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Inspection on 19/07/04 for Glenside (10)

Also see our care home review for Glenside (10) for more information

Care Homes For Adults (18 – 65)Glenside (10)10 Glenside Allerton Liverpool Merseyside L18 9UJAnnounced Inspection19th July 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: • Promote improvement in social care • Inspect all social care - for adults and children - in the public, private and voluntary sectors • Publish annual reports to Parliament on the performance of social care and on the state of the social care market • Inspect and assess ‘Value for Money’ of council social services • Hold performance statistics on social care • Publish the ‘star ratings’ for council social services • Register and inspect services against national standards • Host the Children’s Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Glenside (10) Address 10 Glenside, Allerton, Liverpool, Merseyside, L18 9UJ Email address Tel No: 0151 724 5994 Fax No: 9999Name of registered provider(s)/company (if applicable) North West Community Services Limited Name of registered manager (if applicable) Mr Anthony Carroll Type of registration Care Home No. of places registered (if applicable) 3Category(ies) of registration, with (number of places) Learning disability (3) Registration number F020000829 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 19th March 2004 YES NO 21/11/03 If Yes refer to Part CGlenside (10)Page 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 319th July 2004 10:00 am June BeaverID Code072789Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionAnthony CarrollGlenside (10)Page 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspector’s Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 – 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Provider’s Response Provider’s Comments Action Plan Provider’s AgreementGlenside (10)Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Glenside (10). The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: • Inspection methods used • Key findings and evidence • Overall ratings in relation to the standards • Compliance with the Regulations • Required actions on the part of the provider • Recommended good practice • Summary of the findings • Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Glenside (10)Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 10 Glenside Close is a small home for people with learning disabilities. It is situated in a residential area of Mossley Hill and is close to the city centre. The home is part of a larger organisation known as North West Communities Services Limited who have a number of small homes in the area. The home modern and bright and all rooms are at ground floor level. There is parking space to the front of the premises and a small garden area. At the rear of the building there is a good sized private enclosed garden. The home is staffed twenty four hours a day by regular staff members and the Manager has successfully completed the fit person process and is now registered with the Commission for Social Care Inspectorate. The premises are kept clean and well decorated and there is a satisfactory maintenance contract with the owners of the building. There are a number of local places of interest within walking distance of the home, and a good bus and train service to the city centre. There are small shops in close proximity to the home and a good size shopping centre fairly close by.Glenside (10)Page 5 PART ASUMMARY OF INSPECTION FINDINGSInspector’s Summary (This is an overview of the inspector’s findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The inspection was announced and took place between the hours of 10am and 3.45pm. The Manager of the home was on duty during the inspection and all three service users were at home. There were two other staff members on duty also. The home was clean and tidy and staff were observed to interact with service users well. The service users do not have any very communication skills, however they are able to indicate their needs by way of facial expressions or actions, which the staff are familiar with. Several visitors attended the home during the inspection. Choice of home (Standards 1 – 5) 3 of the 4 standards assessed were met The home has prepared a combined Statement of Purpose and Service User guide that provides information that states the aims and objectives of the home and the facilities it offers. The home has not provided an up to date statement of terms of conditions/contract for each service user. This has been made a requirement on previous occasions and needs to be met within the timescale stated. Individual Needs and Choices (Standards 6 – 10) 3 of the 4 standards assessed were met The Care files were inspected and were completed to a good standard, evidence that service users and their families were involved in the care planning was provided. Past and present medical history details were documented in the files and any visits made by health care professionals were recorded. Risk assessments are completed for both personal risk and environmental risks within and outside the home, however risk associated with the use of cot sides must be documented and signed for by service users advocates. A requirement was made to obtain consent for photographs used in service users files and to ensure that the photographs used are appropriate and preserve service users dignity. Lifestyles (Standards 11 – 17) 6 of the 7 standards assessed were met The service users have a choice of activities which range from individual choice to group outings. Daily life at the home is flexible depending on the needs of the service user. Each of the service user takes a holiday at least once a year, either individually or as a group, abroad or in the U.K. Service users are encouraged to assist themselves as much as possible. Families are involved with planning care also. Service users are encouraged to use the local community services such as the shops, parks and library and all staff are made aware of the need for respecting confidentiality about the home. Personal healthcare and support (Standards 18 – 21) 3 of the 3 standards assessed were met The records indicate that the staff support and guide service users and observation of staff Glenside (10) Page 6 interaction on the day of the inspection confirmed this. The healthcare needs are met by regular monitoring and health checks. The