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Inspection on 06/12/06 for Glengarriff House Nursing Home

Also see our care home review for Glengarriff House Nursing Home for more information

This inspection was carried out on 6th December 2006.

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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Service users get a range of information about the home to help them make choices, and they are involved in a good assessment process to make sure that they will get their needs met. Staff help them to develop very good care plans, and also make sure that they are helped to stay safe. Service users can take part in lots of different activities, and they are helped to join in with the local community. They are also helped to get jobs if they want to. They can tell people how they feel about things and have the help of advocates if they want them. They can also help to make the service better by joining in with service user meetings and quality audits.

What has improved since the last inspection?

Since the last inspection visit staff have talked to service users and their relatives about what they want to happen if they become ill, and what they want for their funeral arrangements; and this has been put into the care plans. There are also now clear arrangements with the local pharmacy for them to dispose of medicines that are not needed anymore.

What the care home could do better:

During this visit the inspector found three things that need to be done better. The first is that there should be a record kept at the home, as well as at the company`s head office, of any complaints that have been made about the home. The second thing is that everywhere in the home should smell fresh and clean all of the time; and the third is that all new staff should get know how to help service users with their behaviours, and how to protect them before they work unsupervised. There are some suggestions made about things that are already done well, but could be done even better, such as signs and notices around the house could be put into easy read words and/or pictures so that service users can understand them better. This includes things like the activity plan, the complaints procedure and the menus. All of the information collected during assessments could be kept on each service user`s file, and the arrangements for taking medicines to the flats across the courtyard could be looked at so as to make things even safer. Lastly the registered manager could help to interview all qualified nurses to make sure that they are the right people to work with the service users.

CARE HOME ADULTS 18-65 Glengarriff House Nursing Home 8 King Street Market Rasen Lincs LN8 3BB Lead Inspector Wendy Taylor Key Announced Inspection 6th December 2006 09:00 Glengarriff House Nursing Home DS0000002629.V322779.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 Glengarriff House Nursing Home DS0000002629.V322779.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. Glengarriff House Nursing Home DS0000002629.V322779.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glengarriff House Nursing Home Address 8 King Street Market Rasen Lincs LN8 3BB 01673 844091 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) info@prime-life.co.ukwww.prime-life.co.uk Prime Life Limited Miss Nicola Jayne Broddle Care Home 18 Category(ies) of Learning disability (18), Learning disability over registration, with number 65 years of age (1) of places Glengarriff House Nursing Home DS0000002629.V322779.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered to provide personal care with nursing to service users whose primary needs fall within the following categories: * Learning Disability (LD) 18 male or female * Learning Disability (LD) Over 65 years of age - 1 female The maximum number registered for is 18 The Category of Learning Disability (LD) over 65 years of age applies to the service user named in the Notice of Proposal to register dated 11/04/05 12th January 2006 2. 3. Date of last inspection Brief Description of the Service: Glengarriff House is owned by Prime Life Homes Ltd. The home is located in the centre of the market town of Market Rasen. The town offers a variety of local amenities such as pubs, cafes and restaurants, banks, shops and a post office. Glengarriff House provides care and support (which includes nursing) for up to eighteen people with a learning disability. The main house is a two-storey building with a first floor extension providing accommodation for twelve people. It stands in its own grounds with gardens to the front and rear, and ample parking also at the rear. Within the grounds, across a courtyard there is also a semi- independent living unit consisting of four flats for six people. The registered manager is Nicola Broddle. The current weekly fees for the home start at £ 392:00 and are individually assessed from there on. Glengarriff House Nursing Home DS0000002629.V322779.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key announced inspection took place during December 2006 and the visit to the home was carried out over approximately 9 hours on one day. The care received by three service users was followed in detail. Service users and relatives spoke about the experience of living there. Individual service user records and general house records were looked at, as wells as staff records. Staff and the registered manager were spoken to and the care being provided was observed. Information already held by the commission was also used as part of the inspection process. The commission are trying to improve the way that we engage with people who use services so that we gain a real understanding of their views and experiences of social care services. We are currently testing a method of working where ‘experts by experience’ are an important part of the inspection team and help inspectors to get a picture of what it is like to live in or use a social care service. The term ‘experts by experience’ used in this report describes people whose knowledge about social care services comes directly from using them. The expert met and talked to service users on their own. A visitor said that they are glad their relative lives in the home and they have confidence in the management. The expert said that ‘..most of the people there made us feel welcomed into their home and some people were great and gave us good feedback and it was nice to talk in general about what people had done.’ Other comments made by service users, relatives and the expert are in the main body of the report. What the service does well: Service users get a range of information about the home to help them make choices, and they are involved in a good assessment process to make sure that they will get their needs met. Staff help them to develop very good care plans, and also make sure that they are helped to stay safe. Service users can take part in lots of different activities, and they are helped to join in with the local community. They are also helped to get jobs if they want to. They can tell people how they feel about things and have the help of advocates if they want them. They can also help to make the service better by joining in with service user meetings and quality audits. Glengarriff House Nursing Home DS0000002629.V322779.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Glengarriff House Nursing Home DS0000002629.V322779.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 Glengarriff House Nursing Home DS0000002629.V322779.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): 1, 2, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from access to a range of information about the home, and they are involved in a comprehensive assessment process; however all assessment information should be kept in individual files. EVIDENCE: There is an up to date statement of purpose and service user guide available, and the service user guide is in picture format. The registered manager said that the service user guide is sent out to prospective service users and/or their representatives with an introduction pack. A recent quality assurance audit suggested the development of bespoke service user guides. Individual contracts are kept in service user files and show the amount of support hours they are to receive. Staff rotas show that the contracted hours of support are being met. There are assessments and care plans available from the placing authority, and the registered manager said that pre admission assessments are carried out by herself and/or her manager. She said that these assessments are held at the provider’s head office and are not kept on service user files. She also said that the pre admission assessments are carried out with the prospective Glengarriff House Nursing Home DS0000002629.V322779.R01.S.doc Version 5.2 Page 9 service user and their representatives, and they contain information about the person’s background, health needs and behaviours. Pre inspection surveys completed by service users indicate that they are given a choice to move into the home and that they received enough information about the home. Glengarriff House Nursing Home DS0000002629.V322779.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, 8, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from being involved in the development of comprehensive care plans that reflect assessed needs and focus on risk management, however they would benefit further from having a person centred plan. Not all information is available in easy read/picture formats therefore some service users may not be able to understand the information. EVIDENCE: Individual care plans are in place including those from placing authorities. The plans contain information about sleeping, eating and drinking, occupation and leisure, maintaining family contacts, finances, infection control, mobility and communication (see also Standards 18-21). There is also a section called ‘my life’ which includes information about spiritual and cultural needs, and decision-making. The plans refer to making individual choices, personal preferences and maintaining privacy. There is evidence in pre inspection questionnaires that policies are available for privacy, dignity, Glengarriff House Nursing Home DS0000002629.V322779.R01.S.doc Version 5.2 Page 11 choice and independence, risk assessing and service user finances; and that those policies were updated in March 2006. Information in care plans is very detailed and service users sign them if they are able to. There is evidence that two of the service users have written their own plans. There is evidence that care plans are reviewed regularly, and minutes of the review meetings show who was involved in the reviews. Risk assessments are available in individual files. The documentation sets out an overview of the risk, the assessment and the intervention. There is evidence that the risk assessments are reviewed regularly, and again they are very detailed. They cover areas such as pressure area care, sleep patterns, behaviours and epilepsy; and they cross-reference with care plans. The expert said that although some residents had put pictures in frames of things they like and one service user had a book of healthy things that they were doing, service users didn’t have a ‘person centred plan’ that sets out their wishes and future goals. They felt that if everyone had their own person centred plan in their room, it would be much better. The registered manager said that she is awaiting training