Lee DS0000039231.V356896.R01.S.doc Version 5.2 Page 16 she had not correctly followed the adult protection procedure but said she had learnt a valuable lesson and said that she would follow the correct procedure for any further incidents. Glen Lee DS0000039231.V356896.R01.S.doc Version 5.2 Page 17 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe and well-maintained environment and have access to comfortable indoor and outdoor facilities. Residents have the specialist equipment they require to maximise their independence and the home was clean, pleasant and hygienic and free from offensive odours. EVIDENCE: We had a look around the home during the visit and all areas of the home were clean and tidy and furniture was in a good state of repair. There is a large enclosed garden at the rear of the property and this was tidy and safe. The home has access to the Southampton city council maintenance team and they carry out routine maintenance and decoration and the manager stated that this works well. There has been new furniture purchased for bedrooms on the ground floor and for 4 bedrooms on the 1st floor and a shower room and bathroom have recently been refurbished. The home has a call system for service users to summon assistance and these were available in all rooms and were easily accessible. Glen Lee DS0000039231.V356896.R01.S.doc Version 5.2 Page 18 The home has a laundry, which provides a full laundry service for residents and this is equipped with industrial washing machines and tumble driers. The home employs dedicated staff to carry out laundry duties and there are housekeepers who keep the home clear and tidy and all areas of the home were clean and there were no offensive odours. Glen Lee DS0000039231.V356896.R01.S.doc Version 5.2 Page 19 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a mix of staff that has a range of skills and there were sufficient numbers of staff on duty to meet the needs of residents. The homes recruitment policy and practice supports and protects residents and they benefit from a staff team that has had sufficient training to meet their needs. EVIDENCE: Staff morale was good and there was a good rapport between residents and staff. The homes staff rota was examined and this showed that the home provides 2 senior staff member plus 5 carers between 0730 – 2130. Between 2130 – 0730 there is 1 senior staff member and 2 carers awake throughout the night. In addition to care staff there is a cook, a kitchen assistant, 1 laundry assistant and 2 housekeepers who work alongside the care staff to provide domestic support. We discussed staffing numbers with the homes manager and were told that at present she felt that staffing levels were sufficient. The home employs a total of 21 care staff and 16 have NVQ level 2, there are also 9 care co-ordinators with 7 having NVQ3 and 2 with NVQ level4. The home has policies and procedures in place with regard to recruitment and staff recruitment records were inspected for 3 staff members: Recruitment takes place with assistance from Southampton City Councils human resources department and staff records are held centrally, however the manager keeps Glen Lee DS0000039231.V356896.R01.S.doc Version 5.2 Page 20 copies of all recruitment records at the home and those seen contained all of the required information. Staff training records showed that staff have completed training in, fire, medication, moving and handling, first aid, adult protection, food hygiene, infection control, managing aggression, dementia care, equality and diversity, care practices, health and safety and COSHH. Staff spoken to confirmed that they receive regular training and they were confident that they could meet the needs of residents. The home has a good induction procedure, which is NVQ based and contains skills for care induction and foundation standards and there is an in house induction to cover procedures within the home. Glen Lee DS0000039231.V356896.R01.S.doc Version 5.2 Page 21 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 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager provides effective management of the home and it is run in the resident’s best interests. The financial interests of residents are protected by the homes policies and procedures and the health, safety and welfare of residents and staff are promoted and protected. EVIDENCE: The manager has been in post for 2 years, she has NVQ4 in care and is currently undertaking the Registered Manager Award, which is due to be completed in March 2008, she has the skills and experience to manage the home. The manager is supported in her role by the care-co-ordinators who are senior care staff and they supervise the care staff in their day-to-day support tasks. The home has a quality control system in place to monitor standards and the home receives regular regulation 26 visits. We were informed that quality Glen Lee DS0000039231.V356896.R01.S.doc Version 5.2 Page 22 questionnaires are sent out to residents and relatives and these are received back by the service manager, however the information received back is not passed down to the homes manager so it is difficult to take positive action on any comments. In order to ensure that the quality audit is effective the results must be given to the manager so that she can address any issues. We spoke to residents at the home, however they could not remember if they were formally consulted about how the home is performing but all those spoken with said that staff are always around to help out and asked them if everything was OK. The home has good systems in place for resident’s finances and this is well documented, each resident has an individual account set up by Southampton City Council (SCC) and there is a clear audit trail of monies received in and paid out. The home manager has been in contact with SCC health and safety team and they have carried out a fire risk assessment for the building. Emergency lighting has been put in place adjacent to emergency exits as requested by Hampshire fire and rescue service and all staff at the home has undertaken fire training. The fire logbook was up to date and all relevant training and testing is carried out within the specified timescales. All staff spoken to were happy with the health and safety arrangements in the home and residents spoken to said that they felt safe at the home. Glen Lee DS0000039231.V356896.R01.S.doc Version 5.2 Page 23 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Glen Lee DS0000039231.V356896.R01.S.doc Version 5.2 Page 24 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 Requirement The registered persons must ensure that resident’s plans of care are kept under review and the review should provide an evaluation of how the care plan is working for the individual. In order that staff are fully aware of the recording procedures for any “when required” medication the registered persons must produce clear written guidelines so that staff are aware of their responsibilities in this area. Timescale for action 28/02/08 2. OP9 13(2) 14/02/08 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 Glen Lee DS0000039231.V356896.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Glen Lee DS0000039231.V356896.R01.S.doc Version 5.2 Page 26 - 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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