medication administration and procedures for storing and disposing of medicines used at the home is satisfactory. Complaints & Protection (Standards 22 to 23) 2 of the 2 standards assessed were met The home has a complaints procedure and a satisfactory Whistle Blowing policy. The staff are given training on induction on safe practice, and regular up dates when necessary. There have been no complaints recorded since the last inspection. Environment (Standards 24 – 30) 5 of the 7 standards assessed were met The home is decorated to a good standard and each service user has their own bedroom which are all well furnished. There is a large private garden which is not overlooked. The standard of housekeeping in the home is high and all staff attend to the laundry daily. The home provides a shower and bathing aids to meet the service users needs and there is a separate staff toilet. The trolley in the bathroom needs attention and the registered person is required to address this in the timescales given to ensure the safety of service users during bathing. Staffing (Standards 31 – 36) 5 of the 6 standards assessed were met There is a good compliment of staff, and staffing levels remain consistent with little turnover. There is a mix of male and female experience care staff. During informal staff interviews the Inspector was satisfied that the staff were able to demonstrate that they had a good knowledge and understanding of the service users needs. The staff are given training in various aspects of care and health and safety, however a requirement was made to ensure that staff had adequate training in Adult Protection Protocols and recognising all forms of abuse. A requirement was also made to ensure that the personnel files kept at the home contain all the relevant information required by registration. Conduct and Management of the Home (Standards 37 – 43) 5 of the 7 standards assessed were met The Manager of the home has worked at the home in a previous capacity, and has successfully completed the registration process and is now registered with the Commission for Social Care Inspection. The policies and procedures produced by the home on a local level were relevant to the home, and are updated as and when necessary. The safety certificates required by regulation were up to date and available for inspection. The fire log was recorded to a satisfactory standard indicating that regular checks are carried out and staff are given training and hold regular fire drills. A requirement was made to ensure that service users can access their finances at all times.Glenside (10)Page 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard Required actions Timescale for action 2 Reg. 5 YA5 The registered manager must develop and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user The registered person must provide evidence that the home operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. The registered person must ensure that a full risk assessment is carried out regarding using cot sides and that a full explanation of the risks involved given to service users and their families. This should be documented in each file. By 31st December 20034Reg. 18 & 19YA34By 31st December 2003 By 31st December 20043Reg. 13.4YA9Action is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements.Glenside (10)Page 8 RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations Standard NACONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Glenside (10)Page 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard * Requirement Timescale for action The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user The registered person must ensure that a full risk assessment is carried out for the use of bed rails and that a full explanation of the risks involved given to service users and their families. (This requirement is made for the second time) The registered person must ensure that service user dignity is protected at all times and that any photographs used in the care files are appropriate and consent obtained for their use. 31st August 2004.1Reg. 5YA52Reg. 13.4YA9By 31st July 2004.3Reg. 12YA16By 31st July 20044Reg. 13YA23The registered person is required to ensure By 31st staff are given adequate training on August recognising and identifying all forms of abuse. 2004.Glenside (10)Page 10 The registered person is required to ensure the following redecoration and replacements are carried out: 5 Reg. 23 YA24 1. The office/entertainment room is in need of redecorating as the paint work is showing signs of wear. 2. The carpet in the office/entertainment room is badly stained, torn and needs replacement. 6 Reg. 23 YA27 The registered person is required to ensure that this trolley is repaired or replaced to ensure service users safety. By 31st July 2004 By 30th September 2004.7Reg. 19YA34The registered person is required to ensure that the staff files kept on the premises By 3rd contain all the information listed in Schedule II August of the Care Homes Regulations 2001 2004 including details of employee’s health status and proof of identity. The registered person must ensure that suitable financial arrangements are made at the home to allow service users to access their building society accounts at all times. By 31st July 2004.8Reg. 25YA43RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Refer to Good Practice Recommendations Standard * It is recommended that risk assessments are carried out to ensure there are no trip hazards inside or outside of the home, and that water temperatures are checked routinely to minimise the risk of scalding. (Bath water temperatures are checked prior to bathing).1YA9* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.Glenside (10)Page 11 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling • Pre-inspection questionnaire • Records • Care plans / Care pathways • Meals • Activities • Other enter details here ‘Tracking’ care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES YES NO YES NA YES YES NO YES YES YES NO YES NO YES NO YES 3 5 X NO YES YES YES 7 X 19/7/04 10AM 6Glenside (10)Page 12 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. “X” is used where a percentage value or numerical value is not applicable.Glenside (10)Page 13 Choice of HomeThe intended outcomes for the following set of standards are: • • • • • Prospective service users have the information they need to make an informed choice about where to live. Prospective service users’ individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 – 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users’ guide. 