Inspection on 12/07/07 for Glenfields Care Home

This inspection was carried out on 12th July 2007.

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

The inspector 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

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

CARE HOMES FOR OLDER PEOPLE Glenfields Care Home 7 Montgomery Square Driffield East Yorkshire YO25 9EX Lead Inspector Diane Wilkinson Key Unannounced Inspection 12th July 2007 10:00 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 Glenfields Care Home DS0000069413.V346103.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. Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glenfields Care Home Address 7 Montgomery Square Driffield East Yorkshire YO25 9EX 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) 01377 254042 01482 662615 Glenfields Care Home Ltd Vacant post Care Home 28 Category(ies) of Dementia - over 65 years of age (12), Old age, registration, with number not falling within any other category (16) of places Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC: To service users of the following gender: Either; Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE The maximum number of service users who can be accommodated is: 28 26th July 2006 2. Date of last inspection Brief Description of the Service: Glenfields is a privately owned care home that is registered to accommodate and care for 28 service users, including those with dementia. It is situated on the outskirts of the market town of Driffield, in the East Riding of Yorkshire. The home has recently been extended and refurbished. Private accommodation is provided mainly in single rooms but there are a small number of shared rooms; most bedrooms have en-suite facilities. Communal space consists of two dining areas, a small lounge and a large lounge/dining area. The home, including a garden and new paved patio area, is accessible to residents via the provision of ramps and a stair lift. There is a car parking area to the side of the building. The registered provider informed the inspector that current accommodation fees range from £365.00 to £550.00 per week. Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection report is based on information received by the Commission for Social Care Inspection (CSCI) since the last Key Inspection of the home on the 26th July 2006, including information gathered during a site visit to the home. The unannounced site visit was undertaken by one inspector over two days. It began at 10.00 am and ended at 4.30 pm on the first day, and began at 10.30 am and ended at 12.00 noon on the second day, the 16th July. On the first day of the site visit the inspector spoke with four residents, five relatives, the deputy manager and a member of staff on a one to one basis, and chatted to other residents and staff. On the second day the inspector spoke with the manager. Inspection of the premises and close examination of a range of documentation, including five care plans, were also undertaken. The manager submitted information about the service in advance of the site visit by completing and returning an annual quality assurance assessment. Survey forms were sent out as part of the inspection; two were returned by relatives and two were returned by care managers. Comments from returned surveys and from discussions with residents, staff and others varied, such as, ‘the care home would improve by having more staff’ and ‘the carers are lovely’. Comments from surveys and from discussions on the day of the site visit will be included, anonymously, throughout the report. The inspector would like to thank residents, relatives, staff and the manager for their assistance on the day of the site visit, and to everyone who completed a survey. What the service does well: Residents are assessed prior to their admission to the home and only offered accommodation if their assessed needs can be met. Residents and relatives express satisfaction with the care provided by staff at the home and speak highly of the manager and the staff group. There is a robust system in place for the administration of medication that protects the safety and well-being of residents. Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 6 Glenfields provides attractive and comfortable surroundings for the people who live there, with high standards of cleanliness throughout the home. A care manager recorded in a survey, ‘Good standard of hygiene and cleanliness’. The home is well managed. A care manager stated in a survey, ‘The manager has high standards for all care – staff likewise’ and ‘Friendly and approachable management’. What has improved since the last inspection? What they could do better: Separate hand washing facilities are not provided in the laundry room or the medication room to fully control the risk of cross infection. Staff recruitment practices are not robust so the safety of service users is not fully protected. Some assistance with personal care and activities undertaken by residents are not recorded in their care plan; this results in care plans not being a complete record of care provided. Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 7 Not all staff have undertaken training on safeguarding adults and infection control; this training would improve the skills and knowledge of the staff group and help keep service users safe. Service users are not encouraged and supported to manage their own finances; this reduces their level of independence and choice. 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. Glenfields Care Home DS0000069413.V346103.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 Glenfields Care Home DS0000069413.V346103.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. Standard 6 was not assessed, as there is no intermediate care provision at the home. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are assessed prior to their admission to the home and only admitted if it is considered that their assessed needs can be met. EVIDENCE: The owner has recently completed a programme of refurbishment that includes additional bedroom accommodation. As a result, several new residents have been admitted to the home. Records at the home evidence that prospective residents are visited by the manager when they initially make enquiries about admission, and that the assessment process commences at this stage. A full assessment of needs is completed and prospective residents are only offered accommodation at the home if this assessment evidences that their needs can be met by staff. Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 10 Prospective residents and their relatives are invited to look around the home as part of the assessment process, and some residents initially have respite care at the home to assist them in making a decision about permanency. Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of residents are met in a way that respects their privacy and dignity. EVIDENCE: The inspector examined five care plans; these included a copy of the home’s own assessment and a community care assessment and care plan undertaken by the local authority Social Services Department, where appropriate. Care records included various risk assessments including pressure care, moving and handling and nutrition, as well as a general risk assessment. However, not all risk assessments had been completed for all residents. Some residents that are funded by local authorities have had a meeting to formally review the content of their care plan. Residents that are privately funded have not had a formal review of their care plan and this should be considered as good practice. Where in-house monthly reviews of the care plan do take place, care Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 12 plans are amended appropriately as a result; some monthly reviews do not take place consistently. On the day of the site visit, the inspector observed that residents and their relatives are involved in the care planning process. A record is kept of all contact with health care professionals; these include the reason for the contact and any outcome. Relatives reported in surveys that they are kept informed of important events regarding their relative. Continence care and pressure care are promoted at the home. A resident’s individual needs regarding continence care and pressure care are recorded in assessments and care plans, and reviewed appropriately. Some residents have been provided with special pressure care equipment such as mattresses and cushions; the inspector observed on the day of the site visit that residents who spend much of the day in bed are made comfortable and safe. The inspector noted that elimination charts are used for residents at the home, but that these are not being used consistently. These should only be used for residents where this is an identified area of concern, and they should be used consistently to serve a useful purpose. Personal care such as bathing, showers, shaving etc. are recorded in a separate book; the inspector recommends that this care is recorded in care plans as it is an essential part of a person’s care. Residents and relatives spoke highly of the manager and staff on the day of the site visit; all said that staff were pleasant and helpful, and that ‘they really care’ and ‘the staff are lovely’. As part of the refurbishment programme at the home, the medication room has been moved to a more central area. The medication room provides good storage facilities for all medication, including controlled drugs, and for equipment used at the home by district nurses. A special fridge for the storage of medication is in use, and fridge temperatures are recorded appropriately. The manager was advised that the temperature within the medication room should be monitored to ensure that medication is stored at required temperatures, and that hand washing or disinfection facilities should be provided in the medication room for staff. Unused medication is returned to the Pharmacist as required, and the Pharmacist signs the returns book. The inspector noted that excessive stocks of medication are not held at the home. The inspector observed medication being given to residents – all were provided with a drink with which to take their medication, and all were observed by staff to ensure that they actually took their medication. Medication administration records were satisfactory although there were some gaps in recording when medication was ‘not required’. A divider was placed between each set of medication records and the divider included a photograph of the resident to aid identification, especially for new staff. Controlled drugs were administered and recorded in a satisfactory manner. Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 13 The manager informed the inspector that staff that administer medication have undertaken accredited training; this was confirmed by staff on the day of the site visit. Sample signatures for these staff had been mislaid during the move from one medication room to another and the manager assured the inspector that these would be recorded again to enable medication records to be monitored. On the day of the site visit the inspector observed that staff treat residents with respect and that their privacy is maintained as far as is possible; residents were assisted with eating their meals and with personal care in a sensitive manner. This was confirmed by residents and relatives on the day of the site visit. Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are supported to take part in activities inside the home but not external to the home. Visitors to the home are made welcome and meal provision at the home is good. EVIDENCE: Some care plans record a resident’s personal history but others do not. The manager told the inspector that they ask families to complete this information in the care plan whenever possible. This information is needed to enable staff to assist residents to maintain their chosen lifestyle as far as is possible. The Annual Quality Assurance Assessment (AQAA) completed by the home records that they intend to provide new social activities within the home to give residents a greater choice. Some relatives told the inspector that they felt that residents would benefit from more activities being provided by the home. Two activities organisers visit the home, one for 1 – 2 hours per week (usually to organise a ‘sing song’) and another once a fortnight to run a movement to music session. The mobile library visits the home. Some residents prefer to Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 15 spend time in their room watching TV or seeing visitors. The inspector noted that residents do not go out to take part in the local community unless they are taken by family or friends. Only one resident was planning to go to Driffield Show, and they were being taken by a member of staff who would be ‘off duty’. The manager told the inspector that they always make a birthday cake for residents when it is their birthday, and that family and friends are invited to the home to take part in birthday celebrations. The inspector noted that activities that residents take part in are recorded in a separate book; it is recommended that activities be recorded in care plans so that a holistic picture of a person’s care is maintained. The new extension provides a large lounge/dining room area where residents could take part in activities; the room contains an organ and the inspector observed some board games, but no activities were taking place on the day of the site visit. A small group of residents did get together at the end of the afternoon to watch the TV together. Another small lounge was full of residents who enjoy spending their day together watching TV and chatting. On the day of the site visit several residents had visitors and the inspector observed that there was a good rapport between staff and visitors. Visitors told the inspector that they are always made welcome and are offered refreshments. Residents are able to make choices about their day-to-day lives, such as where to spend their day, where to take their meals and what to wear. The inspector noted that information about advocacy services is displayed on the notice board in the hall should anyone be in need of this support. The inspector observed the serving of lunch; some residents chose to take meals in their room but most used one of the two dining rooms. The inspector noted that staff provided residents with a relaxed and pleasant atmosphere so that they could enjoy their lunch at a leisurely pace, and that residents were assisted appropriately to eat their meals. Most residents told the inspector that meals at the home are very good and that there is always a choice available, although two residents told the inspector that the meat on that particular day was ‘tough’. There is a dining table in the new lounge area and the manager told the inspector that this could be used by residents if they have relative staying to have a meal with them. A weekly menu is displayed in the entrance hall and this records that there is an alternative to the main meal on offer. The inspector recommends that the menu be displayed in the main part of the home so that it can be seen by residents; this encourages independence and discussion between residents. Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 16 Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are aware of the complaints process and relatives state that they know how to make a complaint; both feel that their complaints would be listened to. There are appropriate policies and procedures in place on safeguarding adults to alert staff to the importance of this issue; staff training would further protect service users. EVIDENCE: Relatives that completed a survey and that the inspector spoke with said that they knew how to make a complaint. Residents that the inspector spoke with were not certain how to make a complaint but all said that they would be quite happy to speak to the manager and felt confident that their concerns or complaints would be listened to and acted upon. The inspector noted that the complaints procedure is displayed in a prominent area of the home; this was pointed out to the inspector by two relatives. There is a complaints book in operation; no complaints have been made since the last inspection of the home. There are appropriate policies and procedures in place on adult protection. There have been no recorded allegations or incidents of abuse at the home since the last inspection. All staff have received information about safeguarding adults procedures but not all staff have had training; the inspector recommends that all staff undertake this training to ensure that they Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 18 have an understanding of safeguarding adults and whistle blowing policies, procedures and practices. Two surveys were returned by staff after the day of the site visit; these evidenced that the staff members concerned are aware of polices and procedures regarding safeguarding adults. Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 19 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, 21 and 26 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides residents with attractive, comfortable and well-maintained accommodation. Domestic staff and the laundry facilities in place ensure that communal and private areas of the home are always clean and hygienic and that residents’ clothing is clean and in good order. EVIDENCE: The owner has recently added a new extension and this and the rest of the home provides residents with attractive, comfortable and well-maintained accommodation; furniture and fittings are of a high standard. The area between the existing extension and the new extension has been paved and this will provide a safe and accessible area for residents to sit out – one of the lounges has windows and doors overlooking this area. The AQAA Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 20 form completed by the home records that they plan to landscape the surrounding area and provide new patio furniture so that residents can take full advantage of this area; they also plan to instigate some activities involving gardening to further involve residents. The inspector observed that bedroom doors had been fitted with self closers – these are not connected to the fire alarm system so have to be kept closed at all times. The inspector recommends that these doors be fitted with self-closers that are attached to the fire alarm system so that they can be left open if residents request this; one did mention this to the inspector on the day of the site visit. As part of the refurbishment of the home, a ‘wet room’ has been provided. Residents can now have a shower with minimal assistance from staff; this increases a resident’s independence. The two bathrooms have been provided with overhead hoists so that staff can easily and safely assist residents that prefer to have a bath. One resident told the inspector that they could have a bath any time they wished to do so. The premises were clean, hygienic and free from offensive odours on the day of the site visit. Domestic staff are employed and this enables care staff to concentrate on the care needs of residents. The laundry facilities have been relocated and now provide good facilities to meet the needs of the home and residents. The inspector recommends that separate hand washing or disinfecting facilities are provided for staff in the laundry room to fully control the risk of cross infection. The manager and deputy manager have recently undertaken training on infection control and the inspector observed good hygiene practices being used by staff on the day of the site visit. The inspector recommends that all staff should undertake training on infection control to further improve their practice and fully protect themselves and residents. A care manager recorded in a survey, ‘good standard of hygiene and cleanliness’. Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff are well trained but more staff are needed to meet the needs of residents due to a recent increase in registration numbers. Recruitment practices are not robust and do not fully protect residents from the potential to be abused. EVIDENCE: On the day of the site visit there were 22 residents accommodated at the home, and a further two residents were due to be admitted within the next few days. The staff rota evidences that there are three staff on duty am (plus the manager or the deputy manager), two or three staff in the afternoon, three staff in the evenings and two staff overnight. Some shortfalls were noted on the staff rota and the manager informed the inspector that she sometimes has to work a care shift to ensure that the home is fully staffed. The staff rota should include the role of each person recorded. There was a care worker from an agency working on the day of the site visit; they informed the inspector that they had worked at the home on previous occasions so they were familiar with the needs of residents and the routines of the home. The manager informed the inspector that they are in the process of recruiting new staff and that they are hoping to employ a kitchen assistant, so that care staff can become less involved in the serving of food etc. Some Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 22 residents, staff and relatives told the inspector that there are currently not enough staff on duty, probably due to the number of residents increasing and staff not being employed quickly enough to deal with this increase. 33 of care staff have completed NVQ Level 2 in Care or above. The home should have an action plan in place to record how the requirement for 50 of care staff to have completed this award will be achieved. The staff recruitment records were not available on the day of the original site visit and the inspector had to return to the home to examine these records a few days later. Records should be available for examination by the inspector at all times. On her second visit to the home, the inspector examined the records for a two members of staff, one of whom had only recently been employed. The records for the new employee evidenced that an application form that records employment history is completed by applicants. Two written references were obtained but one of these was addressed ‘to whom it may concern’. References should be requested by the manager and returned to the manager to ensure their authenticity. An application form and a POVA first check could not be found for the other member of staff; the manager agreed to forward a copy of these to the CSCI office. The manager informed the inspector that the new applicant referred to above had commenced induction training. There was no evidence available on the day of the site visit to confirm this. However, evidence was subsequently sent to the CSCI. The manager informed the inspector that new induction documentation has been purchased and that, in future, this will be used to record induction training for all staff. A training and development plan for 2007 was displayed in the office – this recorded that various training sessions were planned or had taken place, including moving and handling, foot care, fire safety and dementia care. Staff files include information about individual training achievements but there is no record of the overall training achievements and needs of the staff group. The manager was advised to keep a record of the training undertaken by all staff, including dates, to indicate when refresher training is required. Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 23 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 and 38 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed and the health, welfare and safety of service users and staff are protected. EVIDENCE: The manager is qualified, experienced and skilled and throughout the visit residents, staff and relatives expressed their confidence in her management of the home. The manager told the inspector that she keeps her practice up to date by attending training courses alongside staff, and by reading relevant publications. A care manager recorded in a survey, ‘The manager has high standards for all care – staff likewise’ and ‘Friendly and approachable management’. The manager has not yet submitted an application to the CSCI Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 24 for registration and this should be actioned by the registered providers as soon as possible. There is a quality assurance system in place – this includes a QA calendar that records staff meetings, resident’s meetings, fire training sessions and plans for refurbishment. However, records at the home indicated that the most recent staff meeting took place in May 2006. Monthly checklists are used by the manager to monitor activities within the home – these include laundry, key working and staff working practices. The manager informed the inspector that a survey was recently sent out to relatives and that some were returned. However, these were not at the home on the day of the site visit so the inspector could not determine if survey comments had been collated and published. Policies and procedures are reviewed and updated periodically. The home has achieved the Quality Development Scheme (QDS) Parts 1 and 2; this is a quality scheme introduced by one of the local authorities. No monies are held at the home on behalf of residents. Service users are not able to ask staff to take them out to the shops or to purchase items on their behalf. This restricts the independence and choice of residents, as money has to be obtained from relatives prior to any expenditure being agreed. For example, the chiropodist has to be booked several weeks in advance so that money can be obtained from relatives. In house fire alarm tests and water temperature tests are carried out every week and fire training/drills are carried out on a regular basis. Evidence that the fire alarm system and fire extinguishers are serviced by a contractor annually was seen by the inspector. There is an electrical installation certificate in place and there is a current gas safety certificate in place. A new stair lift has been fitted and bathrooms have been fitted with new overhead hoists. Staff undertake training on health and safety topics and the registered manager has provided a written statement of the policy, organisation and arrangements for maintaining safe working practices, including risk assessments. This is designed to protect the health, welfare and safety of service users and staff. Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 8 2 9 3 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 4 X X X X 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 3 Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard OP29 OP29 Regulation 19 19 Timescale for action Recruitment documentation must 12/07/07 be available for inspection at all times. References must be requested 12/07/07 by the manager and returned to the manager to confirm their authenticity. Requirement 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 4 5 Refer to Standard OP7 OP8 OP8 OP9 OP9 Good Practice Recommendations Monthly reviews of the care plan should be recorded consistently. Elimination charts should only to be used where there is an identified need, and they should then be used consistently. Assistance with personal care should be recorded in a person’s care plan rather than in a separate book. There should be hand washing or disinfecting facilities in the medication room to promote infection control. Medication administration records should accurately record when medication is ‘not required’. DS0000069413.V346103.R01.S.doc Version 5.2 Page 27 Glenfields Care Home 6 OP12 7 8 9 10 11 12 13 14 15 16 OP13 OP18 OP19 OP26 OP26 OP28 OP30 OP31 OP33 OP35 Care plans should include information about a resident’s previous lifestyle so that this can be maintained as far as is possible. Activities undertaken by residents should be recorded in their care plan. Residents should be supported and encouraged to take part in the local community. All staff should undertake training on safeguarding adults to ensure that they are aware of the action to be taken should they observe or suspect any form of abuse. The inspector recommends that the bedroom door selfclosers should be connected to the fire alarm system. Hand washing or disinfecting facilities should be provided for staff in the laundry room to promote infection control. All staff should undertake training on infection control. There should be an action plan in place to record how 50 of staff will achieve NVQ Level 2 in Care. The training achievements and needs of staff should be recorded in a training and development plan to assist with organising refresher training. The manager’s application for registration should be submitted to the CSCI as soon as possible. The QA system should be fully developed to include resident and relative surveys, so that residents and others are able to affect the way in which the home is operated. Residents should be encouraged and supported to manage their own finances and should have immediate access to their own money. Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Glenfields Care Home DS0000069413.V346103.R01.S.doc Version 5.2 Page 29 - 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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