Inspection on 13/07/07 for Glenholme

This inspection was carried out on 13th July 2007.

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

The inspector 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glenholme 19/07/06

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Glenholme 94 Green Lane West Vale Halifax HX4 8BL Lead Inspector Liz Cuddington Key Unannounced Inspection 13th July 2007 13:15 Glenholme DS0000067105.V342734.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 Glenholme DS0000067105.V342734.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. Glenholme DS0000067105.V342734.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glenholme Address 94 Green Lane West Vale Halifax HX4 8BL 01422 372985 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) karenp@st-annes.org.uk www.st-annes.org.uk St Anne’s Community Services Ms Karen Parrish Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Glenholme DS0000067105.V342734.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named person over the age of 65 years of age named on variation dated 29th September 2006 may reside at the home. 19th July 2006 Date of last inspection Brief Description of the Service: Glenholme is a respite care centre offering short term breaks for younger adults with a learning difficulty. It is a large house providing single bedroom accommodation for fourteen men and women. Ten of the bedrooms have en suite facilities. There are two large lounges and a comfortable seating area in the hallway. There is a separate kitchen for guests to use if they wish. The house is on a bus route and there is ample parking at the rear of the building. From the outside, there is level access into the house and passenger lifts inside make all the rooms accessible. The fees are paid by Social Services. There is a charge of 55p per mile for use of the centre’s vehicle. Glenholme DS0000067105.V342734.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the inspection was to assess the quality of the care and support received by the people who stay at Glenholme respite centre. The methods I used to gather information included conversations with the people staying at the centre and the staff, looking at care plans, examining other records and a walk round the home. I sent questionnaires to guests and their relatives. I received eight completed questionnaires back. I also received the home’s pre-inspection questionnaire. These questionnaires provide a lot of valuable information to help me form a judgement about the quality of the service offered at Glenholme. In the report I have referred to the people who go to stay at the respite centre as ‘guests’, since that is the terminology the service uses. Although there are still areas for development, the respite centre continues to make significant improvements. I would like to thank the people who were staying at Glenholme when I was there, and the staff, for their welcome and hospitality and for taking the time to talk to me during my visit. What the service does well: The interaction between staff and the guests is relaxed and friendly. Staff maintain people’s dignity and privacy. They spend time with people but respect guests’ right to be left alone if they wish. The care plans are centred upon the needs and wishes of each guest and reflect their preferences. They are reviewed regularly and staff showed a high level of knowledge and understanding about the guests. People are protected by the organisation’s recruitment procedures, which are safe and thorough. There is suitable training for staff to give them the skills and knowledge to provide good quality care and support for the guests. Six of the 23 support staff have a recognised qualification and nine are working towards achieving one. The house is clean and fresh and good hygiene and infection control measures are in place. All of the guests who commented said that the home is always, or usually, fresh and clean. The house is suitable to meet the support needs of the guests, and has the adaptations and equipment they need. All of the guests who returned questionnaires said they can always do what they want to and that the staff treat them well. They all said they know how to Glenholme DS0000067105.V342734.R01.S.doc Version 5.2 Page 6 raise any concerns if they need to. One person commented that their relative is well looked after when staying at Glenholme. Two relatives said they are always kept informed of important issues. One relative said they are ‘very pleased with the communication’ and another wrote that they receive ‘good communication from the support staff concerned and their line manager…’. The manager and staff are continuously striving to make improvements and welcome comments and suggestions from guests and their relatives. What has improved since the last inspection? What they could do better: The downstairs shower room needs to be refurbished in order to provide a facility which is hygienic and comfortable. An up to date Service User Guide must be provided for guests, families and carers. This should include a clear complaints guide that guests can use. More staff need to complete a suitable National Vocational Qualification, in order to make sure the centre has a well trained and qualified staff team. One relative said they would like to receive more feedback from staff. Glenholme DS0000067105.V342734.R01.S.doc Version 5.2 Page 7 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. Glenholme DS0000067105.V342734.R01.S.doc Version 5.2 Page 8 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 Glenholme DS0000067105.V342734.R01.S.doc Version 5.2 Page 9 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 & 3 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Statement of Purpose has been updated to reflect the scope of the service. The respite centre carries out a thorough assessment process for prospective guests before their first stay, to make sure the home can meet their needs. EVIDENCE: The Statement of Purpose has been revised and updated and now reflects the services