1163 1163 Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Hairdressing 3 Key findings/Evidence Standard met? The Statement of Purpose has been reviewed since the last inspection to include the registration details of the Manager. The service user guide was not inspected on this occasion.Standard 2 (2.1 – 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? The services users currently living at the home have lived there since it first opened. Should a vacancy occur, a full assessment would be carried out prior to admission. The home provides policies and procedures to support this standard.Glenside (10)Page 14 Standard 3 (3.1 - 3.10) The registered person can demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The home provided evidence to support this standard. Consultation with relevant agencies such as community nurses, dieticians, G.P’s, dentists and chiropodists takes place on a regular basis and is recorded in each service users file. The current service users have access to hoists and wheelchairs and specialist equipment throughout the home.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? Trial visits would be arranged should a vacancy arise within the home. The service users currently living at the home have lived there since it opened and there are no plans for change.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 1 Key findings/Evidence Standard met? There were no copies of any service user contract or statement of terms and conditions available for inspection on the files. The Manager informed the inspector that they are kept at head office. A requirement has been made on previous occasions to provide each service user with a copy of an up to date contract/terms of conditions therefore the registered person must ensure that this requirement is actioned within the timescales given in Section A of this report.Glenside (10)Page 15 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: • • • • • 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.Standard 6 (6.1 – 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 3 Key findings/Evidence Standard met? The care plans and essential life plans were informative, detailed and easy to read. The information they contained would enable all staff to have a good understanding of the service users’ needs. Details of service users likes and dislikes, personal traits and nonverbal communication indicators were clearly documented. Each file had a comprehensive personal and social history as well as family background. Personal and environmental risks assessments are carried out, reviewed on a regular basis and changed if necessary. Evidence was provided to indicate that service users’ families are involved in care planning. Standard 7 (7.1 – 7.7) Staff respect service users’ right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? Service users are encouraged to make decisions for themselves wherever possible. Evidence was provided in each file to support this. Choice includes activities of daily living as well as pursuing individual hobbies. Through discussion with the staff on duty, it was clear that families of some of the service users were also involved in decision making.Glenside (10)Page 16 Standard 8 (8.1 – 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? The service users living at 10 Glenside Close are unable to participate in all aspects of the day to day running of the home, however evidence was provided to support information from staff that service users are present at house meetings and participate in the weekly shopping.Standard 9 (9.1 – 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service user’s individual Plan and of the home’s risk assessment and risk management strategies. 2 Key findings/Evidence Standard met? Evidence was provided to support this standard. Risk assessments are carried out for both personal and environmental risks. All risk assessments are reviewed regularly and changed as necessary giving an explanation why the change is needed. However, there was no evidence in the care files to indicate that agreement had been reached with the service users or their families over the risks involved of using bed rails. The registered person must ensure that a full risk assessment is carried out for the use of bed rails and that a full explanation of the risks involved given to service users and their families. This should be documented in each file. Environmental risks assessments have commenced and a recommendation has been made to include risk assessing any trip hazards in and outside of the home and checking the water temperatures on a regular monthly basis. Standard 10 (10.1 – 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the home’s written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? Confidentiality is maintained at the home by all staff who are giving training during their induction period on the importance of maintaining confidentiality and good record keeping. All documentation relating to the service users is kept securely in the home and the premises is alarmed. Access to files is open to service users and their advocates if wishedGlenside (10)Page 17 LifestyleThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 11 (11.1 – 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? Evidence was provided to support this standard The service users are encouraged by all staff to develop independent life skills such as washing and dressing and choosing clothes. Evidence was also provided to indicate that service users make use of the local community by using shops and parks, local museums and local pubs and restaurants. There is a local bus link with facilities for the disabled and if necessary the staff will use local taxis if they cannot use the home’s minibus.Standard 12 (12.1 – 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? None of the service users have any form of employment nor are they in full time education. However, one of the service users is a member of the deaf/blind society who have facilities and equipment, as well as useful contacts for assisting members. This will be explored more fully on the next inspection as the service user was waiting for documentation from the society.Glenside (10)Page 18 Standard 13 (13.1 – 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? Evidence was provided through