CARE HOME ADULTS 18-65
Glenside (10) 10 Glenside Allerton Liverpool Merseyside L18 9UJ Lead Inspector
Sonya Robinson Unannounced Inspection 10th July 2006 09:45 Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 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 Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Glenside (10) Address 10 Glenside Allerton Liverpool Merseyside L18 9UJ 0151 724 5994 9999 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) North West Community Services (Merseyside) Limited Mr Anthony Carroll Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th January 2006 Brief Description of the Service: 10 Glenside Close is registered to provide personal care to 3 people with learning disabilities. All rooms are at ground floor level. Service users have single bedrooms. There is a large bathroom, a separate toilet, a large living room, kitchen and laundry room. There is a staff sleeping-in room, which is also used as a quiet area for service users and provides access to the garden. Bathing and mobility aids are provided. There is parking space to the front of the premises and a small garden area. The home is situated in a residential area of Mossley Hill and is close to the city centre. There are small shops in close proximity to the home and a good size shopping centre fairly close by. The service users have a minibus and several of the staff are designated drivers. There is access to train and bus services. Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which lasted for six hours and commenced at 09.45. During this time the inspector discussed with the registered manager and members of staff on duty various issues regarding the care provided to service users. All three of the service users were present and the inspector observed how service users care was provided and staff interaction with service users. The inspector looked around the building to assess its suitability to provide a comfortable, homely environment for service users to ensure their safety. Selections of records that are kept were looked at. These included records regarding service users care and records relating to staff. The information gained on the day of the site visit contributes to the basis of any judgments made. Prior to the site visit information about the service that has been accumulated since the last inspection was also reviewed. A pre-inspection questionnaire was sent to the service several weeks before the site visit. This was so that useful information that would assist the inspection process could be collected. However the Commission had not received this prior to the start of the site visit. The main focus of the inspection process was to understand how the home was meeting the needs of the service users and how well staff were themselves supported by the organisation to make sure they had the skills, training and support to meet the needs of the service users. The inspector would wish to acknowledge the assistance and co-operation of the staff of the home during the course of this inspection. The inspector would also wish to particularly thank the service users for their patience and tolerance throughout the inspector’s time in their home. What the service does well:
An examination of an initial assessment pro forma showed that all the information recommended in the National Minimum Standards for Care Home’s for Younger Adults is available. Records of service users likes and dislikes and preferences around daily living, such as what time they like to get up and the activities they enjoy are also in place. Service users have opportunities for personal development and to take part in appropriate activities. The daily routines support the needs of service users.
Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 Page 6 Staff report that the home has positive relationship with neighbours and the local community. There are no restrictions on visiting times and contact with family, where applicable, is encouraged. An examination of the menu records showed that varied meals are provided though the home is seeking advice and guidance from a dietician for one particular service user. Care plans showed service users’ dietary requirements and any assistance with eating that they may require is provided. Staff encourage the service users to eat a balanced diet and they monitor diet and appetite in order to ensure service users their well being. Records show that staff are provided with guidance around providing appropriate personal care to service users. Training records show that staff have received appropriate training in providing personal care sensitively and with dignity. This has included procedures regarding the specific arrangements for one service user. Records show that service users are supported to attend healthcare appointments and have access to health care services when they are needed. Staff training and policies and procedures are in place to ensure that service users are protected from abuse and that their views are heard and appropriate action taken. The home is clean and generally well presented and provides a comfortable and pleasant environment for service users as with any domestic dwelling there are now a couple of areas that require attention. What has improved since the last inspection? What they could do better:
The statement of purpose needs to cover all the required information. The contracts/terms and conditions need to provide clearer information about what the fees payable include. The involvement of family, friends/advocate in supporting service users when drawing up the contract/terms and conditions is recommended. The instructions for the administering of medication need to be reviewed in order to fully safeguard service users. Evidence must be available to show that staff, have had all the required recruitment checks in order to demonstrate that the staff working with service users are competent and
Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 Page 7 suitable to care for vulnerable adults. A copy of the monthly responsible individuals representative reports on visits to the home must be available for inspection. A fire risk assessment needs to be made available. Service users would benefit from 50 of staff having completed a formal qualification in caring for adults with a learning disability. Service user’s care plans are to be reviewed and updated to reflect changing needs; and agreed changes are to be recorded and actioned. Risk assessments carried out for both personal and environmental risks are to be signed, dated and reviewed. Pressure relieving mattresses are to be regularly checked to ensure there continued safety for use and that a record of this should be available for inspection. All staff must have regular supervision, which is to be documented. The fire emergency light in the main corridor needs to be attended to by a person who is qualified to do so. Outstanding requirements must be addressed along with the newly identified requirements arising as a consequence of this report. Failure to do so may lead to the CSCI considering its powers of enforcement. 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. Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 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 Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The current preadmission assessment documentation allows for an adequate initial assessment of need so that the home can be sure that they can meet the needs of the service users. However the current contractual arrangements do not satisfactorily safeguard the service users from the risk of financial abuse. The statement of purpose also needs to be expanded upon to meet the legislation. EVIDENCE: The registered manager stated that there are several documents available, which together cover the information required for the service user guide. However the statement of purpose does not cover all the required information as listed in Schedule 1 of The Care Homes Regulations 2001. The service manager reported during conversation after the site visit that this is currently being reviewed. This when finished should provide useful information for prospective service users to help them and their representatives to reach a decision about whether they wish to move into the home..
Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 Page 10 There have been no new service users admitted to the home since the last inspection. New service users would be assessed by the manager for the home. The manager would visit a prospective service user where they were currently living. Information would be gathered from the service users’ carers, social worker and any other relevant agencies. An examination of an initial assessment pro forma showed that all the information recommended in the National Minimum Standards for Care Home’s for Younger Adults is available. The inspector was informed by staff that given the level of complex needs of the service users it is difficult for staff to communicate with them and for service users to make their needs known. It was stated that communication is mainly through the use of smell and touch with service users responding to certain stimuli. It is strongly recommended that advice be sought from specialist therapists such as language or occupational therapists. This would provide an opportunity for service users to be reassessed to see if there may be alternative methods of communication available. The registered manager stated that the contracts between the service users and North West Community Services have been reviewed. However, as previously reported in past inspection reports the reviewed contracts do not clearly state the services covered by the fees payable. All additional costs to service users are not identified (for example, the contribution toward the cost and use of the mini-bus). The contracts have not been signed. The service manager reported that family/advocates are in the process of being approached to support service users in drawing up the contracts, as appropriate. This must be addressed as a matter of urgency so that service users can be fully safeguarded from any potential for financial abuse. Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7,9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users needs are met by adequate care planning though the care plans must be regularly reviewed to fully reflect the assessed and changing needs of service users. EVIDENCE: A sample of service user care plans were seen, one service user’s care plan was dated February 2005 this should now be reviewed. The care plans provide a lot of detailed information on the needs of the service users and provide guidance to staff. The records and a discussion with staff indicated that service users are assisted to make decisions about their lives in accordance with their abilities. Communication guidelines are in place though staff reported that given the needs of the service users communication was difficult. Visual prompting was a method used to encourage service users to make a choice. For example staff were using three objects with one service user to seek their opinion about
Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 Page 12 whether they wished to go out for a walk using a the wheelchair, without the wheelchair or on the bus. Staff reported due to the changing needs of this service user that this was less approach has become less effective than previous. Methods of communication should now be reviewed and specialist services should be sought if this is appropriate. Records of service users likes and dislikes and preferences around daily living, such as what time they like to get up and the activities they enjoy are also in place, though staff reported that it was difficult to go out for the day as the driver of the service user mini bus had ceased employment. This was discussed with the service manager who will look into this. The service manager did report that there are two other available staff within the home that could take on this role. Given the communication difficulties that were reported to the inspector it is recommended that relatives and/ or advocates are encouraged to help secure the service users opinions in making decisions and individual choices and that were decisions are made by others that this is recorded and why. Risk assessments are carried out for both personal and environmental risks. These indicate the support that service users need to safeguard their wellbeing and take part in activities. However these were found to be undated so it was difficult to assess if and when these had been reviewed. A risk assessment on the use of bed rails was also in place. Agreement around the use of bed rails with the service users families has been recorded with a daily record being made that the bed rails are safe for use and fit for purpose. This ensures service users are not placed at unnecessary risk of injury from ill fitting or unsuitable equipment. Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users have opportunities for personal development and to take part in appropriate activities. The daily routines support the needs of service users. EVIDENCE: The records indicated that service users are encouraged to develop and maintain independent life skills such as washing and dressing and choosing clothes. However staff said that due to the changing needs of the service users this was becoming less so. At present none of the service users attend employment or day care. Staff reported that activities have also become restricted over recent months. Records show that activities have consisted of service users listening to music, spending time in the sensory room, the hydrotherapy pool, enjoying walks in the Local Park and undertaking trips to local shops. One service user also enjoys going for pub lunches. The increasingly limited opportunity as reported by staff was apparently due to the problems of not having a driver for the mini bus as referred to earlier. Records also indicated that service users had been on holiday with staff individually and had visited Dublin, Spain and Centre Parks respectively. Staff reported that
Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 Page 14 service users often enjoy two holidays a year though clarity is needed as to how this was funded and to how the decision on the venues for holidays are arrived at. The arrangements for consultation on such matters need to be explicitly set out in the contractual agreement and statement of purpose. Safeguards must be in place to ensure that any decisions to use service users finances to fund staff to accompany service users on holiday are transparent and duly authorised by the placing authority or person with the legal authority to do so. Service users in long-term placements normally have the cost of an annual holiday included within the overall care package. The manager needs to provide clarification and inform the CSCI of the arrangements accordingly. Staff report that the home has positive relationship with neighbours and the local community. There are no restrictions on visiting times and contact with family where applicable is encouraged. Discussions with the staff and observations confirmed that the home’s routines are flexible as much as possible. An examination of the menu records indicated that varied meals are provided. Though the home is seeking advice and guidance from a dietician for one particular service user. Care plans set out service users’ dietary requirements and any assistance with eating that they may require. Staff encourage the service users to eat a balanced diet and they monitor diet and appetite in order to ensure service users have a balanced diet. Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The health needs of service users are adequately met and personal support is given that meets their identified needs and which generally promotes service users wellbeing. However the administration of medication practice must improve and the practice of ‘potting out’ must cease immediately as it is unsafe and may place service users at unnecessary risk of wrongly administered medication. EVIDENCE: Records show that staff are provided with guidance around providing appropriate personal care to service users. This includes the preferences of service users. Training records show that staff have received appropriate training in providing personal care with dignity as well as supporting individuals who may require assistance with more specialist ways of feeding, such as PEG feeding. Records show that service users are supported to attend healthcare appointments and to have access to health care services when they are needed.
Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 Page 16 The medication records and corresponding medication were examined and in general found to be in order. Medication is stored securely. Members of staff reported and records showed that they have been trained in the administration of medication. However the inspector observed medication being administered at lunchtime. The medication was ‘potted up’ on a tray for the three service users and the medication administration records (MAR) sheets were signed for prior to the administration to service users. This is poor practice as opportunity for error could be high. The home is reminded of ‘ The Administration and Control of Medicines in Care Homes and Children’s Services’ policy document which was published by The Royal Pharmaceutical Society of Great Britain. The practice of ‘potting out ‘ must stop with immediate effect. Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Staff training supported by satisfactory policies and procedures help ensure that service users are protected from abuse. There are adequate systems in place that allow advocates to raise issues on behalf of service users so that their views can be heard. EVIDENCE: There is a complaint procedure available. Given the needs of the service users information is available to enable a complaint to be made on behalf of a service user by an advocate. The complaint procedure describes the stages of the complaint and the timescale for managing complaints. The staff were aware of the content of the complaint procedure and how to respond to complaints. The CSCI has not received any complaints about this service since the last inspection. There is a Whistle Blowing Policy and Liverpool City Council’s Adult Protection Procedures available. Staff are given training on induction on issues surrounding adult protection. A number of staff have received formal training on recognising and reporting all forms of abuse, it is planned that all staff will attend this training on a rolling basis. Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is clean and generally well presented. It provides a comfortable and pleasant environment for service users although, as with any domestic dwelling, there are now a couple of areas that require attention. EVIDENCE: Staff informed the inspector that the home had been redecorated at the beginning of June 2006 and that since the last inspection a new heating system has been installed by Maritime Housing who rent the property to North West Community Services Limited. Staff reported that the staff bedroom, which is also used during the day as a quiet room for service users is now warmer. It was previously reported that this room was cold and a portable heater was being used subject to a risk assessment. A tour of the home showed that the home was clean. It is clear the staff are working hard to ensure good standards of cleanliness are maintained throughout the home. Staff informed the inspector that two of service users bedroom flooring had been recently replaced. It was observed that other carpets throughout the home are now in need of cleaning or replacement as
Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 Page 19 they are stained in areas and are now looking worn. The inspector was informed that staff are visiting a local laundrette on a very regular basis, as their tumble dryer is not working. There has been long discussions the inspector was informed as to whose responsibility it was to install the tumble dryer. Consequently the home has been without a tumble dryer since May 2006. This raises issues of possible infection and hygiene control and staff time away from meaningful engagement with service users. A resolution must be sought to this difficulty that avoids the potential for cross contamination and which meets health and safety standards. Service users bedrooms were found to be personalised and there were appropriate cot sides and pressure relieving mattresses for those service users who have been assessed as requiring such. A daily risk assessment check on the use of cot side is recorded. Records examined with regards to service pumps / mattresses safety checks was dated 04.08.04. The latest safety check certificate should now be forwarded to the Commission and copies of these certificates should be made available for inspection. It is crucial that all equipment is regularly checked as per manufacturers specifications in order to safeguard service users. Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The number of staff available on duty and the training they have received supports Service users. However, service users would benefit further if 50 of staff had completed formal training as outlined in the national minimum standards. The records held at the home do not provide evidence that service users are protected by the homes recruitment practices. EVIDENCE: The staffing rota showed that there is a minimum of two staff on duty during the day and evening with a third member of staff available for some shifts. Staff interviewed said that the staffing levels meet the needs of the service users and enable service users to take part in group and individual activities outside the home. At night there is one sleeping and one waking member of staff available. There are currently no staff vacancies. An induction programme is provided for staff. This covers training around manual handling, health and safety, food hygiene, first aid and the protection of vulnerable adults. Following this the staff files show that staff attend training courses relevant to the duties they perform at the home, such as training in PEG tube feeding, epilepsy management and medication management. Staff are then encouraged to undertake an NVQ in caring for
Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 Page 21 adults with a learning disability. Steps are being taken to ensure that 50 of staff have undertaken this qualification. The inspector was informed by the registered manager that no new members of staff have been employed since the last inspection. Of the sample of staff files observed none of the staff had a health declaration, one staff member required a reference from a previous employer and of the three files observed the last staff supervision was noted down as 19.10.05, 19.03.06 and 02.12.05. The service manager reported that the records of staff recruitment are generally held at the head office of North West Community Services and that in the future the majority of recruitment records will be held there. In accordance with policy and guidance published by CSCI in November 2005, with the agreement of CSCI, providers who have a centralised human resources department can hold some recruitment information within this department as long as there is sufficient documented evidence at the home that all the required checks and references have been undertaken and there is an agreement with CCSI as to the criteria for accessing the records held at the human resources department. The manager of the home should write to the CSCI to propose suitable arrangements for storing the necessary information and the commission will respond to confirm whether they are acceptable. Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 Page 22 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42, 43 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The quality assurance systems are ineffective and there are deficiencies in health and safety that could fail to safeguard service user welfare if not addressed. EVIDENCE: The manager of the home has an NVQ Level 4 in care and management. The manager has had several years’ experience of working with adults with physical and learning disabilities. The manager has undertaken regular training to keep his knowledge and skills up to date. The inspector was informed that the home carries out regular quality assurance audits and the Service Manager visits the home monthly and also carries out a thorough audit of service users’ health and welfare, accidents, risk assessments both personal and environmental, and staffing levels.
Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 Page 23 However copies of the audit report are not sent to the CSCI office as per regulations and a copy was not available at the home for inspection. A financial audit is conducted once a year by the parent company. Again this was unavailable for inspection. A number of risk assessments were observed on inspection and these were found to be undated. The inspector was unable to assess when and if these had been reviewed. The records of fire safety checks, fire drills, gas supply safety check, electrical wiring safety check, portable appliance safety check were seen and were in order. However the inspector observed that the fire emergency light in the main corridor remained on throughout the day of inspection. The inspector was informed by staff that the light had remained on since the decorators had been in at the beginning of June 2006. This is unacceptable and must now be addressed. Training records showed that staff are in general, given appropriate training in safe working practices. A fire risk assessment that is specific to the home was not available. This was also raised in the previous inspection and remains outstanding. General information on how to carry out a fire risk assessment has been obtained. The records showed that fire safety training has been provided to staff at the intervals recommended by the fire service of every 6 months for day staff and every 3 months for night staff. The manager reported that the fire drill is an additional method of providing fire instruction to staff. The names of the staff that took part in the drills is now recorded. A valid certificate of employers liability certificate was displayed along with the registration certificate in the entrance hall of the home. Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 Page 24 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 1 2 3 3 2 4 N/A 5 2 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 3 27 3 28 3 29 2 30 2 STAFFING Standard No Score 31 X 32 2 33 3 34 1 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 1 X X 1 2 Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 4, 5 Requirement The registered person must ensure that the statement of purpose covers all the matters listed in Schedule 1 of the Care Homes Regulations 2001 (previous timescale of 13/10/05 & 06/05/06 not met). The registered person must ensure that the contract/statement of terms and conditions between the home and the service user clearly states the facilities and services that are included in the fees payable and any additional costs to service users and what they are (previous timescale of 13/10/05 & 06/05/06 not met). The registered person must demonstrate that the required information in Schedule 4 of the Care Homes Regulations 2001 has been obtained in respect of staff to ensure their suitability to work with vulnerable adults (previous timescale of
DS0000025273.V294091.R01.S.doc Timescale for action 20/10/06 2. YA5 5 20/10/06 3. YA34 17 20/10/06 Glenside (10) Version 5.1 Page 26 13/07/05 & 06/02/06 not met). 4. YA39 26 The registered person must ensure that copies of the monthly responsible individuals representative reports following their visits to the home are available for inspection (previous timescale of 13/07/05 & 06/02/06 not met). The registered person must ensure that a fire risk assessment specifically detailed with regard to the home is completed (previous timescale of 13/07/05 & 06/03/06 not met). The registered person must ensure that the administering of medication is in accordance with current legislation. The registered person must ensure that staff can communicate effectively with service users using the individual’s preferred mode of communication. The registered person must ensure that service user’s care plans are reviewed and updated to reflect changing needs; and agreed changes are recorded and actioned. The registered person must ensure that risk assessments carried out for both personal and environmental risks are signed, dated and reviewed. The registered person must ensure that medicines are administered and documented according to the requirements of the Medicines Act 1968,
DS0000025273.V294091.R01.S.doc 20/10/06 5. YA42 23 20/10/06 6. YA20 13 10/07/06 7. YA3YA7 12 20/10/06 8. YA6 15 20/10/06 9. YA9 13 20/10/06 10. YA20 13 10/07/06 Glenside (10) Version 5.1 Page 27 11. YA24YA30 16 12. YA29 16 13. 14. YA36 YA42 18 23 15. YA43 25 guidelines form the Royal Pharmaceutical Society of Great Britain and the requirements of the Misuse of Drugs Act 1971. The registered person must ensure that floor coverings and laundry facilities as identified within this report are addressed. The registered person must ensure that pressure relieving mattresses are regularly checked to ensure there continued safety for use and that this is available for inspection. The registered person must ensure that staff have regular supervision. The registered person must ensure that the fire emergency light in the main corridor is attended to by a person who is qualified to do so. The registered person must ensure that a copy of the financial audit conduct once a year is available for inspection. This can be forwarded to CSCI. 20/10/06 10/08/06 20/10/06 10/08/06 20/10/06 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 YA5 Good Practice Recommendations When drawing up the contract the registered person should ensure that the service users are supported by family, friends/advocate as appropriate. The registered person should ensure 50 of staff (including agency) hold an NVQ 2 or equivalent. The registered person should ensure staff are able to demonstrate how individual choices have been made; and record instances when decisions are made by others and
DS0000025273.V294091.R01.S.doc Version 5.1 Page 28 2. 3. YA32 YA7 Glenside (10) 4. 5. YA14 YA14 why. The registered person should ensure service user’s have access to, and choose from arrange of appropriate leisure activities and facilities. The registered person should ensure that service user’s in long term placements have as part of their basis contract price the option of an annual holiday outside the home, which they should be able to choose or plan for. Glenside (10) DS0000025273.V294091.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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