that the respite centre offers. The Service User Guide does not fully reflect the service provided at Glenholme. It is currently being re-written in the form of an information pack for guests, their families and carers. The manager said they plan to make this, and other written information, available in different formats to suit the needs of the individual. There is a comprehensive pre-admission procedure to make sure the respite centre can meet the person’s needs. An assessment of the person’s care and support needs is carried out by senior members of staff and used as the basis for their care plan. Each person has a placement agreement through Calderdale Social Services. Glenholme DS0000067105.V342734.R01.S.doc Version 5.2 Page 10 Social Services’ assessments are also used to determine the care needs of the individual. People are welcome to visit the home before reaching a decision. When someone goes to Glenholme for emergency respite, the senior staff obtain as much detail about the person’s physical and mental health needs as possible before they arrive. The manager told me they also consult with staff from other services where the person is known, such as day centres, in order to obtain as full a picture of the individual as they can. Glenholme DS0000067105.V342734.R01.S.doc Version 5.2 Page 11 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 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. To maintain their autonomy and independence, staff support people to make choices and decisions about all aspects of their daily lives. People are involved in planning their care and are supported to take risks. Care plans show they have been reviewed and updated regularly, to make sure that they reflect people’s current needs. EVIDENCE: I looked at three people’s care plans. They are very informative and each plan shows what the person needs in all aspects of their life, and how staff are to support them during their stay. The plans that I looked at, and conversations with staff, confirmed that people’s cultural and individual preferences are understood by everyone and form an integral part of the care and support they are offered. Glenholme DS0000067105.V342734.R01.S.doc Version 5.2 Page 12 Each person has an ‘All About Me’ support plan which is written in the first person, emphasising the fact that this plan belongs to the guest. There is clear information about the individual’s needs and preferences. The plan clearly shows if the person wishes their family to be present when they make decisions. The plans cover all aspects of guests’ personal care and medical history. The person’s level of independence for each different area of daily life is shown and any support required with mobility and personal safety is detailed. There are risk assessments, showing what measures need to be taken to keep people safe, while not restricting their freedom and choice. People’s preferred leisure activities are noted, and the support they need to follow their chosen pursuits. Each plan includes the staff’s daily record of significant events. These reflect the individual and many are written in the guests’ own words. There is a trained moving and handling assessor on the staff team. Each person’s plan includes guidance on how staff are to assist people to move and transfer safely. The plans are reviewed each year, or sooner if the person’s needs change. Since the centre opened in April 2006, the staff have got to know people better and the plans have been reviewed to reflect their increased understanding of their guests. Some of the people who stay at Glenholme have complex needs and use a variety of ways to communicate. The staff use ‘flash cards’ and other methods of communication. One member of staff has expressed a wish to learn Makaton, to help communicate with people who use this language. All confidential information is stored securely in locked cabinets in a room which is locked when not in use. The staff are aware of the importance of maintaining people’s confidentiality. Glenholme DS0000067105.V342734.R01.S.doc Version 5.2 Page 13 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. A range of leisure activities is provided to try and make sure each person’s recreational needs and expectations are being met. Guests are given a good choice of meals and other foods to make sure their dietary needs and preferences are met. EVIDENCE: The plans show details of people’s choice of leisure activities. Guests are supported to pursue these, either within the centre or through the outreach services. One relative felt that more activities could be provided for guests during their stay, particularly when visiting for more than a couple of days. The guests who were staying at Glenholme when I visited told me what they enjoy doing while they are there. People said they go swimming, walking, shopping and on other outings that they choose. They also said that in the Glenholme DS0000067105.V342734.R01.S.doc Version 5.2 Page 14 home they like playing pool, table tennis, board games and card games. There is a computer for people to use as well as a playstation. The manager confirmed that the guests tell staff what they want to do and staff do their best to arrange it. Currently, the staff cook all the meals, with assistance from guests if they wish to help. One guest was planning to prepare a special, surprise meal for a friend, and a member of staff was helping with the planning and preparation. The home has now employed two cooks, who were expected to start as soon as all the necessary pre-employment checks had been completed. The management and staff decided that this was becoming increasingly important in order to meet guests’ specific dietary needs and maintain a healthy and nutritious diet. Everyone who commented to me said they enjoy their meals. All the staff I spoke with are aware of each person’s needs and preferences. They talked knowledgably about the guests as individuals and showed they are aware of the importance of continuously working towards making improvements, to make the guests’ stay an even better and more positive experience. Glenholme DS0000067105.V342734.