Inspection on 27/09/06 for Glenholme Residential Care Home

This inspection was carried out on 27th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 but made no statutory requirements on the home.

Other inspections for this house

Glenholme Residential Care Home 29/11/07

Glenholme Residential Care Home 08/11/05

Glenholme Residential Care Home 20/04/05

Glenholme Residential Care Home 28/10/04

Glenholme Residential Care Home 18/05/04

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

CARE HOMES FOR OLDER PEOPLE Glenholme Residential Care Home 4 Park Avenue Roker Sunderland SR6 9PU Lead Inspector Sam Doku Key Unannounced Inspection 27 & 29 September 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Glenholme Residential Care Home Address 4 Park Avenue Roker Sunderland SR6 9PU 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) 0191 549 2594 0191 548 6089 Wellburn Care Homes Limited Mrs Christine Purvis Care Home 34 Category(ies) of Dementia (4), Mental disorder, excluding registration, with number learning disability or dementia (2), Old age, not of places falling within any other category (28) Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th November 2005 Brief Description of the Service: Glenholme is a large, redbrick Victorian detached villa. It was built in 1887 and was once the Vicarage for St Andrews Church. It has been extended and is now a residential care home, which provides services for up to thirty-four older people, some of whom may have dementia or mental health needs. The Registered Provider also operates a day centre for older people on the same site but managed separately from the home. The property is close to Roker Park in a mainly residential street close to the sea front. Sunderland city centre is a short distance away and can be reached by public transport, which passes frequently. Local facilities include a church and a small selection of shops. The accommodation is laid out over three floors, with additional mezzanine levels and there are thirty-four single bedrooms, some with en-suite facilities. The first and second floors are accessible by passenger lift, however the mezzanine levels can only be reached by stairs, therefore, is only suitable for mobile residents. There are also two communal lounge areas, a sunroom and two dining areas. External features include a large and secluded walled garden, which is well kept and equipped with outdoor furniture, sunshades and barbecue facilities. The current scale of charges is £377 - £388. Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In preparation for the inspection, a pre-inspection questionnaire was sent to the manager for completion, which was returned with the necessary information required to commence the inspection. The inspection was a key inspection and was carried out over two days by one inspector. It was unannounced and commenced at 10:00 and took place on the 27 and 29 September 2006. The inspection process involved: • Visits to the home to examine activities relating to the day-to-day management and care provided. These included interviews with the manager, discussions with staff, discussions with service users, examination of care plans, risk assessments, staff files, fire safety records, medication systems and other health and safety records. There were discussions with the senior staff and other staff, and a tour of the building. • The observations of staff care practices also contributed to the inspection findings. The atmosphere in the Home was friendly, relaxed and comfortable throughout the time of the inspection. Service users appeared well cared for and comfortable with the staff. Service users were able to express their views to the inspector without staff presence. However, a number of the service users commented on the narrow corridors and the lack of alternative sitting arrangements in the home due to the major renovation work in the home. What the service does well: The home has a friendly and homely atmosphere and staff are approachable, caring, and sensitive when carrying out care tasks with service users. There is a stable staff team with long standing service in the home. The majority of staff have worked at the home for a long time, which ensures consistency of approach to care. The care staff demonstrated good professional standards in carrying out their duties. The home offers varied and nutritious meals and ‘home style’ cooking, which service users said they always enjoyed. One resident said: “ I love the food here, there is always plenty to eat”. The home helps service users to remain in touch with friends and friends. Trips to places of interest and bus trips are a regular feature of the care provided. Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: There is a major building work going on in the home. The Commission was not advised of the date of commencement of the work, which was in May 2006. The Commission should have been advised of this It was of concern that there was no plan in place to ensure the safety of the service users and those who work in the home while the building work is going on. On the first day of the inspection, it was noticed that there was equipment lying in one of the corridors. This was left unattended and was a significant hazard and safety issue. It was noticed that tablets were being given to service users in the wrong way, again causing a risk to the safety and welfare of service users which were supposed to be administered directly from the monitored dosage system had been dispensed into small containers and laid out on a tray ready to be dispensed to the service users. This practice was in violation of the home’s policy on drug administration and seriously compromises the health and welfare of the service users. The arrangements for the management and administration of medicines in the home were poor. These poor practices do potentially compromise the welfare of the service users. Due to the serious lapses in the drugs administration system, an Immediate Requirement Noticed was issued to the manager to take immediate action to address these issues. Since then an action plan had been received by the Commission from the registered manager stating what actions are being taken to ensure safe administration of medicines in the home. It was noticed during the inspection that bedroom doors were wedged open causing a fire safety risk. This practice must cease and where appropriate suitable devices must be provided to promote safe environment for the service users. Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 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. Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 5. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. There are systems in place for assessing prospective service users needs before admission is agreed. This ensures that the care needs are appropriately identified and resources made available to meet those needs. Prospective service users are encouraged to visit the home, meet with staff and other service users before deciding on whether or not to choose to live there. This provides the opportunity for prospective service users to make informed choice about where to live. EVIDENCE: A copy of the service user guide was found in each of the bedrooms and service users confirmed that they are aware of the document and find it useful. Terms and conditions of residence are provided to all new service users either before or shortly after their arrival in the home. Copies of terms and conditions of residence were found on individual files, which had been appropriately Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 10 signed by service users or their representatives. These provide useful information for all the service users about the facilities in the home and also about their obligations under the terms and conditions of residence. Service users confirmed that before they moved into the home, the manager discussed with them details of the contract and also gave them copies of the service user guide. They all stated that they found the process helpful. A number of service users were spoken with about pre-admission arrangements. They described the arrangements and were happy with the opportunity to visit and meet with staff and other service users before making their decisions about coming to live at Glenholme. They confirmed that they found these visits very helpful in reducing their anxieties about going into care thus making their move into a care home a positive experience. Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users care plans provide details on how to meet the needs of the service. This ensures that staff carry out care tasks in a consistent manner for the benefit of the service users. Medication administrative systems are unsafe and seriously compromise the health and welfare of the service users. Service users are treated with respect and dignity thus promoting their sense of worth and self esteem. EVIDENCE: The service users care plans set out their care needs and action plans for meeting these needs. The plans are regularly reviewed and updated to reflect changing care needs. Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 12 The healthcare needs of the service users are generally met. The home continues to maintain a record of contacts with healthcare professionals, including GPs, psychiatrist, chiropody service, dentist, optician and other healthcare services. District nurses make regular visits to the home to see to individuals who require nursing care. This ensures that the service users rights to proper healthcare are being safeguarded by the home. The service users confirmed that their healthcare needs are met through these arrangements. However, due the building work that is going on in the home, a District Nurse and her patient could not gain access to the service user’s bedroom to do her dressing. The nursing task had to be carried out in another part of the building. The nurse expressed concerns about this and commented that by not carrying out such nursing task in the service user’s room, it exposes other service uses to possible cross infection. Service users confirmed that the staff treat them with respect and dignity. Care practices observed during the inspection confirmed the views held by the service users. This has created a sense of being in control of their lives, which was evident in the way that they acted with the staff. Staff were noted to be taking their lead from service users and in so doing encouraging them to make decisions for themselves. It was noticed that the medicines trolley was left unattended both in the office and in the conservatory for over forty minutes with the keys left in the trolley. Again, this was in violation of the home’s policy on drug administration and seriously compromises the welfare of the service users. On examination of the drugs administration system, it was noticed that the correct procedures were not being followed by the home. The inspector and the manager could not establish who some loose tablets belonged to. Medicines had been recorded on the recording sheet as “carried forward” from the previous month without any reasons for it. There had been hand-written prescriptions on the recording sheet by the staff when this should have been the role of the pharmacist and not the staff at the home. In one case, twenty tablets belonging to a service users could not be accounted for. These poor practices do potentially compromise the welfare of the service users. Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are encouraged and supported to lead active lifestyles based on their preferences and abilities, thus promoting their independence and sense of wellbeing. Service users are offered and receive varied, wholesome, nutritious diet. This contributes to their general health and wellbeing. EVIDENCE: The home has a social activities file, which provides details of all the activities that each service user had been engaged in and commented on how much they enjoyed each activity. The home continues to provide a wide range of activities for service users to choose from. Some service users commented on the art and craft sessions that they have in the home. They confirmed that they find this and other social activities useful and have always enjoyed taking part. Other social activities included tea dance, life band music, shopping trip to local supermarket and bus rides along the seafront. There is photographic evidence of some of these activities in the home thus providing further evidence of the activities organised for the service users. Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 14 Service users continue to compliment the catering staff and the quality of the meals provided in the home. Nutritional assessments have been carried out for those service users who require their diet monitored to ensure they receive appropriate food. The records relating to nutritional intake shows that these are reviewed regularly as part of the overall care plan and changes made to the care plan when necessary. A four-week rotational menu remains is operation in the home. Menus show that the home provides wholesome and nutritious meals for the service users thus promoting good health. The two dining areas are pleasantly furnished and provide spacious and congenial settings for the service users. At lunch time the tables were beautifully set with appropriate cutlery, napkins, condiments and choice of drink. The service users indicated that they find the meal time experiences enjoyable. Service users confirmed that their relatives and friends are able to visit at anytime convenient to them and were very appreciative of this level of flexibility. They also confirmed that the daily routines are organised flexibly to take account of individual likes and dislikes. They cited meal times and bed times as examples. The service users stated that although there are set times for meals, they can have their meals at separate times or in their room if they wish. This allows individuals to make choices about these aspects of their routines. Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home has a clear and easy to understand complaints policy, which is available to the service users and relatives. This provides the opportunity for individuals or relatives to raise concerns and in so doing exercising their rights. Suitable arrangements are in place, which ensure that service users are protected from all forms of abuse and to protect their rights. EVIDENCE: The home has a written complaint procedure, which is regularly reviewed by the company. Summary of the complaint procedure is included in the Service User Guide and the terms and conditions of residence. There is also a “Whistle Blowing” policy in place and copies of these procedures are also posted in the foyer for service users and visitors to see. Some of the service users indicated that they are aware of the procedure and would know how to complain if they had a need to do so. A recent complaint against a member of staff was promptly and appropriately dealt with, thus re-assuring service users that any concerns or complaints would be dealt with and in so doing promote their sense of security and wellbeing. Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 16 The staff training record showed that staff have had training in protection of vulnerable adults. Staff who were interviewed showed awareness of the home’s complaint and whistle blowing policies. They were able to describe the various forms of elder abuse and indicated how such abuses could be prevented in residential care settings. Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 25, 26. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. As a result of major building work in the home, there have been breaches in safety measures while work is going on around the service users. This compromises the safety and wellbeing of the service users. EVIDENCE: The home is close to local shops, other amenities, and to local transport routes. These provide the opportunity for service users to continue to exercise their independence and choice. Heating and lighting in individual bedrooms was adequate at the time of the inspection. The type of heating system installed is of the kind that allows individuals to control the room temperature to suit personal preferences. One service user spoke about the opportunity this offers her in ensuring that she maintains the room temperature that suits her. Individual rooms have good Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 18 ventilation and natural lighting, ensuring a comfortable living space for the service users. The home has written policies and procedures relating to safe handling of hazardous materials for staff to follow. The manager indicated that staff have had training in health and safety, infection control and food hygiene. At the time of the inspection the home was noted to be clean and free from offensive odour, enhancing the self-esteem of the people who live there. The laundry machines have facilities for sluicing and washing foul linen at very high temperature to avoid the spread of infection, thus protecting the service users from harm. The kitchen was clean and all cookers and cooking utensils were clean and well maintained, thus promoting the welfare of the service user. However, the back door to the kitchen is permanently left open while the kitchen is in use. A fly screen to the door must be provided to prevent insects and flies getting into the kitchen. There is major building work going on in the home. This is to improve on the accommodation and to provide a spacious centre sitting room for the service users. At the time of the inspection the workmen were involved in a number of activities both inside and outside of the home. There were unguarded tools lying in one of the corridors, causing a hazard and health and safety issue. There was no written risk management plan in place to safeguard the welfare of the service users during this period of work being carried out. The work also limited the access that the service users could have to their bedrooms during the working day. A number of service users were unhappy with the “temporary” sitting arrangements to allow work to the carried out. Three service users described the arrangements as “being packed like sardines”. Also because of the lack of adequate space, the service users who relied on Zimmer frames for mobility were unable to have immediate access to the walking frames as these had to be stored in a separate area because of the lack of space in the sitting room. This limited people’s ability to move around independently without staff assistance. The fire safety precautions in the home were compromised by bedroom doors being wedged-open with items such as slippers, chairs and wooden wedges. There was no risk management plan to indicate how the situation could be managed in the event of a fire. Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The home provides sufficient staffing which meet the needs of the service users. Suitable arrangements for staff training and supervision are in place, which ensures that staff are reasonably equipped to provide a good quality service that benefits the service users. However, the issues relating to the administrations of medicines in the home indicates that the training received does not always translate into good practice. EVIDENCE: Past staff rotas indicate that the home consistently maintains staffing levels which meet the needs of service users. The rotas also show that there had been times when extra staffing were provided in order to escort service users to attend hospital appointments. Service users confirmed that there is always sufficient staff on duty to met their care needs. However, two service users commented that the building work in the home had reduced the staff response time to answering buzzers. This was observed by the inspector when it took a considerably longer time for staff to assist a service user who did not have her walking frame readily at hand. This has increased service users’ sense of frustration and reduces the opportunity for carrying out independent activities. Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 20 The owner of the service places much emphasis on staff training. There has been training in moving and handling, first aid, protection of vulnerable adults, health and safety, fire safety, food hygiene and nutrition. The staff who were interviewed confirmed the training they had received and felt that this had equipped them to do their jobs better. Service users commented that the staff are properly trained and therefore are able to provide them with good quality care. There is a commitment by the provider to train all care staff to NVQ Level 2 or above. Staff who have already acquired this training indicated that NVQ training had equipped them to provide better care for the service users. They also indicated that the training had boosted their confidence in carrying out their care practices for the benefit of the service users. The home’s recruitment procedures ensure protection of service users from possible abuse by applicants who would otherwise be deemed as unsuitable to work with vulnerable people. Staff records showed that the manager had consistently adhered to the policy on recruitment. Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The management approach in the home is geared towards involving service users in some aspects of the running of the home and also in the way they are looked after. This has created a sense of empowerment with the service users and has enhanced their self-esteem. The system for managing the service users monies is good and protects them from financial abuse. The detailed organisational policies and procedures on health safety and welfare are not always adhered to by the staff, which compromises the safety and welfare of the service users. Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 22 EVIDENCE: The manager has long experience of working in a care home and has had extensive management experience in care settings. She has acquired the registered managers award. The staff and service users described the manager as efficient, and indicated that she runs the service for the benefit of the service users and has positive relations with the staff. Similar comments were also made by some of the service users and relatives. However, this inspection highlighted some failings in the drugs administration system and the manager’s responsibility to ensure safe practices in the home for the safety and wellbeing of the service users. There are detailed corporate Health and Safety policies in the home. These serve as training manual and reference documents for staff to use. These cover policy areas such as fire prevention and Care of Substances Hazardous to Health (COSHH). These policies ensured that health and safety of the service users and the staff are maintained at all times. However, on this inspection health and safety arrangements in relation to the major building work in the home had not been robust enough to safeguard the safety and welfare of the service users as noted in this report under the section, Environment. Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 2 X X X 3 3 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 1 Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP8 Regulation 12(1)(b) Requirement Adequate precautions must be taken against practices that would expose other service users to the risk of cross infection. The registered person must provide adequate training and supervision of senior staff to ensure safe and secure practices relating to the administration of medicines. The registered person must ensure that while building work is going on, suitable arrangements are made to ensure reasonable access to service users’ bedrooms during the day. Fly screens must be provided to the back door of the kitchen to control the inflow of flies and insects into the kitchen. The registered person must ensure that the training received by staff is reflected in their practice to ensure safe environment for the service users. These include fire safety and health and safety training. DS0000015709.V294390.R01.S.doc Timescale for action 24/10/06 2 OP9 13(2) 01/12/06 3 OP19 12(1)(a) 27/10/06 4 OP26 13(1)(3) 01/01/07 5 OP30 13(4)(c) 27/10/06 Glenholme Residential Care Home Version 5.1 Page 25 6 OP36 18(1)(c) 7 OP38 12(1)(a) The senior staff must receive 27/10/06 supervision and regular monitoring of their practice to ensure safe practices in the home. The registered person must 27/10/06 ensure that necessary health and safety measures are in place to promote the safety and welfare of the service users. 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 Refer to Standard OP20 OP33 Good Practice Recommendations Temporary arrangements should be made to ensure that service users have sufficient sitting space while the building work goes on. The home should develop a system for consulting and updating the service users on the building work that is going on around them. Glenholme Residential Care Home DS0000015709.V294390.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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