Inspection on 22/01/08 for Glenroyd House

This inspection was carried out on 22nd January 2008.

CSCI found this care home to be providing an Good service.

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

Other inspections for this house

Glenroyd House 15/02/07

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 Sharon Lacey Unannounced Inspection 22nd January 2008 09:00 Glenroyd House DS0000032135.V353939.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.V353939.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.V353939.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 glenroyd@beaconcaregroup.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.V353939.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 2007 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 transport, 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 £1126.00 per week. Additional charges incurred to residents, includes chiropody, personal toiletries, magazines, meals at fast food outlets and pursuing personal hobbies and interests. Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was a routine Unannounced Inspection, which took place over six hours. This was a Key Inspection covering thirty-one of the National Minimum Standards. A tour of the home was completed and also an inspection of relevant records and documentation took place. Areas looked at included information given to residents before being admitted to Glenroyd House; information gained when residents first come into the home; how information is given to staff on the care required; the facilities and environment of the home; and any complaints that may have been received since the last inspection. Also staffing and management of the home were inspected. Discussions with three residents took place and these residents appeared very happy and relaxed in the homely environment. Staff were observed during the day interacting with residents. Questionnaires were sent out to relatives and residents regarding their experiences of the home, and feedback from these have been included in the report. At the end of the day the Inspection was discussed with the Manager and advice and guidance was given regarding the findings. An Annual Quality Assurance Assessment (AQAA) was completed and returned by the required date. This document provided information on how the service is presently meeting its service users needs and also meeting the National Minimum Standards. The AQAA advised the CSCI of areas that had been developed since the last inspection, and also where they hope to improve within the next twelve months. What the service does well: There is a good assessment and care plan process in place. This clearly identifies each individual’s needs, so the home is confident it can meet their residents care needs. The Manager is working towards producing new systems and paperwork to help enhance the lifestyles of the residents. Glenroyd House presents it’s self as ‘homely’. There is a good relationship between staff and residents and it is run to their best interest. During observation it was established that staff have a good understanding of resident’s needs and their interaction and care was appropriate. Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 6 Staff within the home support residents to access community facilities and to become involved in activities, which form part of everyday life. Residents are encouraged to make choices around their daily lives and are provided with a safe and supportive environment. All residents are provided with a single bedroom, which is personalised and individualised. What has improved since the last inspection? What they could do better: It is positive to note that the number of Statutory Requirements and Recommendations had once again reduced significantly since the last key inspection. It was noted that some areas around the home were in need of re-decoration. Also, maintenance issues were raised during the inspection. The Manager had evidence that these issues had been brought to the Providers attention, but no action had been taken. Some areas of the home were also in need of a clean. Staff are still working excessive hours. This is an area that needs addressing as it was highlighted in the last inspection. Although staff receive daily support from the manager, they are not at present receiving formal supervision. Some training updates are required. Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Statement of Purpose and Service Users Guide enables prospective residents to establish whether Glenroyd House will be a suitable home and meet their needs. The assessment process ensures sufficient information is gathered about the care needs of individuals. EVIDENCE: The Statement of Purpose and Service User Guide was available. Both documents had recently been reviewed and were well presented and set out the services that the home seeks to provide. The Manager is in the process of developing these documents in a pictorial format using simple language. Residents had signed a form, which stated they had received a copy of the Service Users Guide and five residents confirmed on the questionnaires that they had received these documents. There is a clear admissions procedure and set assessment forms. An admission assessment is completed to identify the individual needs of prospective residents and includes the areas listed in Standard 2.3 of the National Minimum Standards. Either the Manager or a member of the companies Commissioning Team would complete all new assessments. Three resident files were viewed and all contained a fully completed assessment form, which was comprehensive and detailed. Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 10 It was established that introductory visits to Glenroyd House are encouraged – unless it is an emergency situation. No new residents had been admitted to the home since the last inspection. Of the files seen all three residents had contracts, which included details of the room to be occupied. A copy of the home’s inspection report and registration certificate were also available. Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals are involved in decisions about their lives and are supported to play an active role in planning care and support they receive. EVIDENCE: All documentation required was available and easy to ready. Resident care plans had been developed by the Manager since the last inspection. These were a working document and include information on all areas of the person’s life i.e. health care, daily living skills, community presence, emotional and psychological care needs etc. They clearly describe the needs of the individual residents and had also been regularly reviewed. Care plans seen reflected resident’s changing needs and had been written with residents and contained signatures where possible. New forms, which highlight resident’s needs regarding cultural and diversity have been introduced. The manager had introduced a form to identify residents ‘goals and aspirations’. There is a key worker system at the home and each month a meeting occurs to identify the next months goals for each individual resident. This also assists residents in the process of making decisions about their lives. Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 12 Questionnaires received back confirmed that residents are encouraged to make decision about what they do each day. Residents are supported in taking risks and files contained clear detailed risk assessments, which covered the resident’s health and well being, outside activities and moving and handling. Choice and freedom forms had also been completed, which evidenced where limitations and restrictions may have been put in place i.e. keypad on the front door and access to the community. There was clear written evidence that risk assessment forms had been reviewed on a monthly basis. Most present residents had relatives, but advocacy services can be arranged if required. All present residents manage their own finances there are systems in place to assist with this. Files seen also included details of managing individual’s behaviours and seven staff had also attended challenging behaviour training. Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 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. Activities are provided to enhance resident’s leisure and occupational/ educational opportunities. The menu offers residents choice and meets dietary needs. EVIDENCE: There was clear evidence that all residents living at the home are provided with a range of activities and community contact. Community links are still being developed and the Manager stated he is trying to include local neighbours in events that happen at the home i.e BBQ’s. Events that had been organised included going out to a local firework display, a Halloween party and a Christmas party; a ‘pamper’ party is also to be organised. General activities during the week consist of going to the pub, playing cards, board games, bowling, cinema and personal shopping. There are two clubs during the week that residents can attend. Those residents spoken to confirmed that a variety of activities took place and they looked forward to going out on Friday nights as this was a ‘disco’ and also the ‘take away’ nights. Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 14 In the garden there was a trampoline available and also football goal posts. The Manager stated they were looking into making part of the garden into a ‘miniature car race track’ for residents to use. Some residents also attend college each week as part of their education and to develop independent living skills. Each care plan recorded an individual timetable of activities for residents. Residents are encouraged to participate in the community and there is a car to assist in transport. Staff support residents to maintain family links and the home has an open visiting policy. One resident had been on social leave to visit their relatives and another resident was making arrangements to visit a friend. Family and friends are welcome to visit and there is space around the home to entertain. The AQAA stated that they aim to increase community activity during he next 12 months and also offer more comprehensive educational choice. They also want to introduce more leisurely type activities and day centres. Where possible the daily routines within the home are planned around the needs of the individual resident. On the day of the inspection one resident did not get up until lunchtime, as it was their day off from college and they liked a lie in. Residents spoken to confirmed that they got up and went to bed when they wanted. Lunch was also served to individual residents needs. Observations during the inspection evidenced that residents have unrestricted access throughout the building. Staff were noted to interact well with residents. There is a set menu, which has been arranged with the residents. A choice of meal is offered each day, but if this is not liked then an alternative is offered. The food budget has gone up since the last inspection, which the Manager stated made shopping and choice easier. Residents are involved in cooking meals and three residents spoken to confirmed that there is a choice of take away on a Saturday night. Residents also confirmed that they have use of the kitchen to make hot and cold drinks as required. Two residents have special dietary needs and these are catered for. There is a separate dining area, but it was noted that garden’ chairs were in use as there was not sufficient dining chairs available. Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to receive personal support in the way they prefer and to have their physical and emotional care needs monitored and met. There are clear procedures on the safekeeping and administration of medication, which safeguards residents. EVIDENCE: There was evidence that the physical and emotional needs of residents are monitored and they have access to community health facilities. Care plans contained information on health care needs of the individual and there was also a log of hospital, GP or dental visits. Evidence was available that residents receive personal support in the way they prefer. There is a key worker system, which enable a staff member to get to know the individual resident and provide care, which enhances the individual’s life. Each resident spoken to were able to advise whom their key worker was. Residents are encouraged to choose their own clothes and hairstyles and are taken shopping individually. Support is given to try and enable residents to have choice in getting up, going to bed and also other general routines within the home. Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 16 There was a medication policy and procedure 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 and a consent form for staff to administer their medication. The Manager has introduced a monthly audit since the last inspection, to help ensure that the medication policy and procedure is being adhered to. On looking at the MAR sheets it was noted that all had been correctly completed and signed. Four staff had received medication training, but three others still needed to complete this. The Manager stated that they try to let people stay at the home for as long as they are able to meet their health needs. He has already highlighted that the ‘death and dying’ section in the care plans needs to be developed further for present residents. Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their families can expect to be provided with sufficient information to enable them to make a complaint about the service. There are policies and procedures protect them from abuse, neglect and self-harm. EVIDENCE: There is a clear complaints procedure, which is available to all residents and their families and is also part of the Service Users Guide. There is a complaint/compliments folder, but since the previous inspection, no complaints had been received. Set forms were available to record details of the complaint, the investigation and the outcome. Residents who responded to the questionnaires stated they were aware of how to make complaints Policies and procedures were available on Whistle blowing and Safeguarding Adults. At the time of the inspection, there was evidence that all of the staff had completed training on Safeguarding Adults. There had been one Safeguarding referral since the last inspection, but this had been unfounded. There were clear policies and procedures regarding resident’s money and financial affairs. Glenroyd House DS0000032135.V353939.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 adequate. This judgement has been made using available evidence including a visit to this service. Glenroyd House is homely and the style and layout of the accommodation meets the resident’s needs. There were areas around Glenroyd that were in need of redecoration and maintenance. EVIDENCE: Glenroyd House is suitable for its stated purpose, but the decoration is beginning to look tired and it was noted that some areas around the home had not been well maintained. The manager advised that one bedroom is presently out of use due to subsidence, but this has been locked to keep a safe environment for the residents. The kitchen had watermarks on the wall backing onto the previous mentioned bedroom. The manager stated that the room had been assessed to identify what course of action needed to be taken, but no date had been organised for the work. Most parts of the premises were safe and clean, although it was noted that some areas were in the need of re-decoration due to scuffmarks on the walls and holes or cracks in the plaster. The Manager confirmed that it was the staff’s responsibility to do the housework and keep the home clean, but it was Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 19 noted that some of the walls and ceilings had evidence of cobwebs. The Manager provided evidence that maintenance requirement forms had been completed and sent to Head Office on a monthly basis, identifying some of these issues, but to date they had not been rectified. One fire door also had a broken closure. The Manager had stated on the AQAA under ‘barriers to improvement’ that there was an inability for head office to prioritise maintenance requests and he would like to be more involved in the budget planning of the home. All residents have single bedrooms with en-suite facilities. Of those resident’s bedrooms randomly inspected, all were personalised and individualised. One resident had recently had his bedroom decorated and was clearly pleased with the colour. Residents looked happy and relaxed in their accommodation and residents were observed in the communal lounge, kitchen and bedrooms. There were policies and procedures for infection control and ten staff had completed training, three still needed to attend. Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing is sufficient to meet resident’s individual needs, but some staff were working excessive hours which could put themselves and residents at risk. Staff receive appropriate training and have the knowledge and skills to carry out their roles. EVIDENCE: Staff are provided with job descriptions, which clearly define their roles and evidence of these could be found on staff files. Staff are also provided with copies of the General Social Care Councils book and details of the philosophy of the home could be found in the staff handbook. The Manager provided a copy of a matrix clearly showing staff training. It was confirmed that all staff had attended care planning and recording training, risk assessment training, safeguarding training, epilepsy, food hygiene, fire awareness, first aid, moving and handling and health and safety training. Six staff had completed challenging behaviour and learning disabilities training; five of the staff had attended training in Autism and Asperger’s and ten had attended infection control training. It was noted that the Manager had highlighted were updates were needed. The Manager was confident that staff Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 21 working at the home had the skills and knowledge to provide the care present residents needed. With regard to staff that had achieved NVQ training, four now had NVQ 2 and three others had commenced this in April 07. Two had achieved NVQ 3 and four others had now started. The Manager is also in the process of completing his NVQ4 and Registered Managers Award. The home is still working towards 50 of its staff being NVQ trained. Staffing rotas were viewed; these contained all the required information. It was confirmed that three staff are on duty between 7.30 a.m. to 22.30 p.m. and at night 1x