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 who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. To maintain their health and wellbeing, people’s personal and healthcare needs are met. People are fully protected by the home’s medication systems. Medications are stored safely and administered accurately. To maintain their dignity, the staff treat people with respect, care and consideration at all times. EVIDENCE: People’s health and wellbeing is observed and monitored during their stay, and any concerns are followed up with relevant health or social care staff, or the family, and their advice followed. The plans contain a lot of detail about the guests’ healthcare needs. One relative commented that ‘All of the support staff…seem to try to understand the needs and disabilities of their clients’. Glenholme DS0000067105.V342734.R01.S.doc Version 5.2 Page 16 The medication is stored securely and safely. The Medicines Administration Record (MAR) charts are accurately completed and quantities of medicines received, in stock and returned to the pharmacy are recorded correctly. The staff that administer medication have all received suitable training. The centre has a protocol for staff to follow when making decisions about when to administer medicines prescribed for use ‘when required’. A running total of all medicines is kept, including a ‘brought forward’ system. This makes sure the staff know exactly what quantities of each medicine they have at any time. People who handle all or some of their own medication keep the medicines in a secure storage area in their bedroom. The bedroom door is kept locked to make sure the items are safe. A medication checklist is completed at every visit. Some of the comments I received from guests and relatives confirmed my own observations that all the staff are respectful and considerate to the people who stay at the centre, and make sure people’s dignity is maintained. Glenholme DS0000067105.V342734.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 who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The guests and their relatives are aware of how to raise a concern or make a complaint if they are dissatisfied with the service. Staff have received suitable training and understand the adult protection policies and procedures, which makes sure that people staying at the centre are safe. EVIDENCE: The surveys I received from relatives and guests confirmed that everyone is aware of how to raise a concern or make a complaint, should they need to do so. There is a complaints log to record any complaints or concerns. The complaints procedure is clear and easily available. The leaflet has not yet been produced in an ‘easy read’ format. The manager told me this will be done as part of the new information pack. The respite centre deals with any concerns effectively and without delay. One relative wrote that any concerns ‘…were dealt with without having to proceed with a complaint’. One guest told me they have ‘no complaints’ about the service. The staff are aware of the need to report any concerns they have about care practice and there are clear guidelines for reporting such incidents. All of the staff have had Adult Protection training. The adult protection information is Glenholme DS0000067105.V342734.R01.S.doc Version 5.2 Page 18 produced in conjunction with Calderdale Social Services. It is shown to carers when they come to visit the respite centre before a service is provided. Glenholme DS0000067105.V342734.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, 27, 28, 29 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The centre offers a safe, comfortable and generally well maintained environment, planned to suit their needs. EVIDENCE: There is a programme of re-decoration for the bedrooms, as well as for the rest of the house. Several areas, including bedrooms and the en suite toilets, have recently been painted and look fresh and attractive. The bedroom doors all have locks and there is a lockable storage space in the rooms, which means that people can keep their belongings private and secure. The upkeep of the fabric of the building, and the permanent fixtures and fittings, is the responsibility of Calderdale MBC who own the building. There are two walk-in, level access showers in the house; one on each floor. When the upstairs shower needed repair, I was told that Calderdale MBC took more than six months to repair it. This left the centre with one useable shower. This is Glenholme DS0000067105.V342734.R01.S.doc Version 5.2 Page 20 unacceptable, particularly when several people need to use the shower in the morning before they are collected to attend their daytime activities. The upstairs shower has now been repaired but the downstairs walk-in shower area is in a very poor state of repair. There are tiles missing and the seal between the tiles and the shower base is broken, allowing water to leak to the room below. There is bare wood showing, which is unhygienic, and the extractor fan is too small for the size of the room. This means the room becomes steamy and uncomfortable, especially after several people have showered in succession. The manager told me this shower room is due to be refurbished. The poor state of repair means that the matter is now urgent. Calderdale MBC needs to attend to this without further delay. All other parts of the house are fresh, clean, comfortable and well looked after. Everyone who commented agreed that the house is well kept. There are good infection control systems in place and staff use protective gloves and other measures, where needed. Glenholme DS0000067105.V342734.