Inspection on 02/08/05 for Glengall Road [83]

This inspection was carried out on 2nd August 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glengall Road [83] 04/05/07

Glengall Road [83] 09/02/06

Glengall Road [83] 21/01/05

Glengall Road [83] 21/07/04

Glengall Road [83] 17/02/04

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Chatsworth Care - Tudor Lodge

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

CARE HOME ADULTS 18-65 Glengall Road (83) 83 Glengall Road Woodford Green Essex IG8 0DP Lead Inspector Jackie Date Announced Inspection 02 August 2005 10:00 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Glengall Road (83) Address 83 Glengall Road, Woodford Green, Essex IG8 0DP 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) 0208 559 0797 0208 506 1744 Redbridge Community Housing Ltd (RCHL) CRH Care Home 10 Category(ies) of LD Learning disability (10) registration, with number of places Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 21 January 2005 Brief Description of the Service: Glengall Road is a care home for adults with learning disabilities. It is one of a number of homes run by RCHL, a not-for-profit organisation. The home is registered for 10 people but as the double rooms are no longer being used for two people they will be changing this to seven. The residents have profound learning disabilities, additional physical disabilities and little or no verbal communication skills. They have limited ability to make decisions about their lives. Glengall Road is a large detached house in Woodford Green close to shops and public transport. There is an annex in the garden and the laundry, storage facilities and a disused spa are in this. There is a small garden with a raised fishpond. Some of the residents go to day services and activities are organised by the staff. There is an adapted minibus that is used for activities and trips. Earlier this year the home was granted a variation in its registration criteria to remove its nursing care status. Shortly after that the manager and several staff transferred to Glengall Road from a care home providing nursing care for people with mental health problems when it closed. Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection lasted for about six and a half hours and started at 10 in the morning. It was the first of the two inspections that each home must have during the inspection year. Five staff and six of the residents were spoken to. All of the communal rooms, the kitchen and all of the bedrooms were seen. Care and other records were checked. In addition to this the inspector had previously visited the organisation’s head office to view staff records. What the service does well: What has improved since the last inspection? Since the previous inspection a permanent experienced manager is now in post and there is a consistent staff team. Improvements have been made to the home both in terms of decoration, flooring and furniture and also aids and adaptations to meet the needs of the residents. Residents are now doing more activities both in the home and in the community. The care plans of four of the seven residents have been reviewed and updated. There were 23 requirements outstanding from previous inspections and the new manager and staff team have addressed 19 of these. The manager and Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 6 staff team have done a lot of work to develop and improve the service in the last few months. 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. Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 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 standard(s) 1, 2, 3, 4 and 5 Information is available to enable the staff team to meet residents’ needs. If a vacancy arose, the required information would be gathered on a prospective resident and they and their relatives could spend time in the home to find out what it would be like to live there and to enable the resident to make a choice about living in the home, within their capacity to do so. Residents receive information about what the home provides and the service that they can expect to receive. EVIDENCE: The statement of purpose and service user guide have been reviewed and updated as required by previous inspections. They now reflect the current situation in the home. The service user guide has pictures and symbols to make it more easily understandable by residents. There have not been any new admissions for some time. The organisation has an admissions procedure that includes gathering of information and assessments. It also contains details of how a prospective resident would be introduced to the home. The staff are aware of this and would be able to assess and introduce a new resident to the home if needed. Each resident has a care plan that contains information about what they can do, their likes and dislikes and what help and support they need. The staff team know residents Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 9 well and know what they can do, their likes and dislikes and what help and support they need and can meet these needs. The residents are unable to comment on what it is like to live in the home, but they all appear to be happy and relaxed when they are there. The residents have a contract between themselves and the Housing Association/provider. However the two previous inspections have required that the organisation must provide a fully costed contract/statement of terms and conditions to each resident. This was not available in residents’ files. The manager said that the organisation has now developed a format for this and it will be completed in the near future. In view of this, the date for completion of this piece of work has been extended but if this requirement is not met the Commission will consider enforcement action to ensure compliance Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 10 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 standard(s) 6, 7 and 9 Residents’ plans focus on their individual needs and abilities and contain detailed information so that staff can meet their needs. The manager and staff team are in the process of updating and reviewing care plans and assessments. EVIDENCE: All of the residents have a support plan and these