waking staff and 1x sleep in person are on duty. The manager stated that they had a vacancy for at least 24 hours and due to holidays and sickness they had been short staffed. The home does not use agency staff. On viewing the rotas for the week before and the week after the inspection, it was highlighted that some staff had either done or were due to work 24-hour shifts. On one occasion a staff member would have worked 48 hours. The issue of staff working excessive hours had been highlighted at past inspections and requirements made. Although the hours had slightly decreased it was still pointed out to the Manager that is poor practice and could put both staff and residents at risk. The Manager has introduced a ‘cross over’ of shift times to improve communication with staff and to ensure relevant information is passed on between shift. Staff spoken to were very positive with this move as it also gave them time to write up a care plan or notes that were required. With regard to the supervision of staff, the Manager stated that this was an area that needs further development. Some supervision had taken place, but it had not been regular. Regular handover meetings occurred and daily support is offered, but more formal supervision needs to be arranged. Some staff meetings had occurred last year, but little had happened since May 05. It was noted that the Manager had been absent from the home for a number of months last year and was in the process of introducing new systems and catching up with outstanding work. This is an area that was highlighted in the last inspection and the Manager was advised that this is not in line with National Minimum Standards or Regulations. The home has a clear recruitment policy and residents are actively involved in the interview process. Only one new staff member had been employed since the last inspection. On viewing the file this contained all the required information; although it was noted that a full employment history had not been gained and it did not contain details of the staff members next of kin. The newly appointed staff member had received an induction. Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 22 During the inspection staff undertook their roles in a professional manner and were clear about their responsibilities. Staff were observed interacting with residents in a professional but warm manner and it was evident that good working relationships existed. Staff had a clear understanding of the resident’s individual needs. Feedback from residents was that the ‘staff were nice’. Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect the home to be managed effectively and in their best interests and the manager has a fair understanding of the National Minimum Standards and Care Homes Regulations and how these should be met. EVIDENCE: The present Manager had taken over the management of the home since the last inspection. It is clear that he has the knowledge and skills to manage the home and has introduced systems, which will be positive for both residents and staff. He is also completing his NVQ4 and Registered Managers award. During the inspection the Manager showed good knowledge of the Standards and Regulations and had systems in place to enable him to find the evidence required. Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 24 There was an open atmosphere in the home and staff spoken to were very positive about the Manager and stated he was very approachable and offered advice when needed. Residents observed with the Manager were relaxed and felt able to ask for assistance. Policies and Procedures had recently been updated and reviewed. These are kept in the office and staff had also been provided with details of these in their staff handbook. The Manager was aware of his responsibilities regarding the health and safety of both staff and residents. It was noted that some updates were required on moving and handling and infection control training. Regular checks on gas appliances, fire alarm system, water temperatures and electrics were seen and in order. An accident folder was viewed and in order. Registration certificate was on show and also the home’s insurance – both documents were in order. Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 x 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 2 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 2 2 3 x 3 x 3 x Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 26 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 YA24 Regulation 23(2)(b)(d) Requirement The home should be of maintained internally and externally. All parts of the home should be kept clean and reasonably decorated. Equipment at the home should be in well maintained. This is in connection to residents using garden chairs in the dinning area due to the dinning chairs being broken. 2. YA33 18(1)(a) Excessive hours should not be worked and staff must be competent to undertake their role. This refers specifically to some staff working excessive hours. Repeat requirement – new timescale set as previous timescale of 7/5/07 not fully met. 3. YA36 18(2) Staff must receive formal staff supervision on a regular basis. Repeat requirement – new timescale set as Previous Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 27 Timescale for action 31/05/08 30/04/08 31/05/08 timescale of 14.8.06 and 01/06/07 not met New timescale given 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 YA21 Good Practice Recommendations It is recommended that the resident’s death and dying care plans are developed further – as many either have little information or are blank. Ensure staff receive regular updates on infection control training. Ensure that a full employment history is gained during the recruitment process and any gaps in employment discussed and clearly recorded. Ensure next of kin details are gained. 4. YA42 Ensure that all staff receive regular updates on moving and handling training. 2. 3. YA30 YA34 Glenroyd House DS0000032135.V353939.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge CB21 5XE 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.V353939.R01.S.doc Version 5.2 Page 29 - 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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