for staff from the local community team in how to develop ‘person centred plans’. During discussions, staff demonstrated a clear knowledge of individual needs and the care plans in place to address them. There is evidence that service users have regular meetings, which include topics such as holiday arrangements, menu’s, takeaways and day trips. In pre inspection surveys some service users said that they could make decisions for themselves. During the inspection, service users said ‘I can choose to do what I want’; another said ‘it’s lovely here, love the staff’. One service user told the expert that they were ‘not too sure’ if they liked the staff. The expert also found that although there is a key worker system in place, some residents said that they don’t get to choose their workers. The expert found that signs and notices, including the complaints procedure, displayed around the house are not in easy read words and pictures, which means that some service users are not able to understand them. Glengarriff House Nursing Home DS0000002629.V322779.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): 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a wide range of social and leisure activities, and they are fully supported to access and develop employment opportunities. Service users are supported to develop a healthy and balanced menu, however they should be able to choose where they eat, and have access to the menus that have alternatives recorded. EVIDENCE: In pre inspection surveys service users said that they can choose what they want to do during the day, evening and weekends. There is a photograph file available with reminders of outings, and a plan is in place, which lists activities such as pub lunches, shopping trips, parties, art sessions, relaxation sessions and exercise sessions. Although the plan is in place, it is not freely available to service users. Glengarriff House Nursing Home DS0000002629.V322779.R01.S.doc Version 5.2 Page 13 Some service users told the expert that they spend most of the time watching television, however individual records show a wide range of activities that people have engaged in. One service user said that they ‘go out a lot to shops, the zoo and we have parties’, another used sign language to say that they help with the gardening, and another said that they help to grow lettuce and herbs in the summer. Four service users have jobs in local businesses, one attends a catering course at college, and two service users were meeting with an employment adviser on the day of the visit. There is a mini bus available to service users and some people have a travel card for trains and buses. Service users described the arrangements they have for visiting with family. During the inspection visit the expert observed some service users making Christmas cards and others going out Christmas shopping, and they found that the staff were helpful and kind. In the morning, service users were seen taking breakfast at the times that they chose, however the expert observed that one service user was not allowed to take fruit out of the dinning room after lunch. One resident told the expert that there is ‘good food, we get to choose what we want, and I like eating anything’, and another said that they choose their own packed lunches. The expert found that the food served at lunch looked nice and healthy but no alternatives were offered when meals were served. Menus do not clearly reflect choice, however the minutes of service user meetings show that menus are discussed and alternatives are available. The expert also noted that the menu was not on show for service users. The expert found that most of the staff are very friendly and respectful to the service users, and one service user told them “I like the staff, we get new stuff for Christmas (and they) get rid of your junk’. Although the expert thought that people’s choices were not always being respected, for example staff putting someone’s shoes on whilst they are saying ‘no’, however care plans show that this is part of a known behaviour and structured routine. A visitor said that their relative has a very good quality of life at the home, does a lot of activity and goes on holidays. They also said that the food is very good and their relative gets to make choices for themselves where they are able. Glengarriff House Nursing Home DS0000002629.V322779.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from robust medication policies but some procedures should be reviewed to ensure that medication is protected when transported. There are robust arrangements and processes for the provision of personal and healthcare support which meets the individual needs of service users. EVIDENCE: Individual care plans are available for needs such as medication, personal care, mental health and infection control; and there is clear information regarding any health need or condition that a service user has been diagnosed with. There are individual health action plans in place and records are kept for weight, epilepsy, opticians, dentist and chiropody. Personal wishes and arrangements for end of life are recorded, and a health profile sheet for use in emergencies (e.g. hospital admissions) is available. In pre inspection surveys service users said that they see a doctor when they need to and staff treat them well. A service user showed the expert a folder that they have compiled about how to keep healthy and about first aid issues. Glengarriff House Nursing Home DS0000002629.V322779.R01.S.doc Version 5.2 Page 15 Medication records are completed satisfactorily and administration protocols for individual service users were followed on the day of the visit. Some individual medication is currently carried from the main home, across the courtyard to the flats in open pots, and whilst some precautions are taken, medications could be exposed to the weather. Medicines are stored appropriately and an up to date medicines policy is available. The home has regular monitoring visits from the local pharmacy and they have made arrangements with the pharmacy for the disposal of unwanted medicines. During the visit, staff demonstrated that they have a good knowledge of which service users have medication ‘when necessary’ and what they have it for. They were also able to describe individual signs that indicate when a medication may be needed. Protocols are in place for the administration of ‘when necessary’ medication. Glengarriff House Nursing Home DS0000002629.V322779.