contain information about how each person likes and needs to be supported. The new manager has been at the home since April and so far has reviewed the care of four residents and new support plans have been developed for these. New assessments of need have also been carried out. Relatives and social workers were invited to the reviews. The degree to which residents can be involved in the development of the plan is very limited due to their profound learning and communication difficulties. The manager said that they are reviewing two care plans per month and then everyone will be reviewed every six months. Each resident has a daily log that is completed by the staff. The information in these logs tended to be about feeding, toileting and personal care. The daily recordings must be more specific and linked to the care plan. They should also include information about what a resident has done during the day and if they enjoyed Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 11 that activity. The manager had already identified this as an area for development and will be working with the staff team on this. The requirement from the previous two inspections with regard to care plans and daily recordings have therefore not been fully met. However as such good progress has been made towards these the timescale for this requirement has been extended. As the requirements have been stated on more than one occasion, the Commission will consider enforcement action to secure compliance if the new timescales are not met. There are risk assessments in place. These identify risks for the residents and indicate ways in which the risks can be reduced to enable the residents’ needs to be met as safely as possible. For example one resident has osteoporosis and has a detailed risk assessment around moving and handling. Risk assessments have been updated. Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 12 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 standard(s) 12, 13, 14, 15, 16 and 17 The residents are supported to take part in activities and to be part of the local community. Residents are supported to keep in contact with their relatives. Residents are given meals that they like and that meet their needs and individual preferences. EVIDENCE: The residents all have profound disabilities and very high support needs. They are extremely dependent on staff. Some of the residents attend local day centres and others are supported to access activities by the staff team. The manager and staff team have been working to increase the number of activities both in the home and in the community. For example arts, music, videos and manicures in the home. Also a pianist visits two weekly to play for the residents. The manager said that residents like different types of music Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 13 and one in particular likes classical music. On the day of the inspection two of the residents went to use the sensory room of the local day centre. Other residents go to a pottery group and then go out for a pub lunch. Examples of items that they had made were in the home. Four of the residents are booked to go for a long weekend break in Bognor later in the year. The number and type of activities available to residents has increased since the last inspection and it is obvious that the staff have put a lot of effort into this and are keen to develop this area further. The residents have differing amounts of contact with relatives and friends. One residents boyfriend visits every Saturday and Sunday afternoon, some relatives visit weekly, others two weekly and some only have contact by telephone. Two of the residents recently had a birthday and a garden party was organised to celebrate this and families were invited. Relatives’ meetings have been held. But at the last one only one relative attended. As a result of this it has been decided that the meetings will now only be held every six months. Menus are based on the staffs knowledge of residents’ likes, dislikes and needs. The food offered is nutritious and varied. A cook is employed for five days per week and the main meal is usually at lunchtime. Two residents are on low-fat diets and one has their food blended. Another resident receives their food via a PEG feed tube directly into the stomach and the staff are trained to deal with this. The inspector joined the residents for lunch on the day of the visit and residents were given the support that they needed. One resident did not want the dessert and was offered various alternatives by the cook. She listed different options and he finally chose some cake. Staff spoken to were aware of residents’ likes and dislikes. For example one resident does not like white food. Staff described how they offer residents choice. For example if you say to one resident “do you want the red or the blue shirt” he will be able to indicate which one. Another resident will come up to you if she wants something and take you to it. Staff also said that you have to get to know residents’ facial expressions so that you can find out what they like. Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 14 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 standard(s) 18, 19 and 20 Residents receive personal care that meets their individual needs and preferences. The staff team support the residents to get the healthcare that they need. Medication is appropriately administered by the staff. EVIDENCE: The residents all require a lot of support with their personal care and details of the help that they need and how they prefer to be supported are in their support plans. Some of the personal care routines have been altered to allow more time for activities in the afternoon. A walk-in shower has been fitted since the last inspection and staff say that some of the residents enjoy using this instead of bathing. All of the residents are registered with a local doctor and specialist help is received when needed. Staff take residents to all of their medical appointments. Residents’ files have details of health care issues and show that residents have regular access to health care professionals. Records are kept of medical appointments and these show that residents have checks from the optician, dentist and