discussion with staff and by inspecting the Care files that service users are given the opportunity of using local facilities and services such as transport, restaurants, pubs, cafes and the library. The staff also informed the inspector that the service users pursue their individual hobbies such as visiting the light sensory room, going to the pub, watching T.V., shopping locally, or visiting the city centre. The service users have individual holidays either at home or abroad and do occasionally go away as a group. This year the home plan to go away as a group in September to Anglesey (three service users and six staff). The company provide service users with a holiday allowance. Standard 14 (14.1 – 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? The service users are offered a variety of activities to pursue either as a group or individually with support from staff. All activities undertaken are documented in the care files and activity records and an evaluation of activities is carried out monthly.Standard 15 (15.1 – 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Visitors are welcome at the home at any reasonable time and can either use the service users’ bedroom or the communal rooms such as the lounge or dining room. Any visits that need to be carried out in private can be conducted in the manager’s office at the rear of the property. Visits are encouraged from other service users/staff from other homes in the area, and from family and friends. On the day of the inspection one of the service users had a visit from several family members.Glenside (10)Page 19 Standard 16 (16.1 – 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 2 Key findings/Evidence Standard met? Evidence was provided through discussion with the manager and staff and by direct observation, that service users privacy is maintained by for example, knocking before entering rooms and by the provision of keys for each service users bedroom. The care files for each service user detail what each individual likes to do and is able to do, and include details of how privacy is to be respected and of daily routines. There are photographs in each file of service users enjoying various activities such as outings, holidays and enjoying the garden. Photographs are also used to demonstrate how care is delivered such as how service users enjoy a foot spa or hand and arm massage. However, the registered person must ensure that service user dignity is maintained by using suitable and appropriate photographs. Standard 17 (17.1 – 17.9) The registered person promotes service users’ health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Mealtimes were not directly observed on this inspection, however the records of food eaten were inspected which indicated that a wide variety of food is served to the service users which included fresh fruit and vegetables. Each service user has their favourite meal and this is taken into account when menu planning, it is also recorded in the care files. One of the service users has PEG tube feeds that are monitored by the community dietician. The service users are also given the opportunity to eat out either at local pubs and restaurants or at one of the fast food outlets in the area as a treat. Evidence of basic food hygiene training was available in the staff’s personnel files.Glenside (10)Page 20 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: • • • • 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.Standard 18 (18.1 – 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users’ privacy, dignity, independence and control over their lives. 0 Key findings/Evidence Standard met? This standard was not assessed on this visit.Standard 19 (19.1 – 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) XX3 Key findings/Evidence Standard met? Evidence was provided in the records to indicate that all healthcare needs of service users are continually being assessed and evaluated, and when necessary action is taken to address any health matters that arise. All staff are aware of how to contact the relevant agencies such as G.P.’s dentists etc., and staff will accompany any service who needs to visit hospital for consultation. The Manager of the home informed the inspector that they have a good relationship with the service users G.P. practise and the community nurses.Glenside (10)Page 21 Standard 20 (20.1 – 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the home’s policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? None of the current service users self medicate. Policies are in place to support staff to assist any service users who wish to self medicate. The medication administration records were inspected and found to be accurately recorded, the stocks are kept securely in a locked cupboard and a random sample of the stock balances was found to be correct.Standard 21 (21.1 – 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? There has been no change to policy or procedure since the last inspection therefore this standard was not assessed on this visit.Glenside (10)Page 22 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: • • Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 – 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days X X X X X X X 3 Key findings/Evidence Standard met? The home has a satisfactory policy and procedure relating to complaints. It has recently been revised to include reference to the service user guide. Advice was given to amend the policy so that it includes the changes to the registration body’s name. Each service user is given a pictoral copy of the complaints procedure which outlines the steps needed to be taken when making a complaint.Glenside (10)Page 23 Standard 23 (23.1 – 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YESX1 Key findings/Evidence Standard met? All staff are aware of the home’s Whistle Blowing Policy. There have been no incidences reported since the last inspection. Staff are given training on induction on issues surrounding adult protection, however evidence of formal training was not available. The registered person is required to ensure staff are given adequate training on recognising and identifying all forms of abuse.Glenside (10)Page 24 EnvironmentThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 24 (24.1 – 24.13) The home’s premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users’ individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 1 Key findings/Evidence