Inspection on 06/09/05 for Glendale Lodge Residental Care Home

This inspection was carried out on 6th September 2005.

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 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

Glendale Lodge Residental Care... 13/03/07

Glendale Lodge Residental Care... 06/01/06

Glendale Lodge Residental Care... 17/01/05

Glendale Lodge Residental Care... 08/06/04

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

CARE HOMES FOR OLDER PEOPLE Glendale Lodge Glen Road Kingsdown, Deal Kent CT14 8BS Lead Inspector June Davies Announced 06/09/05 at 10:00am 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 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. Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Glendale Lodge Address Glen Road, Kingsdown, Deal, Kent CT14 8BS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01304 363449 01304 363449 Extrafriend Limited Mrs Carole Lesley McNamara Registered Care Home 25 Category(ies) of Old Age registration, with number of places Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17/01/05 Brief Description of the Service: Glendale Lodge is a purpose built residential care home, registered for twenty five older people over the age of 65. The property has 23 single bedrooms and one double bedroom. Fifteen bedrooms have en suite facilities. Twenty two bedrooms are situatated on the ground floor, with one single and one double bedroom on the first floor. The first floor is accessed by a stair case with chair lift in situ. On the ground floor there are three communal lounge areas, which provide pleasant surroundings to relax and eat in. The home is situated in the village of Kingsdown, Deal; the village bus stop is a short walk away. The home also has impressive rural views. The gardens of the home are well maintained and attractive, and there is ample parking facilities at the front of Glendale Lodge. The home is owned by Extrafriend Limited and is managed on a daily basis by Mrs Carole McNamara, with the assistance of a deputy manager, an administrator and a further twenty two care staff, who work on a rota basis. Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection to Glendale Lodge of eight hours duration. The inspector was able to speak to the registered manager, senior staff and fourteen residents in the home, as well as looking at documents and paperwork relevant to the inspection. The inspector was also able to walk round the home both externally and internally. The residents all stated that they were very happy in the home, some stated that they still miss their own homes, but know that they are safe and well cared for in Glendale Lodge. What the service does well: What has improved since the last inspection? Since the last announced inspection staff training both mandatory, work related and NVQ has improved. Medication is very well managed and all paperwork in relation to medication is appropriately completed. The inspector found the medication cupboard and trolley to be clean and hygienic. Activities for the residents has improved since the last announced inspection, and it was noted on one morning of the inspection that several residents were sitting playing a game of dominoes together. Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 Page 6 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. Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 Page 7 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 Standards Statutory Requirements Identified During the Inspection Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4, 5, The homes statement of purpose and service user guide are good, providing residents and prospective residents with the information they need to make a decision about moving into the home. Each resident is aware of their role and responsibilities in the home and residents move into the home knowing their needs can be met and that their independence will be maximised and promoted. EVIDENCE: The inspector viewed the statement of purpose/service user guide, and contract/statement of terms and conditions. Statement of purpose and service user guide has recently been reviewed and contained all the information required by the standard. The inspector has made one recommendation, that the fire precautions within these documents are more informative in respect of a resident who smokes, and the fire procedure for residents to be included in the document. The residents contract/statement of terms and conditions, again has recently been reviewed and gives good information to new residents in regard to room number to be occupied, what services are covered by the weekly fee, what the resident would need to pay extra for, the rights and obligations of the residents and the provider, and the Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 Page 9 terms and conditions of residency. The inspector viewed pre-admission assessments for three residents, which are kept at the rear of the care plan, a variety of detailed pre-admission assessments were available from care managers, and other external health professionals together with the homes pre-admission assessment. The registered manager visits prospective residents in their own home or in hospital, to make her own assessment as to whether the home will be able to meet the prospective residents needs. Where pre admission assessments give evidence of input from external health professionals, the registered manager will ensure that this will be ongoing when a prospective resident comes to live at the home. Some residents who have audiology problems are able to have loop systems installed in their bedrooms to enable them to watch and listen to their television, and at the present time the registered manager, is looking a way of giving residents with failing sight a clear means of identifying communal toilets. Evidence was also available to show that in emergencies and out of working hours senior staff, have the knowledge of how to contact external health services for advice and action. Each new resident comes into the home on a four-week trial period to make sure that the home is able to meet their needs, and they feel happy living in the home. The home also offers respite care when a bedroom becomes vacant, in many cases a resident in respite care requests that they are able to become permanent residents in the home. The inspector spoke to twelve residents in the home all stated that they were happy in the home, their needs were met, and that staff gave excellent support to them. Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10, 11. Residents know that their personal goals are reflected in their individual plans and that potential risks are managed. Residents know that their views are listened to and that their records will be kept securely maintaining their confidentiality. The health needs of the residents are well met with evidence of good multi disciplinary working taking place on a regular basis. The medication at this home is well managed promoting good health. EVIDENCE: The inspector viewed three excellent care plans, where it was obvious that the pre-admission assessment had been taken into account. There was also evidence of very good risk assessments, which had been highlighted as being red, amber or green and marked with the appropriate coloured disk. The risk assessments had been thoroughly completed a give staff good guidelines as to how much input they need to have with the resident to reduce the risk. The care plans were easy to case track, and there was evidence of well written daily reports, together with detailed tracking of personal hygiene care, which again is going to be reviewed to ensure that staff check on a regular basis, the tissue viability of the resident(s). Each care plan showed that regular monthly reviews take place, and any changes to assessed care needs of the resident are recorded. Two residents spoken to said that they were aware that they Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 Page 11 were able to view their care plans if they wished to do so. Staff are aware that where there is concern in regard to the tissue viability of a resident this must be recorded, and the district nurse informed. The inspector evidenced that this is the case and that the district nurse provides residents at risk with suitable cushions and aids to maintain tissue viability. A continence nurse visits the home on a regular basis to review those residents receiving continence aids, and is also available as and when assessment is required for a resident needing assistance. The registered manager is able to contact the mental health team at any time if there are concerns for the mental welfare of a resident, the manager stated that the response from the mental health team was good, and she also ensure that any referral is recorded in the residents care plan, and this was evidenced by the inspector. Each care plan contains a sheet to show that residents are regularly weighed, and any concerns in regard to weight loss or gain are recorded and reported immediately to the general practitioner. The activities programme in the home shows that residents have the opportunity to be involved on a weekly gentle exercise programme. Evidence was also available in the care plan to show that residents have a choice of visiting their own private optician, chiropodist, dentist, but the home also has a visiting optician, chiropodist and dentist for those residents who prefer to be seen in-house. The registered manager has access to an audiologist, and a NHS sponsored volunteer visits the home to replace batteries and tubes on the residents’ hearing aids. The inspector carried out an audit of medication and this was observed as being well recorded, stored, handled, and administered, with unused medication returned to pharmacy appropriately. All medication had been appropriately ordered, MAR sheets had been correctly signed by staff members trained to administer medication, the returned medications book showed medication is returned regularly and signed for on pick up from the home. Medication trolley was clean and well ordered, medication store, was clean, well ordered and was not overstocked. Where residents choose to self medicate, this is appropriately recorded in care plan, and the residents’ medication is checked on a monthly basis. The deputy manager is very much involved in the ordering, administration, storage and returning of medication, with the registered manager carrying out monthly auditing checks. During the inspection the inspector noted that the staff in the home, respected the privacy and dignity of the resident’s, knocking or doors before entering, and ensuring that communal toilet doors were kept shut when in use. Six residents in the home have their own phone line into their bedroom, and one resident has their own mobile phone. One resident subscribes to satellite television. There is only one double room in the home and at the present time there is only one resident in this room at the present time. The home has good policies and procedures in regard to caring for terminally ill residents. The home also receives continuous support from the palliative care team, community nurses, and when required Macmillan nurses. The inspector did notice that some of the care plans did not give details of residents wishes on death and has therefore made a requirement, that all care plans are updated with this information. Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 Page 12 Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15 The home offers activities in line with the residents’ interests and wishes. Links with the community are good and support and enrich the residents’ social opportunities. Residents’ are able to maintain control and choice over their lives according to their assessed needs. The meals in this home are good offering both choice and variety and catering for special diets. EVIDENCE: Information regarding activities are posted in the lounge informing residents of the activities available on each day of the week. The home has a paid activities co-ordinator, who involves residents in pottery, art, and crochet. Residents were keen to show the inspector their recent achievements, where they had decorated earthenware, planting pots, in readiness for planting spring bulbs. One resident stated that she had made a pottery bird to display in her outside garden area. Added to these activities are manicure sessions, reminiscence, gentle exercises, bingo, visiting singers, and a guitar man. The vicar visits the home monthly to give communion and a Roman Catholic priest visits the home on a regular basis. The registered manager and staff take residents shopping and out to lunch. One resident goes out of the home to her bridge club, and the bridge club often visit the home. Another resident has her own electric scooter and