Inspection on 15/02/07 for Glenroyd House

This inspection was carried out on 15th February 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 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 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glenroyd House 22/01/08

Glenroyd House 13/07/06

Glenroyd House 25/03/06

Glenroyd House 10/05/05

Glenroyd House 14/03/05

Glenroyd House 16/09/04

Glenroyd House 10/02/04

Glenroyd House 21/05/03

Glenroyd House 17/12/02

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

CARE HOME ADULTS 18-65 Glenroyd House Glenroyd House 26 High Road North Laindon Basildon Essex SS15 4DP Lead Inspector Michelle Love Unannounced Inspection 15 February 2007 08:30 th Glenroyd House DS0000032135.V324576.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 Glenroyd House DS0000032135.V324576.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. Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glenroyd House Address 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) Glenroyd House 26 High Road North Laindon Basildon Essex SS15 4DP 01268 541333 01268 541333 cushti@blueyonder.co.uk Glenroyd House Ltd Manager post vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th July 2006 Brief Description of the Service: Glenroyd House provides accommodation and personal care for eight adults over the age of eighteen with learning disabilities. The home is situated in a residential area, close to local amenities. Each resident is provided with their own single room within this two storey detached house. There is a large garden to the rear of the property, and a parking area for vehicles at the front. The home has its own mini bus which takes the residents to and from their community based activities and leisure pursuits. Residents also have the opportunity to attend college, and pursue hobbies if they so wish. The range of fees charged to individual residents ranges from £686.24 to £1191.70 per week. Additional charges incurred to residents, includes chiropody, personal toiletries, magazines, meals at fast food outlets and pursuing personal hobbies and interests. This information was not included within the homes pre inspection questionnaire, but obtained on the day of the site visit. The homes Statement of Purpose and Service Users Guide, is not readily accessible/displayed. A copy of both documents can be obtained from the office. Inspection reports are located within the office. Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced site visit and was conducted by Michelle Love, Regulation Inspector over a total period of 9.5 hours. As part of the site visit process, a number of records pertaining to care planning/associated documentation/healthcare records were examined. Additionally staff employment files, training records, complaint records, tour of the premises and the homes medication records/storage facilities were also inspected. On the day of the site visit, this was conducted with both the acting manager and the deputy manager and included discussions with both care staff and residents. A number of surveys were forwarded to resident’s representatives to seek their views about the service provided at Glenroyd House and these have been commented upon throughout the main text of the report. What the service does well: What has improved since the last inspection? The homes care planning processes have been reviewed and updated with much out of date information taken out. There is clear evidence to indicate that resident’s individual needs are much better met by care staff. The homes activity programme for residents is much more realistic and focussed on individual residents wishes and personal preferences. Staff were more confident in their care delivery and as a staff team were observed to be working together as `a team` much more closely. The acting manager appeared better organised and there was evidence that both she and the deputy manager had worked hard to address previous identified shortfalls and concerns raised. No Protection of Vulnerable Adults issues or major complaints have been highlighted. Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 6 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. Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a Statement of Purpose and Service Users Guide which sets out the aims and objectives of the home, and enables prospective residents and their representatives to have the information so as to make an informed choice as to whether or not Glenroyd House is a suitable home. The home has a formal system for assessing prospective resident’s needs. EVIDENCE: Since the last inspection to the home the acting manager has devised a new Statement of Purpose and Service Users Guide. The Statement of Purpose has been devised in the written form and the Service Users Guide has been formulated in both a written and pictorial format using simple language. A copy of both documents were photocopied and provided to the inspector on the day of the site visit but were not inspected until after the site visit. On inspection of the Statement of Purpose, not all elements were clear and in places information recorded were seen to be undecipherable. Some elements of the Statement of Purpose need to be amended and reviewed i.e. the document does not include full details of the acting manager’s experience or the qualifications/experience of the registered provider. Additionally the document relating to the homes complaint procedures needs to be amended to reflect that the Commission for Social Care Inspection no Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 9 longer investigates complaints. The Service Users Guide for individual residents must include information relating to fees payable for services provided, arrangements for paying and additional costs incurred and whether or not there are different charges for people who have all or part of their care funded by a local authority or primary care trust. The home has a good process for assessing the needs of prospective residents. A blank copy of the registered provider’s pre admission assessment was inspected and this was noted to be comprehensive and detailed. The home has a Service User Admission Policy. Since the last inspection no new residents have been admitted to the care home. Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A plan of care is written for all residents and contains information relating to resident’s assessed needs. EVIDENCE: On the day of the site visit two individual plans of care were inspected. Both care plans were observed to be detailed, comprehensive and person centred. Since the last inspection all care files have been updated, reviewed and streamlined with much historical documentation archived. This has meant that the care plans for individual resident’s are now a working document and include information pertaining to all areas of the person’s life i.e. health care, daily living skills, community presence, emotional and psychological care needs etc. The acting manager was advised that she should consider devising day and night routines. It was positive to note that information had been sought in relation to resident’s immediate goals/aspirations and achievements i.e. for one resident is was very clear that they were successfully with support from staff overcoming a number of problem areas i.e. losing weight and accessing Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 11 the community. In addition to the above, restrictions on choice/freedom were clearly documented, including the rationale i.e. to be accompanied whilst accessing the community, dietary requirements etc. Each care plan was noted to include comprehensive risk assessments identifying specific areas of risk, action to be taken to minimise the identified risk and guidelines for staff. Daily care records were seen to be much improved. The acting manager was advised that daily care records are a good source of evidence to show that care is being provided , as detailed in the care plan. Daily care records when well written, help ensure a consistent approach and good quality of care for residents. Detailed daily records assist the manager to audit the care being provided to residents, and ensure that staff are following the guidelines in the care plans. It is in the homes interests to be able to show what they have done, along with providing the evidence on which to base the monthly review and to record that they are following the assessment of needs. Specific guidelines pertaining to managing individual’s behaviours were readily available. There was clear evidence to indicate that care plans had been reviewed and updated regularly to reflect resident’s changed needs and that care plans had been devised with the resident i.e. care plans were signed where possible by the resident and one resident confirmed that they had been included in the process. Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A programme of activities both formal and informal are available for residents and are undertaken both `in house` and within the local community. The dietary needs for residents who reside at the care home are much improved. EVIDENCE: The homes pre inspection questionnaire details that residents attend a variety of formal and informal activities i.e. adult education classes, day-centres, ten pin bowling, cinema, shopping (both for the house and for personal items), Wednesday Club, swimming and the theatre. Each care plan recorded an individual timetable of activities for residents. The acting manager was advised that specific information detailing resident’s likes, dislikes, hobbies and interests must be better recorded. Two residents spoken with confirmed that they now have more opportunity to participate within a range of leisure and social activities and this was seen as positive. Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 13 The home was observed to have a festivities/events folder and this detailed over the past 2-3 months, residents have attended Dick Whittingdon, Wizard of Oz and Peter Pan on Ice. The acting manager advised that residents are scheduled to see Joseph and the Technicolour Dream Coat in March 2007. The acting manager advised that in addition to the above she has made a request to the registered provider for the purchase of inflatable goal posts and football, croquet set, badminton set, pottery wheel, arts and craft materials etc. It was disappointing to note that the request was forwarded to the organisations head office on 18.1.07 and the only response received on 6.2.07 was “I’m looking in to this”. The acting manager also advised that a request to purchase a gazebo for the garden was made in December 2006. At the time of the inspection no response had been received from the registered provider. Since the last inspection staff and residents have devised a `Glenroyd Gossip Newsletter`, and to date four copies have been produced. Food provided to residents is of a satisfactory quality, well presented and menus are varied. The inspector was advised that two residents require a specialist dietary intake i.e. one resident requires a low fat diet and the other resident is on dialysis. Both care plans included information pertaining to the above issues. Concerns raised at the last inspection relating to individual resident’s dietary needs have reduced significantly and there was clear evidence to indicate that one resident’s needs are now being addressed to meet their needs. The acting manager advised that the homes food budget is £121.00 per week, however the home often go over budget as a result of providing for two specialist diets. Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents have access to a range of healthcare services and professionals. Some minor issues relating to the homes medication procedures and recording keeping were evident. EVIDENCE: On inspection of individual resident’s care files, there was evidence to indicate that people have access to a range of healthcare services and professionals i.e. GP, Consultant Psychiatry, Community Nurse, Chiropody etc. Records indicate that health care needs of resident’s are monitored and appropriate action and interventions taken by care staff. The homes medication was observed to be stored safely and appropriately. On inspection of Medication Administration Records (MAR) a few omissions of staff signatures/initials were observed, whereby staff had omitted to sign the MAR sheet to indicate that medication had been administered to and received by residents. The acting manager was advised that the staff list of those staff deemed competent to administer medication to residents needs to be reviewed and updated to reflect those people who have left the homes employment. Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 15 The home was noted to have a medication policy and procedure (including a homely remedy medication list) and a copy of the Royal Pharmaceutical Guidelines for the Safe Administration of Medication. Additionally all residents were noted to have a medication profile/photograph on file. Following discussion with both the acting and deputy manager, the inspector was advised that 8x staff commenced medication training on 14.2.07. Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure, which in general terms meets the National Minimum Standards and Regulations, however minor alterations need to be made. Some staff are trained in relation to protection of vulnerable adults/challenging behaviour. EVIDENCE: On inspection of the homes pre inspection questionnaire and following discussion with the acting manager, the home has received 2x complaints since the last inspection. The home has a complaints procedure, however this needs to be updated to reflect that the Commission no longer has any statutory responsibility to investigate complaints. Any complaints received at the Commission will be referred back to the registered provider or to the local authority if they are contractually involved. As part of the inspection process inspectors will examine how the registered provider has dealt with issues and as to whether regulations are being met. On inspection of complaint records, no information detailing the specific nature, investigation, action taken and outcome for one complaint was recorded. The acting manager advised the inspector that a multi-disciplinary meeting was undertaken with the resident’s placing authority, representatives from health professionals, the acting/deputy managers, the resident and their parents. The acting manager was advised that the lack of recorded information was unsatisfactory and needs to reviewed for the future. Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 17 On the day of the inspection two newly appointed members of staff were observed to receive training relating to challenging behaviour. The homes training matrix submitted on the day of the site visit indicated that only one other member of staff completed this training in October 2006. Records also indicate that three members of staff have not undertaken Protection of Vulnerable Adults Training. The above training need must be completed so that all staff working at the home are appropriately trained. Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely, comfortable and safe environment. EVIDENCE: Of those resident’s bedrooms randomly inspected, all were seen to be personalised and individualised. All residents have a single bedroom with ensuite facilities. On the day of the site visit the home was observed to be clean, tidy and odour free. No health and safety issues were highlighted. Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 19 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 and 36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Staffing levels are appropriate to meet resident’s needs. The homes recruitment practices and procedures, were seen to be much improved however some gaps still remain which do not ultimately protect residents. The importance of training is recognised despite some gaps. Formal staff supervision remains not in line with National Minimum Standards or Statutory Requirements. EVIDENCE: On inspection of 4 weeks staff rosters it was noted that appropriate staffing levels of 3x staff between 07.30 a.m. to 22.30 p.m. and at night 1x waking staff and 1x sleep in person had been undertaken on all but one occasion i.e. the staff roster for 12.2.07 (a.m.) was unclear and evidenced only 2x staff on duty. The rosters evidence as highlighted previously that some staff are working excessive hours i.e. for week commencing 5.2.07 the roster evidenced that the deputy manager worked a total of 74 hours (inclusive of 2x sleeping in duties). Additionally in the same week one member of staff worked a total of 83 hours (inclusive of 3x sleeping in duties). The rosters also detail that some staff are consistently working long days/double shifts totalling 16 hours. The acting manager was advised that this is poor practice and the competence of Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 20 staff to perform their duties must be monitored continually. The full names of all staff working at the care home must be recorded on the staff roster. It is positive to note that there has been a vast reduction in the number of shifts where agency staff are utilised. On inspection of one staff recruitment file it was evident that the person has status as a student and can only work up to 20 hours during term time. The staff rosters indicated that for week commencing 29.1.07 they worked a total of 56 hours and for week of the 5.2.07 they completed 57.5 hours (inclusive of 1x sleeping in duty). On inspection of six staff recruitment files, recruitment procedures were observed to be much improved, however gaps in record keeping were noted i.e. no photographs available within any of the files inspected, in some cases references received after the applicant had commenced employment and no second reference for two applicants. The training matrix submitted with the pre inspection questionnaire was noted to not be the most up to date. A new copy of the training schedule for 20062007 was handed to the inspector on the day of the site visit. Since the last key inspection 6x staff had attained training relating to health and safety and fire safety in October 06, 7x staff attained training relating to food hygiene, first aid, manual handling and infection control in October 06, 8x staff had undertaken training pertaining to protection of vulnerable adults and 6x staff had received training relating to epilepsy/rectal diazepam between 2003 and 2006. The acting manager was advised that in relation to the latter confirmation must be sought by the training provider that staff are competent to undertake this task, that the resident concerned has given their consent for this procedure to be carried out, that staff are happy and consenting to undertake the administration of rectal diazepam and that there are clear procedures, guidelines and risk assessments recorded. It remains of concern that very little specialist training has been provided to support staff for those needs associated with adults who have a learning disability/specialist areas i.e. autism, total communication, learning disabilities etc. It was concerning to note that 2x staff newly recruited had not received any training other than for medication. The training matrix indicated that 1x member of staff has completed NVQ Level 2 and 1x staff member has commenced training in February 07. Additionally 2x staff have achieved NVQ Level 3 and 1x staff member has commenced this training in February 07. All newly appointed staff were noted to have received an induction. The supervision schedule for staff indicated that out of 7x members of staff, 5x staff had received a formal staff supervision in January 07. Additionally it was evident that some staff had received 1 or 2 supervisions prior. The acting manager was advised that this remains insufficient and not in line with National Minimum Standards or requirements. Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 21 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 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The acting manager has a fair understanding of the National Minimum Standards and Care Homes Regulations. EVIDENCE: At the time of the site visit the acting manager had been officially in post for approximately 6-7 months. Although there was evidence to indicate that many areas highlighted at the previous inspection were being addressed, the majority of the work undertaken had been completed by the deputy manager and not the acting manager. Following discussion with the deputy manager it was clearly evident that he had a very good understanding of the National Minimum Standards/Care Homes Regulations and demonstrated a sound knowledge of good practice/care procedures. It was evident throughout the inspection that the deputy manager had the respect of other member’s of staff Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 22 working at the care home and that resident’s responded well to him and liked him. The acting manager advised the inspector that the registered provider had mislaid her completed application to be formally registered with the Commission. The acting manager was advised that a new application would need to be completed and submitted as a matter of urgency. Since the inspection the acting manager has been dismissed for gross misconduct and as a result of this the deputy manager has been appointed as the acting manager. The homes Operations Manager has since written to the Commission advising that all efforts by the registered provider will be made to support the newly appointed acting manager in their role and to undertake the Registered Manager’s Award. The Commission supports the registered provider’s decision to appoint the deputy manager to this new role and feels that with support and guidance he will be competent to undertake the running of the home satisfactorily. Following the site visit a number of surveys for relatives, advocates and other health professionals were forwarded to seek their views about the service provided at Glenroyd House. One survey was very complimentary regarding the deputy manager and stated “since the introduction of the deputy manager any information we have required has been excellent”. Another completed survey was very complimentary about the management of the home and the care provided to their member of family e.g. “Since the arrival of the new manager, the level of care has been noticeably greater-more personalised and I believe it has given the staff team confidence and support that they had lacked. This needs to continue where possible”. Currently the homes policies and procedures are being updated and rewritten by the registered provider’s Operation’s Managers. On the day of the site visit the acting manager advised that she would forward the homes quality assurance records to the Commission evidencing that residents, their representatives and others view about the service provided at Glenroyd House had been sought. To date no records have been received or evidenced. A random sample of records as required by regulation were inspected and all were deemed satisfactory. Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 23 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 2 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 X 1 X X 3 X Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 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 YA1 Regulation 4 and 5 Requirement Timescale for action 01/06/07 2. YA8 12(2) 3. YA20 13(2) 4. YA22 22(3) The registered provider must ensure that the Statement of Purpose and Service Users Guide is reviewed and updated. The registered provider must 14/05/07 ensure that individual residents are consulted and make choices pertaining to their health and welfare. The registered provider must 07/05/07 ensure that appropriate arrangements are made for the safe recording and administration of medication. This refers specifically to omissions on the MAR. The registered provider must 07/05/07 ensure that any complaints received into the home are fully investigated and that records relating to the issue, investigation and action taken are readily available. Previous timescale of 14.8.06 not met. The registered provider must ensure that appropriate arrangements are made for staff to receive training DS0000032135.V324576.R01.S.doc 5. YA23 13(6) 01/09/07 Glenroyd House Version 5.2 Page 25 pertaining to challenging behaviour and POVA. Previous timescale of 1.11.06 not met. 18(1)(a) The registered provider must 07/05/07 ensure that staff are competent to undertake their role. This refers specifically to some staff working excessive hours. 17(2), Sch 4 The registered provider must 07/05/07 (7) ensure that the full names of all staff are detailed on the staff roster. 17(2),19(1), The registered provider must 07/05/07 Sch2&4 ensure that robust recruitment procedures are adopted at all times and that records as required by regulation are sought and available. Previous timescale of 14.8.06 not met. The registered provider must ensure that all staff receive appropriate training relating to specialist training courses which meet the needs of residents. Previous timescale of 1.12.06 not met. The registered provider must ensure that all staff receive formal staff supervision on a regular basis. Previous timescale of 14.8.06 not met The registered provider must ensure that a quality assurance system is implemented and that the views of residents, their representatives and visiting professionals are sought and a report compiled and made available. 6. YA33 7. YA33 8. YA34 9. YA35 18(1)(c) 01/08/07 10. YA36 18(2) 01/06/07 11. YA39 24 01/07/07 Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 26 Previous timescale of 1.1.07 not met. 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. 4. Refer to Standard YA6 YA20 YA35 YA37 Good Practice Recommendations Ensure that daily care records are detailed and recorded after every shift. Ensure that the list of those staff deemed competent to administer medication is updated and reviewed. Ensure that information as detailed within the report pertaining to rectal diazepam are addressed. The registered provider should ensure that sufficient support is provided to the deputy manager. Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection South Essex Local Office Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG 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 Glenroyd House DS0000032135.V324576.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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