Inspection on 30/05/06 for Glenarie Manor

This inspection was carried out on 30th May 2006.

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 found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glenarie Manor 22/06/07

Glenarie Manor 26/10/05

Glenarie Manor 05/05/05

Glenarie Manor 09/11/04

Glenarie Manor 17/05/04

Glenarie Manor 02/02/04

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

CARE HOME ADULTS 18-65 Glenarie Manor 15 Aigburth Drive Sefton Park Liverpool Merseyside L17 4JG Lead Inspector Natalie Charnley Unannounced Inspection 30th May 2006 09:30 Glenarie Manor DS0000025105.V297749.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 Glenarie Manor DS0000025105.V297749.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. Glenarie Manor DS0000025105.V297749.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glenarie Manor Address 15 Aigburth Drive Sefton Park Liverpool Merseyside L17 4JG 0151 726 0814 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) Colin McCabe Ian Boycott-Samuels Care Home 26 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (26) of places Glenarie Manor DS0000025105.V297749.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents between ages 16 and 64 years Within the overall total of 26 residents two named male residents may be accommodated who are over 65 years of age until such time as either persons assessed needs change and they cannot be safely cared for at home 25th May 2006 Date of last inspection Brief Description of the Service: The home is a large well maintained three storey Victorian House situated in Sefton Park in a suburb of Liverpool called Aigburth. The care home can accommodate 26 residents, most referred from various Primary Care Mental Health Trusts. All residents have their own single bedrooms, which have been personalised by the residents according to their cultural preferences and choices. The home has easy access to buses trains, local bistros and pubs. All of the residents have access to GPs and Social Workers, and access to a Community Psychiatric Nurse (CPN.) Glenarie Manor DS0000025105.V297749.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out over a period of one day. The inspector arrived at the home at 09:00 and left at 15:40 .The inspector spoke with 5 staff and 6 residents. No visitors were available at the time of the inspection. The home was asked to provide a selection of pre inspection information, however this had not arrived at the time of the field visit. Comment cards were left at the home for residents, staff and visitors to complete. The person in charge was also given an ‘inspection feedback’ card to complete regarding the inspection process. The inspector completed the inspection by looking at the homes records, a tour of the building, formal and informal interviews and information from previous inspection reports. The inspector followed an inspection plan written before the start of the inspection using all information held on file at Commission for Social Care Inspection regarding the home, to ensure that all areas that needed covering were done so. Feedback was given to the person in charge during and at the end of the inspection. Due to serious concerns regarding the administration of medications that were identified during the inspection, a pharmacy inspection will be arranged. What the service does well: The home actively seeks the views of staff and residents and act upon any suggestions that are made. The staff team is strong and works well together. Support is given by the management team at all times. Residents are encouraged to live independent lives, with staff supporting them when they need it. Choices are able to be made on a daily basis, and are supported by appropriate checks for risk. The environment is well maintained, on the whole. Residents are very happy with the accommodation that is provided and the communal areas suit the needs of individuals. Glenarie Manor DS0000025105.V297749.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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. Glenarie Manor DS0000025105.V297749.R01.S.doc Version 5.2 Page 7 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 Glenarie Manor DS0000025105.V297749.R01.S.doc Version 5.2 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality outcome in this area is good. This judgement has been made using available evidence including a visit to the service. Information gathered by the home before a resident moves in ensures that they can care for residents. Residents clearly understand their individual responsibilities about living at the home and are not restricted in any way. EVIDENCE: Four residents were case tracked as part of the inspection process. The care plans for these residents were looked at in detail. Residents have a pre admission assessment undertaken by the home before they move in. This is to ensure that the home feel that they can meet the needs of the residents effectively. Other information is also gathered from outside agencies such as psychiatrist reports and social work assessments in order to help the home make this decision. This process was discussed with the last resident who was admitted to the home and the deputy manager, all of whom confirmed this process takes place. Residents have an ‘agreement’ which they sign when the move to the home. This outlines what they can and cant do. Residents spoken to were all clear as to the way they need to conduct themselves at the home and commented that this doesn’t make them feel restricted in any way. Glenarie Manor DS0000025105.V297749.