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although service users are protected by the use of advocates and robust policies and procedures, they would benefit from the policies and procedures being available in easy read/picture formats. The home is unable to demonstrate that complaints are investigated in accordance with policies and procedures. EVIDENCE: There are clear and up to date policies and procedures available for safeguarding adults, complaints and whistle blowing. The complaints procedure is contained within the service user guide, and it is displayed in the entrance hall of the home but this copy is not in an easy read or picture format (see Standard 8). Since the last inspection there has been one incident reported through local authority safeguarding adult procedures, which is not yet resolved. There is evidence in records that appropriate action was taken to report the incident in a timely manner. All staff except one new member (see Standard 32) said that they have received training in safeguarding adults issues either in house or by way of a formal course, and they were able to explain what to do if they suspected or witnessed such. Training records support this. The registered manager said that she is awaiting an up to date alerter’s training pack that can be used in the induction process, although general responses to abuse and neglect is covered in the induction booklet currently used at the home. Glengarriff House Nursing Home DS0000002629.V322779.R01.S.doc Version 5.2 Page 17 One complaint has been received by the home since last inspection regarding behaviour management approaches. The registered manager said that the complaint had been investigated and found to be unsubstantiated but there were no records available in the home to demonstrate this. In pre inspection surveys some service users said that they know who to talk to if they’re unhappy with anything, and they know how to make a complaint. They also said that staff listen to them and act upon what they raise, however one service user told the expert that staff did not listen to them. A relative said that they know how to make a complaint. Records show that three service users are accessing advocacy services at present. The expert made a suggestion that advocates are asked to come to service user meetings to help to promote self-advocacy. Glengarriff House Nursing Home DS0000002629.V322779.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from generally comfortable and safe accommodation, however some communal areas are in need of attention with regard to décor and hygiene. EVIDENCE: A tour of the home showed that most areas of the home including service user bedrooms were clean, tidy and comfortably furnished, and service user’s bedrooms are well personalised, however there was an unpleasant odour in the entrance hall. The registered manager described current odour control methods and said that the odour results from on-going behavioural issues. Décor is generally good but some areas need attention such as the ground floor corridor in the main house, where walls are stained and woodwork paint is scuffed and chipped. The registered manager said that the renewal and decorating programme would address these issues. There is a cleaning rota in the kitchen and there are hand-washing notices near communal sinks. Glengarriff House Nursing Home DS0000002629.V322779.R01.S.doc Version 5.2 Page 19 Environmental risk assessments are in place for the kitchen area, intruders, damage to property, safe keeping of keys, privacy, use of stairs and tripping hazards. There are well-kept gardens and a courtyard area, and one of the service users said that they enjoy working in the garden. Glengarriff House Nursing Home DS0000002629.V322779.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst service users benefit from a generally well-trained and knowledgeable staff team, they are at risk from newly employed staff who do not have experience and/or training to manage complex needs. EVIDENCE: Recruitment files contain application forms, references, criminal record checks and identification. The registered manager said that she is not involved in interviewing for qualified nurses, but feels that she should have input so as to ensure that they have to training and/or experience to guide staff appropriately in the management of the complex needs of the service user group. During the visit an incident occurred that was related to a new member of staff not managing a behavioural issue appropriately. The member of staff had not yet received training in behavioural management or safeguarding adult issues and was not being fully supervised. An experienced member of staff resolved the incident quickly and appropriately, and when informed of the incident the registered manager also took appropriate actions in respect of training, development and supervision for the new member of staff. Glengarriff House Nursing Home DS0000002629.V322779.R01.S.doc Version 5.2 Page 21 Records show that most staff