Inspection on 11/12/07 for Glenkealey Residential Home

This inspection was carried out on 11th December 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Glenkealey Residential Home 17/02/09

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

CARE HOMES FOR OLDER PEOPLE Glenkealey Residential Home Upper Hermosa Road Teignmouth Devon TQ14 9JW Lead Inspector Judy Hill Unannounced Inspection 10:30 11th & 12 December 2007 th 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 Glenkealey Residential Home DS0000070343.V351174.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 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. Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glenkealey Residential Home Address Upper Hermosa Road Teignmouth Devon TQ14 9JW 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) 01626 774214 Saffron Care Ltd Post Vacant Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Old age, not falling within any other category (Code OP) The maximum number of service users who can be accommodated is 15. First Inspection Date of last inspection Brief Description of the Service: Glenkealey Residential Home is registered to provide accommodation and care for a maximum of fifteen people who are elderly. The current owners, Saffron Care Limited, brought the business as a going concern were registered in July 2007. This was their first inspection. The home is situated in a residential area of Teignmouth, it is on a bus route and is less than a mile from the town centre, railway station and beach. The service providers are in the process of completing a Statement of Purpose and a Service Users’ Guide, which will provide information about the service for prospective service users and their representatives. The current fees range from £314 to £415 a week. Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was carried out by one inspector on 11th & 12th December 2007. It is the first inspection of the service since the new owners purchased the business in July 2007. Most of the information contained in this report was gained in conversation with the Simon and Jo Spurle (Directors of Saffron Care Limited), the staff and the people who live at Glenkealey. Additional information was gained from an Annual Quality Assurance Assessment, completed by Simon Spurle, a Statement of Purpose and Service Users Guide. A tour was made of the premises and various records, including individual needs assessments and care plans and staff recruitment and training records. What the service does well: The revised Service Users’ Guides, which contain a Statement of Purpose and Contract, provide good information about the service provided, although some small amendments are needed to ensure that all of the information provided is accurate. The people who use the service are encouraged to continue to make choices in their daily lives. The people who use the service enjoy their meals and are offered choices and/or alternatives to the set meals. The people who use the service may invite their friends and families to visit them at any time. The people who use the service are invited to attend regular meetings to discuss the day-to-day running of their home. The people who use the service are given the opportunity to engage in inhouse activities and occasional group outings if they wish to do so Complaints will be taken seriously and dealt with appropriately and policies, procedures and staff training are provided to protect the people who use the service from the threat of abuse. The home is clean and well presented. The communal rooms are spacious and homely. Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 6 The new owners are committed to improving the training of staff and supporting and encouraging them to gain National Vocational Qualifications. 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. Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 7 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 Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Quality in this outcome area is adequate. People considering using this service and their representatives have access to most of the information they need, although initial pre-admission needs assessments do need to be more comprehensive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of this inspection the service providers were in the process of reviewing their Service Users’ Guide. A copy of the revised Service Users’ Guide, which contains a Statement of Purpose and contract, has since been forwarded to the Commission. This document contain a small number of inaccuracies which need to be dealt to ensure that the people who use the service and their representatives have access to accurate information about the service provided. Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 9 Since taking over the running of the home in July 2007 only one vacancy had arisen so only one new person had been admitted. The admission process had included a visit by Simon Spurle (Co-director) to the prospective service user in hospital to carry out a needs assessment. This was seen during the inspection and although basic information had been collected about the persons needs, the service providers do need to develop their assessment practices in line with the guidance provided in the National Minimum Standards to ensure that all of the areas of need and/or potential need are covered. Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. Care planning, risk assessments and reviews do not currently provide sufficient information about the individual needs of the people who use the service but these practices are currently being reviewed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of this inspection individual care plans were in the process of being re-written for all of the people who use the service. The areas of the care plans that had been finished were seen to be clearly presented and to focus on what people could do for themselves as well as the things that they need help with and this is recognised as an example of good practice. Further work is however needed to ensure that all areas of need are covered and that individual risk assessments and risk management plans are included as and when necessary. Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 11 None of the care plans seen had been signed by the people using the service or, where necessary, their representatives. Conversations with the care staff identified that they do not always refer to the care plans. As the purpose of care planning, including risk assessment, is to provide guidance to the staff on how to meet the individually assessment needs of the people living at the home, it is suggested that the importance of referring to these documents is included in a staff meeting and/or staff training. A system for regularly reviewing care plans is in place but no evidence was seen to indicate that reviews are taking place. The Service Users’ Guide states that reviews will be carried out annually with the people who use the service. However, the care plans should be reviewed at least once a month and updated to reflect changing needs and current objectives for health and personal care. Glenkealey does not have sufficient staff to accommodate people with a high level of dependency and the layout of the building limits the number of people who can be accommodated who have mobility problems. Several of the people who use the service are currently accommodated in bedrooms that they cannot access without staff assistance and consideration must be given to transferring them to more suitable bedrooms as and when they become available. Conversations with the management and staff identified that since taking over the running of the home Saffron Care Limited had done a lot of work to bring the staffs training up to date and to fill gaps in their training. Further training was planned and it is suggested that in addition to the training needs identified by the service providers, training is provided in Dementia Care, Continence Control and Deaf Awareness. The mental and physical well-being of the people who use the service is being monitored and evidence was seen to demonstrate that referrals are being made to the primary health care services as and when necessary. Conversation with the service providers identified that they are aware of their limitations with regard to providing a suitable service for people with a very high level of dependency. The medication is currently being kept in a locked cupboard in the office but consideration is being given to providing a medication trolley, which could be stored in any one of several lockable cupboards. A facility is provided for the storage of controlled drugs. A Pharmacy controlled system is used to order, administer and dispose of medicines. The medication administration records were seen to be signed up to date and/or the coding system used if medicines had not been administered. The staff administering the medication had received training to do so safely. Information sheets are kept with the Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 12 medication administration sheets to identify what each item of medication is used for. This is recognised as good practice, but it is suggested that possible side effects that the staff need to look out for are included with this information. Throughout the inspection the management and staff were observed to be treating the people who use the service with dignity and respect and several of the people who were spoken with made very positive comments about the kindness of the management and staff. Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. The people who use the service are encouraged to continue to make decisions about their daily lives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The people who use the service spend most mornings in their rooms and those spoken with confirmed that it was their choice to do so. Some said that they enjoyed the companionship of others in the afternoons and choose to sit in the conservatory or the lounge reading and/or talking. The mobile library service visits the home on a regular basis and so there is no shortage of books to read. Since the current owners took over the home in July 2007 three group outings have been arranged. One to Powderham Castle, one to a donkey sanctuary and one to Exeter Cathedral. One of the people who use the service said that she had been on two of these outings and that everyone had enjoyed them very much. Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 14 Some of the people who use the service do not need to be escorted when they go out but will be offered a lift to and from the town centre. Others are regularly taken out by their families and friends. One of the care workers said that she does sometimes take less mobile people out for a short walk or for a stroll in the garden. One of the people who use the service said that the residents meet up for a drink before lunch on Sundays and another said that she attended residents meetings and weekly service. One of the care workers said that she tries to interest the people who use the service in quizzes and Bingo most afternoons but that these are often declined. The management said that visitors are welcome at any time and that the people who use the service are welcome to invite their families and friends for a meal at no extra charge. Most of the people who use the service choose to eat their lunch in the dining room and this was observed to be a social occasion. One of the people spoken with said that choices were offered for breakfast and tea but not for the set meal at lunchtime, although alternatives would be provided if anyone disliked the set meal. Several of the people spoken with said that the quality of the food provided was very good and the meals that were seen being prepared and/or served on both days of the site visit were well cooked and well balanced. A choice of hot drinks are offered at 10am, 3pm and at bed-time but the people who use the service can request a hot drink and snack at any time. Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. Complaints will be dealt with appropriately and the people who use the service are protected from the threat of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is displayed in the entrance hall. A record book is kept in the entrance hall for the people who use the service and visitors to the home to record complaints, concerns or compliments. No complaints were recorded and the Commission has not received any concerns, complaints or allegations about this service. The Annual Quality Assurance Assessment completed by the registered providers for the Commission prior to the inspection identified that policies and procedures are in place to protect the people who use the service from the threat of abuse. The staff spoken with said that all of the homes policies and procedures are kept in the dining room and that they have been asked to read these and sign that they have read them and understood their contents. Records showed that most of the staff had received training on the Protection of Vulnerable Adults (Safeguarding). Four of the staff still need to attend this training course and arrangements have been made for them to do so. Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21 & 26 Quality in this outcome area is adequate. The home is clean, homely and well presented but some of the bedrooms are difficult for people with poor mobility to access without assistance. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The original building was arranged on two floors. A passenger lift has been installed to enable people with poor mobility to gain easy access to the first floor. However, the home also has bedrooms on three other levels and access to these is facilitated by stairs, most of which have been fitted with stair lifts. It was observed that some of the rooms would be difficult for a person with poor mobility to access without assistance and the management and staff confirmed this. The staff stated that they could not assist one of the people who use the service from their bedroom, so she could not utilise the communal Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 17 areas at all. Although both the people who use the service and the management stated that the staff respond quickly to call bells, which are accessible to all of the people who use the service in their bedrooms, this situation is not ideal and consideration must be given to offering people rooms that they can access independently as and when they become available. The Service Users’ Guide states that all of Glenkealey’s bedrooms are spacious, however, a physical inspection of the homes showed that this is not the case and that the sizes of the rooms vary considerably (see Requirement 1). Most of the bedrooms have en-suite toilet facilities and some also have en-suite bathing facilities. All of the bedrooms that were seen were found to be clean and well decorated. The communal bathrooms, shower room and toilets were seen to be adequate for the needs of the home and suitable mobility equipment, including hoists, had been provided to enable the staff and service users to use the facilities safely. It was observed that not all of the communal facilities were provided with disposable towels, liquid soap and toilet paper and more frequent checks are needed to ensure that these have not run out. The communal lounge was seen to be comfortably furnished and homely, as were the dining room and conservatory. The kitchen, which is adequate for the needs of the home, is at the back of the house. The laundry facilities are sited in an extension to the back of the house and are accessed through the kitchen and passed a food storage area. The service providers are aware this is not satisfactory and should provide doors between the laundry, kitchen and food storage area and instruct the staff to transfer soiled washing via an outside route. Three additional rooms are currently being converted from a former flat within the home and these will need to be inspected by the Fire Safety Service and the Commission before they are used to accommodate people. A further extension is planned which, if approved, will provide additional ground and first floor rooms. Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. Most of the staff are very experienced and the provision of training under the new management has been good. Care does, however need to be taken to ensuring that sufficient staff are employed at all times to meet the assessed needs of the people who use the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information on staffing levels was taken from the rota for 9th to 15th December 2007, which was provided to the Commission on request. From the information provided the home employs one care assistant on waking night duty from 8pm to 8am and another care assistant to provide sleeping in cover. The registered provider said that one of the service users regularly needs the assistance of two members of staff during the night and that the waking night carer wakes the person sleeping in the provide this but this was not confirmed by a waking night worker, who said that she was seldom disturbed. The staff rota indicates that there are usually three care staff on duty from 8am to 2pm am two from 2pm to 8pm. Cleaning staff are employed from Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 19 Monday to Friday and the care staff take on cleaning duties at the weekends. Two cooks are employed to cover lunches seven days a week. Although most of the people who currently use the service do not require a high level of staff support, some do and regular checks must be made to ensure that the care staffing levels are sufficient to meet the assessed needs of the people who use the service. Consideration should also be given to reducing the lengths of some of the shifts, as twelve-hour shifts are not recommended. This is because the staff may become overtired and not able to function to their full capacity and because cover may be difficult to arrange if they phone in sick. Since taking over the business in July the new owners have been very proactive in encouraging the care staff to take National Vocational Qualifications. One member of staff spoken with said that she had completed her NVQ at Level 2 in Care and was not starting Level 3. A further two staff had completed their NVQ at Level 2 and five were working towards gaining this qualification. The provision of training under the new management has also been good. Although some gaps remain, the staff have been building up their training portfolios and additional training needs had been identified and courses were being planned. The home benefits from having a low staff turnover and many of the staff have worked at the home for several years. Since the current owners took over the home in July 2007 they have employed a member of staff who they intend to register as manager, one care worker and a care worker/cook, who has since left. Records of the recruitment practices used were inspected and found to be safe. Records of regular staff meetings and individual formal supervision are being kept. Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. Although the service is operating under the guidance of the responsible individual and a prospective manager, no application has been received to register a manager. This judgement has been made using available evidence including a visit to this service. EVIDENCE: When the registered service providers took over the home as a going concern in July 2007 one of the former owners was registered as manager. She terminated her employment in August 2007. A prospective manager has been appointed but no application has been received to register her as manager. Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 21 A quality assurance system is in the process of being developed and copies of questionnaires that will be used to gain feedback from the people who use the service and professional people who have contact with them were seen. It was suggested that an additional questionnaire is written to gain feedback from the friends and relatives of the people who use the service. Both staff and residents meetings are held to enable information to be shared and views to be sought from both groups about the running of the home. Minutes of staff meetings were seen and feedback from people who use the service confirmed that they are able to raise issues within these meetings if they wish to do so. The home does not provide assistance to help the people who use the service manage their financial affairs and this is recognised as good practice. People who need help receive it from friends, family or a legal representative. The home does, however hold small amounts of personal spending money for four of the service users for safekeeping purposes and signed records of income and outgoings were seen. A lockable facility or piece of furniture must be provided to each of the people who use the service to enable them to store their own valuables safely if they so wish. The Annual Quality Assurance Assessment (AQAA) carried out prior to the inspection by one of the company directors identifies that all of the required policies and procedures are in place and that work is in progress to update all of these documents. The policies and procedures manual is kept in the dining room and available for staff, the people who use the service and their representatives to read at any time. The staff have been asked to sign to state when they have read and understood each document, which is recognised as an example of good practice. The AQAA also identifies that the servicing of appliances and equipment is up to date. Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 22 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 3 X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 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 2 X 2 X X X X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 2 X 2 X X 3 Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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 OP1 Regulation 4, 5 & Schedule 1 14 Requirement The registered providers must revise their Service Users’ Guide to ensure that all of the information provided is accurate. The registered providers must ensure that individual preadmission needs assessments cover the full range of needs itemised in NMS 3 in order to enable the service to provide written confirmation to potential service users and their carers that the home will be able to meet the persons individual needs. The registered providers must ensure that individual care plans cover the health, personal and social care needs of the people who use the service and that they include risk assessments and guidance on how to manage identified risks. Care plans should be reviewed monthly and the care staff should be instructed to refer to them for guidance on how to Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 24 Timescale for action 12/02/08 2. OP3 12/02/08 3. OP7 12, 13 & 15 12/02/08 meet the individual needs of the people who use the service. 4. OP8 13 The registered providers must ensure that the people who use the service are able to access and egress their bedrooms and the communal rooms safely. People who cannot currently do so should be moved to more accessible rooms as and when they become vacant. The registered persons must ensure that the risk of cross infection is minimised by instructing the staff no to carry soiled laundry through the kitchen and by creating a fixed barrier between the laundry and the kitchen and food storage areas. The registered persons must review the staffing levels to ensure that there are sufficient care staff on duty at all times to meet the assessed needs of the people who use the service. The registered providers must submit an application to register a manager. 12/12/08 5. OP26 13 12/01/08 6. OP27 18 12/01/08 7. OP31 8 12/01/08 8. OP33 24 The registered provider must use 12/03/08 a quality monitoring/quality assurance programme to gain feedback from the people who use the service and their representatives. Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 25 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 OP8 Good Practice Recommendations Consideration should be given to providing staff training should be provided on Dementia Care, Continence Control and Deaf Awareness. Information about possible side effects should be included on information sheets itemising medicines used and the conditions they are used to treat. People with poor mobility should be transferred to bedrooms which are accessible to them without assistance as and when they become vacant. Regular checks should be carried out to ensure that communal toilets are always equipped with disposable towels, liquid soap and toilet paper. Consideration should be given to developing a system of staff deployment so that twelve-hour care shifts are not included in the rotas. This is because the staff could become over tired and unable to fulfil their role to the best of their ability and because shifts could be difficult to cover in the event of staff absences. A lockable piece of furniture should be provided to each of the people who use the service to enable them to store their private or valuable things in. 2. OP9 3. OP19 4. OP21 5. OP27 6. OP35 Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Glenkealey Residential Home DS0000070343.V351174.R01.S.doc Version 5.2 Page 27 - 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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