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9 Quality outcomes in this area are adequate. This judgement has been made using available evidence including a visit to the service Care plans do no reflect the views of individual residents and not all risks are appropriately monitored. Residents are encouraged and supported to participate in aspects of the running of the home and make regular individual decisions on a daily basis. EVIDENCE: Every resident has an individual care plan, which outlines the support that they need. These plans are currently updated, according to the deputy manager, 612 monthly, however it was recommended that this is increased to 3-6 monthly to ensure any changes in care needs are recorded. Along side these documents, residents have risk assessments for things such as ‘self medication’, ‘smoking’ and ‘participating in work’. One resident who was case tracked was identified in his care plan as having poor mobility, and being at risk from falling. No risk assessment was available to show that staff had looked at this problem. This must be carried out as soon as possible. The home is able to show that they assess not only mental health but physical health also. Glenarie Manor DS0000025105.V297749.R01.S.doc Version 5.2 Page 10 Details of weight and blood pressure are recorded on admission to the home, and residents who take certain medications that require regular monitoring from blood tests have this carried out on a regular basis. New residents to the home have a temporary care plan put in place for approximately 6-8 weeks to give the staff time to complete a further assessment period, this is an example of good practice. Discussion with residents highlighted that they were not aware that they had a care plan and no signatures were on care plans to show that residents had agreed to goals and targets that staff had set, this must be addressed by the home. Residents were able to give examples of how they make decisions on a daily basis and commented “ I come and go as I please at the home”, “ I decide when I go to bed and when to get up” and “ staff only help me when I ask for help, I decide what I do here”. Financial records showed that different residents require different levels of support in this area; any restrictions that are imposed are documented and agreed by the residents. Residents were seen taking control of varyining amounts of money during the inspection and records were up to date and of a good standard. Residents participate in a regular ‘resident meeting’ where any areas of concern or praise can be highlighted. Minutes of these meetings were seen and staff could demonstrate how they had acted on any suggestions that were made. One resident commented, “ I enjoy the meetings we have, we can say exactly what we feel”. Glenarie Manor DS0000025105.V297749.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality outcomes in this area are good. This judgement has been made using available evidence including a visit to the service Residents are supported to make lifestyle choices and staff can demonstrate a sound understanding on the support residents need. EVIDENCE: Two residents at the home have gardening jobs organised through local day centres and out patient clinics. Another resident helps staff do daily jobs around the home, for this he receives a small payment. Currently there are no residents that are doing educational qualifications, however staff recalled previous residents whom had been supported to do this. Activities at the home are not formally organised but are done on an ‘as and when’ basis. Residents have access to a gym and pool room, and most of the residents spoken to stated that they do their own activities on a daily basis outside of the home. Staff on the whole, do not accompany residents when they go out of the home, however sometimes circumstances mean that they have to. Trips out are arranged and are enjoyed by staff and residents. One resident spoken with discussed how he is supported to attend a social group, which help him fulfil his religious practices as a Jew. Glenarie Manor DS0000025105.V297749.R01.S.doc Version 5.2 Page 12 He stated that the home assist him in ensuring that he recalls and participates in religious festivals and that he can have leave on a Friday night to join in Sabbath celebrations with his family. Staff at the home also has access to information regarding Jewish beliefs and practices to ensure that they can support the resident correctly. Residents commented “we can have visitors here at any time” and “ my family can come and see me in private” when asked about having visitors at the home. The home offers a separate room that residents can use to access a telephone in private. Residents spoke of the friendships that have developed within the home and commented that they enjoyed the social aspects of living at the home. Members of staff interviewed demonstrated a sound understanding of the support the individuals needed at the home, they confirmed that visiting is “open” and that they support residents in an individual and culturally acceptable way. Meals at the home are based on a four-week rotating menu. Choices are offered on the menu and residents make a choice of what they want the weekend before, however this can always be changed. The home caters for three vegetarians, two diabetic and one kosher diet. Residents also have access to a rehabilitation kitchen where they can prepare their own meals. Comments were positive about the food at the home, stating it was “ tasty”, “very nice” and “lovely”. Glenarie Manor DS0000025105.V297749.