Inspection on 04/05/07 for Glengall Road [83]

This inspection was carried out on 4th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Glengall Road [83] 09/02/06

Glengall Road [83] 02/08/05

Glengall Road [83] 21/01/05

Glengall Road [83] 21/07/04

Glengall Road [83] 17/02/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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 ODP Lead Inspector Jackie Date Unannounced Inspection 4th May 2007 9:20 Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glengall Road [83] Address 83 Glengall Road Woodford Green Essex IG8 ODP 0208 559 0797 0208 506 1744 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) www.rchl.org.uk Redbridge Community Housing Limited [RCHL] Mrs Catherine Bernadette Copestake Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th February 2006 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 7 people and at the time of the visit 7 people were living at the there. Most of 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. The basic charge per week for each service user is £1372.28. The manager provided this information on the day of the visit. Information about the service provided is contained in the service users’ guide. Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 9:20 am. It took place over 6 hours. This was a key inspection and all of the key inspection standards were tested. Staff were asked about the care that residents receive, and were also observed carrying out their duties. Where possible residents were asked to give their views on the service and their experience of living in the home. All of the shared areas and bedrooms were seen. Staff, care and other records were checked. Relatives were contacted and asked for their opinions of the service. In addition the inspector attended a relatives meeting last year. Feedback was received from three relatives. This was a key inspection and all of the key inspection standards were tested. The inspector would like to thank the residents and staff for their input during the inspection. What the service does well: What has improved since the last inspection? The organisation has looked at all of their staff records and made sure that all of the required checks have been made on staff in post. They have also made their recruitment procedure better. This will help to keep residents safe. More work has been done to make the environment better. The lift has been refurbished and the lounge has been redecorated and has new blinds, curtains and a new TV. New flooring has been fitted in the hallway and one of the bedrooms has been redecorated. Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 6 Residents are doing more activities and going out more. Last year some people went on holiday, they have also been to the theatre. There is a full staff team and so residents are supported by people that know them and that they know. The menu has been changed and residents are supported to “eat healthily”. 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. The summary of this inspection report can be made available in other formats on request. Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4 & 5. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. The required information is gathered on a prospective resident and they and their relatives can 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, and to be confident that the home meets their needs. Residents and their representatives have a written and costed contract/statement of terms and conditions and will therefore be clear about what they are entitled to. EVIDENCE: The organisation has an admissions procedure that includes the gathering of information and assessments. It also contains details of how a prospective resident would be introduced to the home. A new resident moved into the home earlier this year. The file of this person contained information from his previous placement, from other professionals and also comprehensive assessments that had been carried out by the manager. This assessment included healthcare, social needs, mobility, cultural, ethical and spiritual needs. The person visited the home on several occasions before he moved in. This Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 9 started with short visits and built up to overnight stays. A record was kept of the visits and how the person had been. This resident had been living in his previous home for about 7 years but had to move because this was a respite unit. On his first visit he had been upset and tearful. The manager therefore asked that a relative was contacted and asked to join him for his next visit. The resident’s first language is not English and the relative was able to explain what was happening and about the home. He was also given a copy of the Service Users guide, which has pictures and symbols to make it easier to understand. After this the resident was more settled and at the time of this visit said that he was very happy. This introduction to the home exceeds minimum standards. Each resident has a detailed 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 well and know what they can do, their likes and dislikes and what help and support they need and can meet these needs. Most residents are unable to comment on what it is like to live in the home, but they all appeared to be happy and relaxed. The residents have a contract between themselves and the Housing Association/provider. These include information about individual financial arrangements. The contracts were available at the home. This means that there is clear information available about the service that will be provided to individual residents. Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Residents’ plans focus on their individual needs and abilities and contain detailed information so that staff can meet their needs. EVIDENCE: All of the residents have a support plan and these contain detailed information about how each person likes and needs to be supported. Assessments of need have also been carried out and these are reviewed regularly. Each resident has a daily log and the staff record details of what the person has done, what care has been provided and how the individual has been. Residents have a key worker and the key worker reviews the support plans every month. Relatives and social workers are invited to six monthly reviews. The support plans seen had all been updated when needed. 