have received training in management of behaviours, first aid, safe handling of medication, record keeping, legislation, communication, risk assessing and health and safety. There is also evidence that staff undertake nationally recognised programmes of training, including a comprehensive induction programme. Staff said that the training programme is very good, including the induction process. New staff are provided with an induction booklet, which covers areas such as understanding of care principles, communicating effectively and developing as a worker. A visitor said that the staff are ‘very good’ and they know how to manage their relatives need very well. Records demonstrate that staff receive regular supervision and staff confirmed this during discussions. There is also evidence of regular staff meetings, where staff said that they can air their views and they receive a lot of information. Glengarriff House Nursing Home DS0000002629.V322779.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust record keeping and the implementation of safe procedures and practices protect the health, safety and welfare of service users. Service users are able to participate in the development of the service through the comprehensive quality assurance programme. EVIDENCE: Staff said that the registered manager is very approachable and listens to people’s opinions, and they get plenty of support to do their job. A relative said that they have confidence in the manager and feel that she is very good at her job. The registered manager said she and the deputy manager have recently completed the Registered Managers Award. Glengarriff House Nursing Home DS0000002629.V322779.R01.S.doc Version 5.2 Page 23 Pre inspection information shows that policies and procedures are available for quality assurance, management of hazardous substances, continence, equal opportunities, fire safety, food safety, pressure relief, record keeping, moving and handling, health and safety and racial harassment. Staff said that they have access to policies and procedures as they are kept in the office, and some are issued with their induction packs. There is evidence that policies and procedures were updated in March 2006. There are risk assessments and data sheets available for hazardous substances and those substances are securely stored outside of the main house. Records show that staff receive training in the management of hazardous substances. Records also show that fire equipment checks, fire evacuation drills and fire safety training are carried out regularly. Staff demonstrated very clear knowledge of fire safety issues, including evacuation procedures. Accident/incident records are in place and cross-reference with detailed daily notes for individual service users; and there are regularly updated property records for each service user. Service user files are stored securely in a locked office. Records show that there is an annual audit of service user finances. There are also clear in-house records kept for income and expenditure, which are sent to the provider’s head office on a monthly basis for audit purposes. There is evidence of a comprehensive quality assurance programme, which includes surveys for service users and their relatives. A report from the most recent quality review (November 2006) was available, which gave the service a ‘4 star’ superior rating and issues for improvement, such as providing wheelchair access at the front of the home, were identified. Glengarriff House Nursing Home DS0000002629.V322779.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 3 3 3 X Glengarriff House Nursing Home DS0000002629.V322779.R01.S.doc Version 5.2 Page 25 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA22, Regulation 17(2), Schedule 4 (11) Requirement Timescale for action 06/01/07 2. 3. YA30 YA32 The responsible person must ensure that a record of all complaints made about the operation of the home, and the actions taken in respect of any such complaint, is kept in the home. 23(2)(d) The responsible person must ensure that all parts of the home are free from unpleasant odours. 18(1)(c)(i) The responsible person must ensure that all staff receive training appropriate to the needs of the service users, including behaviour management and safeguarding adults. 06/01/07 06/01/07 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 YA2 Good Practice Recommendations It is recommended that pre admission assessments carried out by staff in the home be kept in individual service user files. DS0000002629.V322779.R01.S.doc Version 5.2 Page 26 Glengarriff House Nursing Home 2. 3. 4. YA8 YA14 YA17 It is recommended that signs and notices around the home be translated into easy read words and pictures, including the complaints procedure. It is recommended that the service users have access to the activity plan. It is recommended that service users are able to choose where they eat, that menus reflect alternatives and service users have access to menus. It is recommended that procedures for transporting medication across the courtyard be reviewed. It is recommended that, given the complex needs of the service user group, the registered manager be involved in the interview process for all qualified nurses. It is recommended that new members of staff are fully supervised or supernumery until they have received training in behavioural management and safeguarding adult issues. 5. 6. 7. YA20 YA34 YA36 Glengarriff House Nursing Home DS0000002629.V322779.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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 Glengarriff House Nursing Home DS0000002629.V322779.R01.S.doc Version 5.2 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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