regularly goes into the village to visit her daughter, or into Deal for the shops. Brownies and beavers come into the home to visit the residents. The home has an open visiting policy, and visitors Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 Page 14 are welcome at any time. Where relatives and friends have to travel long distances to visit they are always offered a meal at the home. Where possible residents are encouraged to handle their own financial affairs, and the registered manager will give them every assistance to do so. The registered manager has also ensured that residents and their relatives, representatives have access to advocacy services, and leaflets about advocacy are available in the main hallway. The inspector visited fourteen of the residents’ bedrooms, and found that all were very individual to each resident, and displayed ornaments and pictures which the residents had brought into the home with them. The inspector was able to speak with many of the residents in their own rooms, and all stated how comfortable they were. During the course of the inspection the inspector was able to talk to residents at lunchtime and noted that meals were well presented, and in accordance with each individual residents dietary intake. All residents stated that the food in the home was of a very high standard, and that they were able to have a choice if they wished. The home caters for vegetarian and diabetic diets at the present time, but in the past have produced liquidised meals when requested to. Liquidised meals always have each portion individually liquidised to enhance presentation. The inspector was able to view the menu for the home, which showed well balanced, varied and nutritious meals are offered to the residents, with many choices available to cater for likes and dislikes. Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17, 18 The residents know their complaints will be listened to and acted on. Staff have a good knowledge and understanding of adult protection issues which protect the residents. EVIDENCE: The inspector viewed the complaints policy and procedure, which has recently been reviewed. This policy and procedure clearly outlines the steps the complainant would need to take, and that the complaint will be investigated fairly and within 28days and that the outcome will be relayed to the complainant. The home has received one complaint since the last inspection. The inspector witnessed that this complaint had been appropriately recorded, the investigation and action had been taken and that this had been relayed to the complainant. One resident spoken to by the inspector stated that they would know how to make a complaint. The majority of the residents in the home have relatives who act on their behalf, none of the residents at the present time use the service of an advocate. All the residents with the exception in the home use postal voting because they choose to do so. The registered manager was able to confirm that all staff have completed challenging behaviour and protection of vulnerable adults training. The inspector evidenced that the home has policies and procedures in relation to the protection of vulnerable adults, and whistle blowing. Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25, 26. The standard of the environment within the home is good providing the residents with an attractive and homely place to live. EVIDENCE: Glendale Lodge is ideally suited as a residential care home, part of the home has been purpose built. The inspector witnessed that the home has a programme of routine maintenance, and renewal. The company who own the home insist that any marks on walls or paintwork are attended to immediately, to ensure that the home remains in a good state of repair. The grounds surrounding the home are well tended, attractive and easily accessible to the residents in the home. The fire safety officer has issued a letter to state that the home meets the fire standards and the home has also achieved a clean food award for the second year running from the environmental health officer. The home has three large communal lounge/dining areas that are well decorated, have domestic style furniture and fittings, both rooms have views of the garden area and panoramic views of the surrounding countryside. Fifteen of the bedrooms have en-suite facility’s, the communal toilets are situated Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 Page 17 close to bedrooms without this facility and are also close to the communal facilities. The home also has the benefit of two bathrooms fitted with over bath hoists, and one shower room. Glendale Lodge has recently fitted handrails in the corridors of the building, which the residents find quite useful when moving about the home. All communal toilets are fitted with raised toilet seats and grab rails, the home also had a mobile hoist, and bathrooms are fitted with appropriate hoists. Each resident has an accessible call bell in the bedroom. The home has one double bedroom and twenty-three single bedrooms. At the present time the double bedroom is being used as a single room. On inspection of the environment the inspector found that each bedroom was appropriately furnished with domestic style furniture and fittings, and that each room had been individualised with the resident’s own ornaments, pictures and small items of furniture. Each bedroom has its own patio door, with ramps fitted as required to enable access to the garden area. All bathrooms and the shower room have thermostatic valves fitted to the hot water taps to ensure that water is delivered at 43 degrees centigrade. Emergency lighting is provided throughout the building and this is tested on a monthly basis, and a record of this test is kept, with any faults recorded, reported and repaired. On the days of the inspection the home was clean and in the main there were no offensive smells in the home with the exception of one area at the bottom of the corridor and in one bedroom. The registered manager explained what the situation was, and that action was in place, which would not remedy this issue overnight but will be dealt with as a matter of urgency. The inspector viewed the laundry room, which although small in size was clean and tidy. The home has policies and procedure in place for dealing with cross infection, and the inspector witnessed that staff had easy access to vinyl gloves, liquid soap and paper hand towels, although it was noted that in the two communal toilets there were no paper hand towels holders and a recommendation has been made for these to be fitted. Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30 Staff morale is high resulting in an enthusiastic workforce that works positively with the residents to improve their whole quality of life. The recruitment practises are good with appropriate checks being carried out and residents receiving consistent care. The arrangements for the induction of staff are good with the staff demonstrating a clear understanding of their roles. EVIDENCE: The inspector viewed the staff rota over a period of four weeks and this showed that over a twenty four hour period there are sufficient staff are on duty to meet the assessed needs of the residents. The training matrix showed that staff, have a variety of skills and knowledge to ensure a good skill mix of staff on duty throughout each shift. At the present time 39 of staff have NVQ certificates, and some staff are awaiting certification, which will ensure the 52 of staff will have NVQ qualifications. The inspector was able to view three staff files, all had CRB checks in place and one of the latest recruits had a POVA first check, with the exception of identification the personal files contained all relevant information including two references. The inspector has made a recommendation that all staff files contain two forms of identification. Evidence was available via the training matrix and staff certificates to show that the majority of staff have either completed or updated their mandatory training, and where this was not applicable, mandatory training is taking place within the next four weeks to ensure that all staff, have completed this training. The registered manager has compiled a very good induction programme that is TOPSS related, all new staff are put through this induction Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 Page 19 process and the registered manager was able to show completed inductions to the inspector. Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36. 37, 38 The manager is supported well by the senior in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. The home regularly reviews aspects of its performance through a good programme of self-review and consultations, which include the views of the residents, relatives and staff. All staff, have a good understanding of health and safety within the home, to ensure that the residents are not put at risk. EVIDENCE: The registered manager has just completed her NVQ level 4 and RMA and has many years experience of managing the home. The training matrix showed that the registered manager has also been involved in work related training within the last year. Through discussion with the registered manager the inspector was able to ascertain that she has a good knowledge of conditions/diseases related to old age. Twelve residents spoken with during Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 Page 21 the course of the inspection stated that the registered manager was very good, and that she does all she can to ensure they are comfortable and well cared for. The registered manager holds regular staff and resident meetings. The inspector witnessed that there was a good quality assurance system within the home to ensure that a high quality of care is offered and that the environment complies with health and safety issues, and is maintained in a satisfactory manner. The inspector was able to see that all policies and procedures have been reviewed within the last year. Where the registered manager is requested to keep personal monies for the residents, this is appropriately recorded on an individual ledger sheet, any purchases made at the request of the resident has a receipt retained as proof of purchase. The registered manager does not act as an agent for any of the residents in the home. The inspector was able to ascertain that while staff supervision does take place, this would not necessarily take place at least six times per year, and is not always recorded, therefore the inspector has made a requirement that staff supervision is recorded and does take place at least six times per year. All records in the home are kept appropriately and individual information is kept under appropriate lock and key to ensure confidentiality. Two residents told the inspector that they were aware that they would be able to see their care plans if they wished to do so. The registered manager has appropriate risk assessments in place to ensure the health and safety of both residents and staff. All staff, receive appropriate mandatory training. The inspector was able to ascertain that all equipment used in the home has up to date maintenance certificates in place. During a tour of the building the inspector viewed appropriate health and safety posters, together with the policy and procedure for health and safety. The fire log is maintained weekly for fire call points, weekly for emergency lighting, and all fire panels and extinguishers are checked on a regular basis. The inspector was able to witness that the home uses the appropriate Health and Safety Executive accident report forms. Accident reports are correctly completed, and a falls log is kept for each individual resident. Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 x 3 2 3 3 Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 Page 23 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 11 Regulation 12 Requirement The service users wishes concerning terminal care and arrangements after death are discussed and carried out. All staff receive at least six supervisions per year, and that these supervisions are recorded. Timescale for action 1/11/05 2. 36 18 1/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 1 2 29 Good Practice Recommendations Statement of pupose and service user guide to give more information in the fire precautions section. Paper hand towels are supplied in the communal toilet/bathroom 104 and 105. All staff have two forms of identification on file. Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 11th Floor, International House Dover Place Ashford, Kent TN23 1HU 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 Glendale Lodge H56-H05 S23282 Gendale Lodge V237317 060905 Stage 4.doc Version 1.30 Page 25 - 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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