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. Information about residents’ Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 11 needs is comprehensive and is up to date and therefore gives staff the information that they need to support each individual and to meet their needs. 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, to prevent falls. Risk assessments are also being reviewed regularly to ensure that they are up-todate. Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17. People using the service experience excellent quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. 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 and relatives are made welcome at the home. Residents are given meals that they like and that meet their needs and individual preferences and this exceeds minimum standards. EVIDENCE: Most residents have profound disabilities and very high support needs. They are extremely dependent on staff. Some of the residents attend local day Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 13 centres and others are supported to access activities by the staff team. For example arts, music, videos, relaxation and manicures in the home. A pianist visits two weekly to play for the residents. An aroma therapist visits weekly and three of the residents enjoy having aromatherapy. Outreach services have been arranged to support residents to do activities in the community. Some of the residents had a short holiday last year and two of the residents went to a show in Southend and stayed overnight at a hotel. Photographs of the trip to Southend were available and one resident was able to tell the inspector who was in this and what they had done. He had obviously enjoyed the trip. Holidays are being planned for this year and a trip to a more specialised accommodation is being arranged for one of the residents. Two staff are going with her and they said that they wanted to plan some special things for her that they thought she would really like. Residents support plans include information about what they like and dislike doing. The manager and staff continue to try to increase the number of activities that residents can participate in both in the home and in the community. Care plans also include ways in which residents are encouraged to be as independent as possible and to maintain the skills and mobility that they have. The newest resident is more independent than the others and he likes to help. He helps to water the garden and with the recycling. Staff said that at present they are still helping him to settle and to find out more about his likes and also that they he will be enrolling for college. One resident is a Hindu but staff were told that he does not wish to practice his religion. They were told that a keyworker from his past placement took him to the temple but he became distressed and did not want to go in. Staff said that they would be discussing this further with the resident and his relatives. One of the residents has become confused and her care plan indicates that she becomes very distressed in strange places and is reluctant to do activities outside the home. It also states that she is okay to go to the local shops and to be taken for walks in the local area. Therefore residents are supported to do activities that they like and that meet their needs. Celebrations are arranged for special occasions and families and friends are invited. One of the residents has a boyfriend and he visits every weekend. A relative said that the family were made very welcome when they visited. Relatives meetings are held twice a year and as stated in the summary the inspector also attended one of these last year to get some feedback from relatives. Residents’ care plans contain information about their dietary needs and their likes and dislikes. 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. This year the staff team have been focussing on healthy eating and the cook has introduced more fruit, vegetables and salads. The cook is also studying for a VRQ in nutrition. The result of this Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 14 is that some residents who needed to have lost weight and others are maintaining their weight. One resident has soft or blended food. On the day of the visit he was asked what he wanted for lunch and chose his favourite scrambled eggs. At lunch time residents had different food according to their preferences Residents used different plates and cutlery according to need. Some residents were given their food by the staff. One of the residents has become very confused and it has been difficult to get her to eat. The inspector observed that staff spent a lot of time encouraging and supporting her to eat and to give her as much time as she needed. She has full fat milk and cream in her food and at present the staff team have been able to maintain her weight. Throughout the visit it was observed that residents were frequently offered drinks throughout the day and that staff knew their likes. For example a member of staff said that one of the residents likes several cups of coffee in the mornings. The newest resident does not have any specific dietary requirement with regard to his religion but some additional dishes have been included in the menu for him. This includes curry and naan bread. One of the staff cooks some items especially for him. Therefore residents do get meals that they like and that meet their needs. They are also given very good support at mealtimes. Meals and mealtimes exceed minimum standards. Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. People using the service experience excellent quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Residents receive personal care that meets their individual needs and preferences. The principles of respect, dignity and privacy are put into practice. Care is taken to ensure that residents are nicely and appropriately dressed and this exceeds minimum standards Residents receive good quality health care. Residents’ receive their prescribed medication as prescribed and this is safely and appropriately administered by staff that have been trained to do this. 