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality outcomes for these areas are poor. This judgement has been made using available evidence including a visit to the service Residents can access a wide range of health services, however medication practices are poor and leave residents at risk from harm. EVIDENCE: The home access information and guidance from a variety of health professionals. Residents have regular access to CPN’s (community psychiatric nurses), Psychiatrists, GP’s (general practitioners), Dentists and Chiropodists, to monitor both their physical and mental health. Residents confirmed that when these professionals come to the home, they are seen in private, to maintain confidentiality. Serious concerns were highlighted with regard to medication practices at the home. Storage, medication administration records (MAR’S) and medication administration practices were all assessed as part of the inspection process. No photos were available to identify residents on medication records. A specimen signature list was available but needed updating as staff who are no longer employed at the home are recorded on it. Nursing staff have no access to copies of the Royal Pharmaceutical Society Guidelines or NMC (Nursing and Midwifery Council) guidelines on administering medication, which is recommended. Glenarie Manor DS0000025105.V297749.R01.S.doc Version 5.2 Page 14 A significant number of records had gaps in the records where nurses sign that medications have been given and all handwritten entries were not double signed by staff to prevent errors occurring. Five medications that were prescribed to residents had not been given in the correct dosage according to the prescription, and of the three medications case tracked; two did not tally with the recorded dose on the MAR chart. The fridge that stores medications was in need of defrosting, to ensure that it runs effectively. Seven medications were stored in this fridge that needed to be stored at room temperature and the home were not keeping checks on the temperature that the fridge was running at. The treatment room that stores medication was clean and tidy, however a box of Accu-check lancets (needles used for checking the blood sugar levels in diabetic residents) had expired on 12/2005 and were for a resident no longer living at the home. Medication pots were in the storage room with slips of paper with residents names on, suggesting that some staff were ‘potting up’ medications, however this was denied by staff. This is a dangerous and unacceptable practice that can result in drug errors occurring and must not carry on. A medication pot was identified as containing 33 orange tablets, the home had no audit trail available to follow how many of these tablets should have been in the pot, and the tablets were not securely stored. The deputy manager was advised to dispose of these tablets as soon as possible. It is recommended that the manager of the home carry our regular audits on medication administration and required that up to date training be given to all nursing staff. The home records all medications entering and leaving the home and has had the approval from the residents GP for the administration of homely remedies, which is an example of good practice. Glenarie Manor DS0000025105.V297749.R01.S.doc Version 5.2 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality outcomes for this area are adequate. This judgement has been made using available evidence including a visit to the service Not all residents know how to make a complaint. Policies are in place for staff to follow regarding adult protection. EVIDENCE: The home has no formal record for recording any complaints that are made. The deputy manager stated that all complaints are dealt with and raised during residents meetings and showed that the home log ‘incidents’, two of which have been recorded since the last inspection. The home policy on complaints informs the reader of whom to contact to make a complaint, however it needs to be amended to show that the home will deal with a complaint within 28 days. A formal record will also need to be kept of all complaints, wherever they have been raised and clearly outline what the home have done to address the issue. Residents spoken to were not sure how to make a complaint, staff should go over this with them to ensure they understand the procedure. Staff interviewed showed that they had a good knowledge of adult protection issues and had received recent training. The home is aware that a new policy is shortly to be produced by the local authority, and have the current policy in place. Staff files were not available to be checked, but staff stated that they had provided suitable references and undertaken Police checks before starting work. Glenarie Manor DS0000025105.V297749.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality outcomes for this area are adequate. This judgement has been made using available evidence including a visit to the service Residents are satisfied with their environment, however adjustments need to be made to ensure individual needs are met. EVIDENCE: A full tour of the home was undertaken, and a sample of bedrooms were looked at with the residents permission. The home has a selection of communal areas including a games room where smoking is permitted; all other areas are no smoking, including bedrooms. Most areas were well maintained and in a good state of repair. The home has a full time handy man, who completes daily checks of the home environment, to ensure that it is kept in good condition. The handy man stated that he redecorates all bedrooms when residents move out and showed the inspector examples. During the tour, bathroom 20 was identified as needing two ceiling tiles replacing from a recent flood and bedroom 14 was found to have a strong smell of smoke, which the home need to investigate. Glenarie Manor DS0000025105.V297749.R01.S.doc Version 5.2 Page 17 The kitchen and laundry areas were well maintained and clean. Staff confirmed that the home provide good stocks of cleaning materials and provide good levels of cleaning cover. The home stock bleaches as a cleaning material, however it is strongly recommended that this be substituted for a more appropriate alternative. The kitchen fire door was found to be wedged open with a traffic cone, which was removed immediately. Residents described their home environment as “ nice and clean”, “great” and “having plenty of space to move around”. One new resident was identified as having no suitable bathing facilities, and currently had to kneel down in the bath to wash himself. The home do not have any