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): 32, 33, 34, 35 & 36 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Sufficient staff are employed to meet people’s needs. People are protected by thorough recruitment procedures, which ensure that staff are suitable to work with the guests who stay at the centre. Suitable training is provided to make sure staff have the skills and knowledge they require to meet people’s needs. EVIDENCE: The staff rotas confirmed my observations that there are plenty of staff on duty to meet the care, social and leisure needs of the people who stay at the centre. The number of staff on duty is adjusted to reflect the needs of the guests. The centre aims to provide a ratio of either two or three staff to every guest, depending on their needs. The respite centre is not yet fully staffed and sometimes needs to employ agency staff. The staff turnover is low. Three new staff, including two cooks, were due to start soon after my visit. All staff complete an application form and provide two written references. Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) Glenholme DS0000067105.V342734.R01.S.doc Version 5.2 Page 22 register checks are obtained and no new staff begin work until these checks have been completed satisfactorily. Short-listed staff go to Glenholme for a pre-interview visit and the people staying at Glenholme are involved at this stage. The centre is looking to develop guests’ involvement in their recruitment process. The manager makes sure that staff have the necessary training to help them do their work as well as possible. There is a wide range of courses available and the records confirmed that the staff are allowed the time to attend. The manager is planning to arrange training to help staff understand people who have suffered sexual abuse and people who self-harm. Two senior staff have recently attended training about autism, in conjunction with Lancaster University. Staff have completed Positive Behaviour Support training and have had training for managing specific behaviours. Training needs are re-assessed when a new person starts to use the respite service, to make sure staff have the skills and understanding to meet his or her needs. Three of the relatives said that they felt staff have the skills they need. Another relative said that staff ‘All seem pleasant and competent’. Six of the 23 support staff have a relevant National Vocational Qualification (NVQ) at level 2 or above. Nine staff are working towards achieving an NVQ award. New support staff all take the Learning Disabilities Award Framework training as part of their induction and foundation training. This makes sure they have a good understanding of their role and responsibilities, and provides a sound basis for NVQ study. The manager, deputy manager and four senior support staff carry out one to one supervision with staff every six weeks. Glenholme DS0000067105.V342734.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, 39, 40 & 42 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is safe and well managed and everyone who visits and works at the home can contribute to the decision-making processes. EVIDENCE: The manager has the qualifications and the skills to manage the home effectively. There is a good management structure within the home, which supports the manager. The manager promotes an open and inclusive management style and everyone is involved in the decision-making processes. My own observations, and comments from other people, confirm that everyone’s views are valued and taken into account. The policies and procedures are kept up to date to make sure they provide relevant information to guide staff on how to act in every situation. All the Glenholme DS0000067105.V342734.R01.S.doc Version 5.2 Page 24 regular health and safety checks for the centre are carried out in a timely manner. Staff have basic health and safety training. All these measures make sure that the health, safety and welfare of the people at the centre is promoted and safeguarded. The home sends out questionnaires to relatives and carers each year, in order to gain information about how people view the service and what improvements they would like to see. About one third of them were returned last time. The responses are analysed and any necessary follow up action is taken. During this year the respite centre has held a parent and carer forum and an open day. The manager told me these were both poorly attended. She is to look at other ways to gain people’s views and ideas. In September 2007 three of the guests are attending St Anne’s annual forum, along with members of staff. The home looks after small amounts of people’s money, to pay for their day to day expenses. The records are accurately kept and stored in people’s care plans. Calderdale MBC have replaced one of the washing machines with a model that has an integral sluice programme. This is an important measure in supporting the centre’s infection control procedures. Glenholme DS0000067105.V342734.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 3 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 X 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 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 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 X 3 X Glenholme DS0000067105.V342734.R01.S.doc Version 5.2 Page 26 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 YA1 Regulation Schedule 14(1) & 5(1) Requirement The Service User Guide must contain all the necessary information so that service users and their carers know what the service provides. This is an outstanding requirement from 31/10/06. Timescale for action 31/10/07 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. 2. 3. Refer to Standard YA22 YA27 YA32 Good Practice Recommendations A more suitable, easier to read, complaints leaflet for people who use the service should be developed. Calderdale MBC needs to refurbish the downstairs shower room without further delay, in order to make it safe and hygienic. More staff need to complete a National Vocational Qualification in order to meet this standard and ensure the centre has a well qualified staff team. Glenholme DS0000067105.V342734.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Glenholme DS0000067105.V342734.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. 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