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. One is assisted in the shower but then staff leave him to dry and dress himself. A member of staff said “he shaves himself and is very Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 16 proud of that”. It was evident that residents receive effective personal care and healthcare support in a person centred manner. This was observed by the inspector in the interaction between staff and residents in that staff were aware of non verbal signals that indicate likes, dislikes and the state of well being of residents. From viewing care plans, talking to staff, residents and relatives it was also evident that staff are aware of the changing needs of the residents and that staff respect their preferences when providing support, including personal care. Whenever possible, even if to a very limited extent, residents are encouraged to be as independent as possible. Care plans also show that residents are encouraged to choose what they wear as far as possible. The staff team also make a lot of effort to ensure that residents are always appropriately dressed. This exceeds minimum standards. 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. One resident has a fleece under his sheet to alleviate pressure. Records are kept of medical appointments and these show that residents have checks from the optician, dentist and when needed the chiropodist. As previously stated one of the residents has become confused and it can be difficult to encourage her to eat. However the staff team have continued to support and encourage her and as a result of this she has maintained her weight. She was also assessed and advice sought from a specialist nurse. A relative said “my brother was ill a few years ago and the staff are very active in keeping an eye on him and will take him to the doctor or hospital if they have any concerns. He is very well looked after. The staff team monitor the residents’ health and make sure that any required checks are carried out and followed up and that residents’ health needs are addressed. It was apparent that staff would be very aware if a resident was in pain and they would monitor this and take any necessary action. Staff are trained and competent in health care matters. The home arranges training on health care topics that relate to the health care needs of the residents. Staff have had some dementia care training to assist them to understand the needs of and to support one of the residents. None of the residents can self medicate and the shift leader administers medication. Medication is appropriately and safely stored in a locked cabinet and medication administration records are kept. Staff have received medication training from Boots. There are policies and procedures for the handling and recording of medication. A random sample of Medication Administration Record (MAR) charts were examined and these were appropriately completed. Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. People using the service experience excellent quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. There is a user-friendly complaints procedure that would be followed in the event of any complaints being made. Staff have received adult protection training to ensure that they are clear about what constitutes abuse and what to do if abuse is seen or suspected. This gives residents a greater protection from abuse. Residents’ finances are appropriately managed and monitored and this lessens the risk of financial 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 most of the residents would be able to make a complaint without support. However residents are able to demonstrate if they are unhappy with anything through facial expressions, behaviour changes or vocalisation. In discussions with staff they were able to demonstrate an understanding of this non-verbal communication. A relative said “I cannot find fault with the home, it is excellent”. There was one complaint recorded from a relative of a resident and this had been appropriately dealt with. The Commission has not received any complaints in relation to this service. Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 18 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 spoken to were aware of the issues of abuse and aware of their responsibility to residents. They had received training on safeguarding adults and this subject also forms part of the LDAF (Learning Disability Award Framework) and the NVQ training. The home has an open culture and staff and relatives feel able to raise any concerns that they might have. Staff understand what restraint is and the use of any equipment that may be used to restrain individuals such as bed rails and wheelchair belts is decided within a risk assessment framework. All of the residents need help with their finances and most do not have the capacity to understand about the concept of spending or saving money. Residents’ financial affairs are managed by the head office. Records are kept of financial transactions. Regular checks are made by the manager to ensure that these are correct. The cash held for two of the residents was checked at the time of the inspection and were found to be correct. Appropriate receipts were on file. The organisation carries out unannounced annual financial audits. Therefore systems are in place to ensure that residents are protected from financial abuse and that residents’ finances are appropriately managed and monitored. Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 & 30. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. The residents live in a clean and comfortable home that has suitable aids and adaptations for their needs. The staff team continue to work to improve the environment and to make it as environment as homely as possible. EVIDENCE: Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 20 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. Last year the lift was refurbished and the lounge has been redecorated. There are new curtains in the lounge and a new flat screen television has been fitted on the wall. During the course of the inspection one of the residents was obviously enjoying a cowboy film. Each resident has a single bedroom and these have been personalised to meet individual likes and interests. Two of the relatives spoken to commented that the environment has improved and that “the place looks very nice”. There are enough baths, showers and toilets and these are adapted to meet the residents’ needs. A ceiling hoist is fitted in the ground floor bathroom and a first-floor bathroom has a walk-in shower fitted. Hoists and slings are available for residents that need these. Therefore the equipment needed to meet the residents’ specialist needs is available in the home. The kitchen is appropriately equipped and is clean. Food was appropriately labelled and stored. The cook carries out the necessary checks to ensure that the environment meets the necessary standards of hygiene and that residents’ food is prepared in line with good food hygiene practice. At the time of the inspection the home was clean and free from offensive odours. There is an infection control policy and advice is sought from external specialists if the need arises. Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36. People using the service experience good quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. Residents 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 know them well and who are committed to providing a good quality service. EVIDENCE: The staff team comprises project workers and support workers. The staff team have experience of working with people with learning disabilities and have access to a wide range of training courses. The home is fully staffed and any additional shifts are usually covered by the staff team. Therefore residents Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 22 receive a consistent service from a staff group that are aware of their needs and how to meet them. The staffing on the early shift is one project worker (the shift leader) and three support workers. The late shift has one project worker and two support workers. At night there are two waking night staff. In addition there is a cook and a domestic assistant. Feedback from staff and, relatives was that staff availability was satisfactory. Staffing levels are sufficient to meet the residents’ needs. All staff have to complete the LDAF (Learning Disability Award Framework) as part of their probationary period. Most of the staff have NVQ level 2 and/or level 3. Staff spoken to said that there is comprehensive training available and that this included food hygiene, fire safety, moving and handling and safeguarding adults. One member of staff said that she was doing NVQ level 3 and that the standards and practices that she is learning there are already put into practice in the home. Another member of staff said the manager would not accept poor practice, everyone knows what is expected and the standards are high” Staff were clear about their duties and responsibilities towards the residents and have the skills to meet the residents’ needs. Staff have job descriptions and in discussion were clear as to their individual role in the home. An inspection, at the organisations head office, of a sample of personnel files showed that the previous requirements with regards to staff recruitment and checks have now all been addressed. The organisation worked cooperatively with the Commission and reviewed their procedures and all of their staff files. They then took the necessary action to address any shortfalls and to ensure that the future recruitment procedure would be robust and would safeguard residents. A random sample of staff records were checked during the inspection and were found to contain the required information. 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 said that there is very good communication and teamwork in the home. Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 41 & 42. People using the service experience excellent quality outcomes in this area. We have made the judgement using a range of evidence including a visit to this service. The home is very well managed and provides a safe environment for the residents and this exceeds minimum standards. EVIDENCE: The manager has substantial experience of services for people with learning disabilities. She is an enrolled nurse, a registered learning disabilities nurse and has obtained NVQ level 4 and a Registered Managers Award (RMA). Staff, relatives, and as far as possible, residents are involved in the running of the home and discuss any developments and changes. A relative said the changes Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 24 at the home have been for the better, I could not be happier with the service provided. The manager communicates a clear sense of direction and staff are aware of the standards that are expected of them. She also promotes equality and diversity issues and is aware of good practice issues. A member of staff said “she is a terrific manager, understanding and approachable.” Another staff said that the manager makes it clear what is required and would not tolerate bad practice. The quality of the service provided to the residents is monitored by the 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 addition to this the organisation carries out a quality audit each year and also a financial audit. All of the necessary health and safety checks are carried out and records are kept of these checks. The home has a comprehensive range of policies and procedures to promote and protect residents’ and staff safety. Staff receive the training that they need to understand and use these. Staff carry out monthly health and safety audits and every three months a ‘housing officer’ from the head office carries out a more in depth audit. Therefore the organisation also monitors health & safety. All the working practices in the home are safe and there have not been any preventable accidents. Records show that there are very few accidents at all and staff and confirmed this. A safe environment is provided for the residents. During last year an inspection of a sample of personnel files at the organisations head office showed that not all of the required staff records were maintained. This was discussed with the organisation and the Commission received an action plan of how this was going to be addressed. A further visit to head office confirmed that all of the necessary action has been taken and that the necessary records are kept. All records inspected were appropriately kept and up to date. The requirement with regard to records has therefore been met. Glengall Road [83] DS0000025954.V337377.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 4 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 3 4 4 X 3 4 X Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 26 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Glengall Road [83] DS0000025954.V337377.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU 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. 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