when needed the chiropodist. The staff team have had Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 15 concerns about the health care needs of one of the residents and a review was arranged. Assessments were going to be carried out to see if she in fact requires nursing care. None of the residents can self medicate and medication is administered by the project workers who lead the shifts. Medication is appropriately and safely stored in a locked cabinet and medication administration records are kept. The previous inspection made two requirements with regard to medication. The first was that protocols/guidelines must be in place for the administration of “as required” medication. The second was that the medication policy/procedure must be amended to include the action to be taken in the event of an error in the administration of medication and also the procedure for when medication is taken out of the home. The manager has made some amendments to the policies and developed a protocol. However the information with regard to “as required” medication and the action to be taken in the event of an error where not detailed enough. This was discussed with the manager and she is now aware of what is required and will be making further amendments. The timescale for completion has been extended to allow time for her to complete this piece of work. Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 16 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 standard(s) 22 and 23 There is a complaints procedure that is followed in the event of any complaints being made. There is an adult protection policy that would be followed in the event of any allegations of suspicions of abuse. EVIDENCE: There is a complaints procedure and this is displayed in the home. However due to the degree of their disability it is unlikely that any of the residents would be able to make a complaint without support. There was a recorded complaint from the relative of one of the residents and this had been looked into and appropriately dealt with. The issues raised had also been discussed with the social worker. Views of the service were sought from relatives and one response was received. This relative did not make any specific comments but indicated that they were satisfied with the overall care provided The organisation has produced a detailed adult protection policy that tells staff the actions to take in the event of abuse/suspected abuse being discovered. Staff knowledge and training with regard to abuse will be tested at the next inspection. All of the residents need help with their finances and do not have the capacity to understand about the concept of spending or saving money. Records are kept of financial transactions. Some residents’ financial affairs are managed by their families. Others are managed by the head office. Residents’ monies were not checked as part of this inspection and will be checked during future visits. Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 17 Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 18 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 standard(s) 24, 25, 26, 27, 28, 29 and 30 The residents live in a clean and comfortable home that has suitable aids and adaptations for their needs. EVIDENCE: Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 19 The home is a large detached two-storey house near to the local shops and bus routes. There is a lift to the first floor and the second floor is just used for storage. There is a lounge, dining room, three bedrooms, a bathroom and kitchen on the ground floor. The office, four bedrooms and a shower room are on the first floor. All of the residents now have single rooms. The laundry facilities are situated in an annex in the garden. Previous inspections have made several requirements with regard to the building. These have now all been addressed. Some bedrooms have been redecorated and laminated flooring fitted. Damaged furniture has been replaced. The bedrooms have been personalised to meet individuals likes and preferences. A new suite has been purchased and more pictures and soft furnishings have been added. New music centres have also been purchased. A ceiling hoist has been fitted in the ground floor bathroom and a first-floor bathroom has been refurbished and a walk-in shower fitted. In addition new hoists and slings have been purchased for residents that need these. Overall the standard of the environment has improved and it is more comfortable and homely. In addition to this new equipment and adaptations have made the environment suitable for the residents. At the time of the inspection the home was clean and free from offensive odours. Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 and 36 The Commission for Social Care Inspection cannot be confident that service users are supported and protected by the organisations recruitment practice, including the recruitment of bank and agency staff. Staffing levels are sufficient, and staff receive the necessary training, supervision and support, in order to meet residents’ current needs and provide a good service for them. Residents are supported by a staff team that are committed to providing a good quality service and to meeting individual needs. EVIDENCE: An inspection of a sample of personnel files at the organisations head office showed that not all of the required checks on staff could be demonstrated to have taken place. This was of particular concern, as many of the files inspected related to staff who have joined the organisation in the past year, and for whom the recruitment process should have been robust, as matters regarding recruitment have been discussed previously with the organisation. Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 21 Some of the staff team have worked at the home for several years during the period it was registered to provide nursing care. The rest of the staff team transferred from a care home providing nursing for people with mental health problems when it closed earlier this year. The staff team have a lot of experience of caring for people with high support needs and in some cases of working with people with learning disabilities. Staff that transferred from the other home all received LDAF (Learning Disabilities Award Framework) training before they started work at Glengall Road. Staff spoken to said they found this very useful. Staff also said that they had received a wide variety of training to enable them to provide an appropriate service to the residents. Four staff have completed NVQ level 3 and two have almost completed this. Two other staff are doing NVQ level 2 and ten staff have completed the LDAF (Learning Disabilities Award Framework) training. Staff were clear about their duties and responsibilities towards the residents. The staffing on the early shift is one project worker and three support workers. The late shift has one project worker and two support workers. At night there is one project worker and one support worker. A cook and a cleaner are also employed. At the last inspection there was not enough evidence to confirm that staffing levels were sufficient to meet residents’ needs at all times, in particular during the late shift. However from discussions with the staff and manager and from checking records it would seem that changes in routines has meant that staff now have more time available in the afternoon. Staffing levels are now sufficient to meet the residents’ needs. Staff meetings and staff supervision have been taking place regularly, providing staff with the opportunity to discuss problems and to be involved in the development of the service. Staff spoken to say that they receive good support from the manager and from each other. It is apparent that staff team is working well together and are committed to developing the service. Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 22 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 41 and 42 The home is well managed and provides a safe environment for the residents. However the organisation has not been robust in maintaining staff records or ensuring that policies and procedures are relevant to this service. This could potentially place service users at risk. EVIDENCE: The manager has substantial experience of managing a residential home. She is a qualified nurse and has completed the NVQ level 4 managers award. Staff are involved in the running of the home and the staff team discuss any developments and changes. Staff spoken to said that the manager asked staff what they think and asked them for their opinions, also that she is very approachable and supportive. Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 23 The quality of the service provided to the residents is monitored by the home manager and by the organisation. The service manager carries out monthly monitoring visits to assess how effectively the home is operating to meet its stated aims and objectives, and reports are written. These indicate the action to be taken when deficiencies are identified. Copies of these reports were available in the home and copies are sent to the Commission. In March 2005 the quality assurance section of the organisation carried out a care support plan audit. This has relevant conclusions and suggestions for improvement All of the required residents’ records are kept but as stated previously an inspection of staff records held at the head office found that staff records as required by Schedule 2 of the Care Homes Regulations 2001 were not available in all staff files. The organisation has been advised that this issue must be addressed and have given commitment to audit staff files and address the problem. There were two health and safety requirements outstanding from previous inspections. The first was that the requirements of the gas safety inspection should be carried out and this has been done. The second was that the COSHH (Control of Substances Hazardous to Health) assessment must be reviewed and updated. This has also been done. All of the necessary health and safety checks are carried out and a safe environment is provided for the residents. However although hot water temperatures are checked weekly to ensure that they do not exceed prescribed 43°C records show that only the hand basins are checked and not the bath and shower. These must be included in the weekly checks. Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 24 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Glengall Road (83) Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x 2 2 x G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 25 Yes 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 YA5 Regulation 4,5 Requirement Each resident must have a written and costed contract/statement of terms and conditions. (Previous timescales of 30 November 2004 and 30 April 2005 not met). Care plans must be up-to-date and accurate and cover all of the residents needs. Recordings must be more specific and linked to the care plan. (Previous timescales of 31 October 2004 and 30 April 2005 not met). Protocol/guidelines must be in place for the administration of as required medication. (Previous timescale of 31 March 2005 not met). The medication policy/procedure must be amended to include full details of the action to be taken in event of an error in the administration of medication. (Previous timescale of 31 March 2005 not met). The registered persons are required to ensure that their recruitment procedure is robust and in line with regulation. The registered persons are required to maintain records for G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Timescale for action 31 October 2005 2. YA6 15 31 October 2005 3. YA20 13 30 September 2005 30 September 2005 4. YA20 13 5. YA34 19 Ongoing 6. YA41 17 30 September Page 26 Glengall Road (83) Version 1.30 7. YA42 13 the protection of service users in line with Schedule 2 of the Care Homes Regulations 2001. For new staff before appointment and for existing staff. The temperature of the hot water to the bath and shower must be checked and recorded each week to ensure that it does not exceed the prescribed 43 C 2005 30 September 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Ferguson House 113 Cranbrook Road Ilford Essex IG1 4PU 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 Glengall Road (83) G55_S0000025954_Glengall Road_V234421_020805_Stage 4.doc Version 1.30 Page 28 - 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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