Standard met? The premises are leased from Maritime Housing who are responsible for maintaining the fabric of the building, and the parent company is responsible for internal decoration and provision of furniture. The home is generally decorated to a high standard and is comfortably furnished. The standard of housekeeping was good, and the home is fairly well maintained. However, the office/entertainment room is in need of redecoration and the carpet is worn and stained therefore needs replacing. The bathroom is equipped with facilities such as a tracking hoist and bathroom trolley, however the leg on the trolley appeared to be loose and the registered person is required to ensure that it is repaired or replaced to avoid any potential accidents. The garden area of the home is well used in the warmer weather with all service users enjoying sitting out ad using the garden furniture. However, the garden was in need of a general tidy up.Glenside (10)Page 25 Standard 25 (25.1 – 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) – single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence YES NO NO 3 X X X Standard met? 3 3 33 3 X XThe bedrooms provided for service users are adequately sized and enable the service users to be moved around the room in wheelchairs. There is a large lounge/dining room and a good sized bathroom. There are separate toilet facilities for staff. None of the service users share a room.Glenside (10)Page 26 Standard 26 (26.1 – 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? The bedrooms were well decorated and personalised to individual taste, each had a lockable piece of furniture and posters and pictures on the wall as well as TV/video or music centres. They are all decorated to a good standard. Privacy locks are provided and each room is equipped with suitable bedroom furniture that is homely and domestic in nature. One of the service users has had a new carpet fitted since the last inspection which enhances the appearance of his room.Standard 27 (27.1 – 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 1 Key findings/Evidence Standard met? The appearance of the bathroom has been improved since the last inspection. The requirement to repair the ceiling has been carried out and blinds have been fitted to the windows. The bathroom is equipped with suitable facilities for bathing including a tracking system and trolley to ensure service user comfort. However, the trolley was in need of repair as one of the supporting legs was loose. The registered person is required to ensure that this trolley is repaired or replaced in the timescales given in Section A of this report. Standard 28 (28.1 – 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? The lounge/dining area of the home was comfortably furnished with bright modern furniture with matching curtains and soft furnishings. There was a large television and music centre, and the provision of photographs, ornaments and plants made the room appear domestic and homely. The kitchen was a good size and fully fitted. The kitchen appliances are modern and maintained by the parent company. The records inspected indicated that regular monitoring of the fridge and freezer temperatures are carried out. The foods stocks were inspected and found to be sufficient for the number of service users in the home.Glenside (10)Page 27 Standard 29 ( 29.1 – 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the home’s stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? The hoists, wheelchairs and other lifting aids used at the home are regularly serviced and repaired if necessary. The leather supports on one of the service users wheelchairs (identified on inspection) looked worn along the arms and it is recommended that consideration is given to replacing these. All of the communal rooms used by service users are on the ground floor, access to and from the front and back of the house was satisfactory and service users have freedom of movement around the home. The washing machine and dryer are housed in a small utility room within the building. The inspector was informed that a new minibus is on order and will be delivered shortly. This will be inspected on the next visit to the home.Standard 30 (30.1 – 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? The home was clean, odour free and the standard of housekeeping on inspection was very high. The staff help maintain the high standards within the home, and it was apparent on the day of the inspection visit that the staff took pride in keeping the place clean. All of the staff have laundry and cleaning duties and are aware of COSHH regulations. COSHH policies are available at the home and staff sign to state they have read and understood them.Glenside (10)Page 28 StaffingThe intended outcomes for the following set of standards are: • • • • • • 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.Standard 31 (31.1 – 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and other’s roles and responsibilities. 3 Key findings/Evidence Standard met? An inspection of the staffing rota provided evidence that the home is adequately staff by a stable work force. The staff at the home have many years experience of working with service users with a learning disability and there is very little use of agency staff. If necessary the home’s staff will cover any absences or they will use the company’s “bank” staff. There are both male and female staff on the rota.Standard 32 (32.1 – 32.6) Staff have the competencies and qualities required to meet service users’ needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 3 Key findings/Evidence Standard met? The home does not supply nursing care to any of the service users, nor are they registered to do so. There have been occasions since the last inspection when the service users have required nursing procedures which have been carried out by the community nurses once contacted by the home. The manager is confident that a number of staff with NVQII training will be employed by the target date of 2005 as at present two members of staff are nearing completion of level II and two more members of staff are to commence level II training in September.Glenside (10)Page 29 Standard 33 (33.1 – 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users’ assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme 3 X X 300 X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided 300 X X 300 Nursing X X XXX3 Key findings/Evidence Standard met? The staff rota indicates that sufficient and regular staff members are available on duty twenty four hours a day, this includes one waking and one sleep in night staff member. The staff on duty on the day of inspection appeared to have a very good rapport with the service users and offered assistance in a friendly and patient manner. Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 1 Key findings/Evidence Standard met? The recruitment files were inspected and an improvement noted. However, there were still some shortfalls such as health checks and proof of identification. Personal details are kept on file and the Manager informed the inspector that more detailed information is kept in Head Office. The home is informed that a CRB check is carried out and supplied with the CRB number, however the Manager is not supplied with a copy or any information that may have a bearing on employment. The application form used does not contain any reference to the health status of any employee nor their immunisation record. The registered person is required to ensure that the staff files kept on the premises contain all the information listed in Schedule II of the Care Homes Regulations 2001 including details of employee’s health status and proof of identity.Glenside (10)Page 30 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users’. 3 Key findings/Evidence Standard met? Staff are encouraged to attend training courses provided by the Company. Certificates of attendance at various study days are available in each staff member’s file, these include participation in statutory training such as basic food hygiene/PEG tube feeding, first aid and fire safety training as well as training on challenging behaviour, epilepsy and medication.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? Evidence that the Manager of the home carries out regular formal supervision on a monthly basis was provided and copies of the notes are kept in the personnel files. The Manager of the home is also available for any informal discussions if the staff wish to seek advice on any matter relating to the care and welfare of the service users.Glenside (10)Page 31 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 37 (37.1 – 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. NO3 Key findings/Evidence Standard met? Since the last inspection, the Manager has successfully completed the registration process including a fit person interview. He had a wide range of experience in caring for clients with learning disabilities prior to obtaining the manager’s post. The inspector was informed that the Manager is to enrol on an NVQ level IV course in care management in September.Standard 38 (38.1 – 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The Manager has an open door policy and service users, their families and staff are free to discuss any aspect of care, the running of the home, outings and choices. There are staffing meetings and house meeting held on a regular basis, service users and their families are welcome.Glenside (10)Page 32 Standard 39 (39.1 – 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 3 Key findings/Evidence Standard met? 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. A financial audit is conducted once a year by the parent company.Standards 40 (40.1 – 40.6) The home’s written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 3 Key findings/Evidence Standard met? A sample of the policies and procedures used by the home was inspected. The company provides a comprehensive policy manual which has recently been revised. The home has a file of local policies and procedures applicable to the service. A number of policies and procedures were inspected and met this standard.Standard 41 (41.1 – 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met ? The records required by registration to ensure health and safety of the service users and staff who work at the home were inspected and found to meet this standard in full. The standard of all record keeping at the home is high and records are kept securely although accessible to service users or their families if they wish to see them.Glenside (10)Page 33 Standard 42 (42.1 – 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? Through constant monitoring and regular auditing the health and safety of both service users and staff who work at the home is protected as far as reasonably practical. Outside agencies such as the gas service, fire brigade and electricity board carry out regular safety checks and have issued safety certificates. The staff are given regular fire evacuation training. Staff are also given basic food hygiene training and first aid.Standard 43 (43.1 – 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 2 Key findings/Evidence Standard met ? A random sample of the personal allowance was checked and found to be correct. The service users have individual building society accounts which can be accessed by the Service Manager. However, at present she is on maternity leave and there have been no alternative arrangements made to ensure the Acting Service Manager can sign any cheques that may be required. The registered person is required to ensure that this matter is dealt with accordingly.Glenside (10)Page 34 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager Date Public reportsJune Beaver Jenni TweedleSignature Signature SignatureIt should be noted that all CSCI inspection reports are public documents.Glenside (10)Page 35 PART DD.1PROVIDER’S RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Person’s comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 19th July 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleGlenside (10)Page 36 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 27 August 2004 , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Provider’s Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action plan YESOther: enter details here Glenside (10)Page 37 D.3PROVIDER’S AGREEMENT Registered Person’s statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Mr Dene Donalds of Glenside Care Home confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I Mr Dene Donalds of Glenside Care Home am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Glenside (10)Page 38 Glenside (10) / 19th July 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000025273.V173265.R02© This report may only be used in its entirety. 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