showering facilities at present, however they must look into providing these as a matter of urgency, or another other such suitable facility to ensure the resident has his needs met. This matter should have been identified prior to him moving into the home. Glenarie Manor DS0000025105.V297749.R01.S.doc Version 5.2 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality outcomes for this area are good. This judgement has been made using available evidence including a visit to the service The home has an effective staff team that are trained and competent to do their jobs. Information regarding adult protection is not up to date and may leave residents at risk. EVIDENCE: The home is staffed by RMN’s (Registered Mental Health Nurses) who are supported by care staff and a team of domestics and cooks. The care staff usually work in teams of one male and one female member of staff, in order to ensure suitable care can be given to individuals and that residents preferences are met. Three members of staff were interviewed and stated that they had received appropriate Police checks before starting work at the home, however access to this information could not be gained. All members of staff commented that the staff team was strong and worked well together. One commented, “I enjoy working here, we are given a lot of training and support”. Staff spoke about the vast amounts of training they had been given over the last six months and were able to give examples, however access to these records was not available. Residents spoken with to stated “staff are ace” and “everyone is friendly”, many spoke about how they had been supported by staff in a variety of ways and how there was always someone available even if it was just for a ‘chat’. Glenarie Manor DS0000025105.V297749.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality outcomes for this area are good. This judgement has been made using available evidence including a visit to the service Records show that the views of staff and residents are sought and acted upon. Health and safety checks are well organised and protect the welfare of the residents. EVIDENCE: The manager was not on duty during the inspection, however records show that he is a trained nurse who has a number of years experience in the care home setting. Staff spoke favourably about the way in which the manager operates the home, commenting that they were “supported” and “always kept informed”. Records showed that regular staff meetings take place, which gives staff the chance to air, their views. Residents are also given an opportunity to discuss issues in their forum and are happy that when suggestions are made that the manager acts upon them. Quality assurance questionnaires are sent every year to residents, these are kept on care plan files. Examples looked at showed very positive comments that had been made. Glenarie Manor DS0000025105.V297749.R01.S.doc Version 5.2 Page 20 A selection of health and safety record checks were looked at. All were found to be up to date. The maintenance man was able to provide information about the roles and responsibilities of staff at the home in undertaking these checks, which are organised well. Glenarie Manor DS0000025105.V297749.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 3 X X 3 X Glenarie Manor DS0000025105.V297749.R01.S.doc Version 5.2 Page 22 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 15(1)(2) Requirement The registered person must ensure that care plans are formulated with input from residents/ and or their families. The registered person must ensure that all areas highlighted within care plans as a ‘risk’ has appropriate risk assessments to back them up that are regularly updated. The registered person must ensure that: 1. All medications are given as prescribed 2. Handwritten entries are double signed and dated by staff 3. The practice of ‘potting up’ medications stops 4. Photographs of residents are held on MAR charts as a form of identification 5. The medication fridge is defrosted and a record is kept of a daily maximum and minimum temperature 6. That medication is stored at the correct temperature 7. That appropriate accredited training is DS0000025105.V297749.R01.S.doc Timescale for action 30/06/06 2. YA9 13(4)(a) 30/06/06 3 YA20 13(2) 01/06/06 Glenarie Manor Version 5.2 Page 23 3 YA22 22 4 YA24 23 provided for all nursing staff The registered person must 30/06/06 ensure that all complaints are recorded and that the complaint policy shows a 28-day timescale for response. Residents must also be made aware of how to make a complaint. The registered person must 30/07/06 ensure that: 1. The fire doors at the home are not wedged open 2. The bathroom ceiling tiles identified in bathroom 20 are replaced 3. The smell to bedroom 14 is investigated and dealt with 4. Suitable bathing facilities ate provided for all residents 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. 2 Refer to Standard YA6 YA20 Good Practice Recommendations It is recommended that care plans be reviewed on a 3-6 monthly basis to ensure staff keep up to date with the changing needs of residents. It is recommended that the manager provide nursing staff that administer medication, copies of the NMC ‘Guidelines on the administration of medication’ and ‘Royal Pharmaceutical Society Guidelines on the administration of medication in care homes’. It is recommended that a new specimen signature list is developed to reflect the signatures of current nurses It is recommended that the manager carry out regular audits of medication administration and storage. It is recommended that an alternative-cleaning product be DS0000025105.V297749.R01.S.doc Version 5.2 Page 24 3 YA30 Glenarie Manor used to bleach. Glenarie Manor DS0000025105.V297749.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Glenarie Manor DS0000025105.V297749.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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