Inspection on 13/03/07 for Glenside Manor - Old Vicarage Wing

This inspection was carried out on 13th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glenside Manor - Old Vicarage... 04/10/05

Glenside Manor - Old Vicarage... 28/07/05

Glenside Manor - Old Vicarage... 04/02/05

Glenside Manor - Old Vicarage... 04/10/04

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

CARE HOME ADULTS 18-65 Glenside Manor - Old Vicarage Wing South Newton Salisbury Wiltshire SP2 0QD Lead Inspector Karen Mandle Key Unannounced Inspection 13th March 2007 09:45 Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glenside Manor - Old Vicarage Wing Address South Newton Salisbury Wiltshire SP2 0QD 01722 742066 01722 744443 oldvicarage@glensidemanor.co.uk 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) Glenside Manor Healthcare Services Ltd Mrs Sheila Marion Pickering Care Home 24 Category(ies) of Dementia (24), Dementia - over 65 years of age registration, with number (24), Mental disorder, excluding learning of places disability or dementia (24), Mental Disorder, excluding learning disability or dementia - over 65 years of age (24) Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users who may be accommodated at any one time is 24 The staffing levels set out in the Notice of Decision dated 11 October 2004 must be met at all times 4th October 2005 Date of last inspection Brief Description of the Service: Glenside Manor- Old Vicarage wing is registered to provide nursing care for 24 people with complex mental health conditions relating to acquired brain injury or dementia. The accommodation is provided over two floors offering single bedrooms and several large communal rooms. The majority of bedrooms have recently been refurbished to a good standard. The Old Vicarage Wing is one of six homes located on the Glenside Manor campus. The registered manager is Shelia Pickering. The nominated responsible individual is Mr Andrew Norman. The group of homes is situated in the village of South Newton, on the A36, five miles north west of the city of Salisbury. Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place March 13th 2007. The inspection commenced at 9.30am and was completed at 3.10pm. The manager Shelia Pickering was available to assist the inspector. Mrs Pickering was open to the inspection process and helpful through the day. Due to the complex mental health needs of the service users, gaining their views and opinions of the service provided was very limited. Therefore much of the inspection was based on observation. During the visit, the inspector observed staff interacting and caring for service users, toured the building, visiting many bedrooms. A number of records were reviewed such as care plans, medications and some health and safety records. All requirement set at the previous inspection had been met. Two requirements were made following this inspection and two good practice recommendations. The judgments contained in this report have been made from evidence gathered during the inspection, which included a visit to the service. What the service does well: What has improved since the last inspection? What they could do better: The flooring in three bedrooms should be replaced to reduce the odours in these particular bedrooms, which has only occurred due to continence issues of the service users. The armchairs should be replaced, which are stained and the Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 6 raised toilets seats replaced. A policy and procedure should be put in place to address the issue of equipment being used across the site. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All service users are fully assessed by the manager prior to the admissiontaking place. EVIDENCE: All prospective service users are assessed by the registered manager, Shelia Pickering, prior to admission to the Old Vicarage to ensure that through the assessment process, the home is able to meet the nursing and social care needs of the service user. Due to the very often, complex mental health needs of the perspective service users, Mrs Pickering will always visit with service users wherever they are based in the country to ensure that the assessment is fully conducted. Service users may also be transferred following rehabilitation from another unit on site; again Mrs Pickering will conduct an assessment. Information will also be gathered from other health care professionals where possible to support the assessment. Two assessments were seen both of which were detailed and provided a clear picture of the service users needs. A copy of the assessment is kept on the service users records and used towards implementing a care plan. Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. All service users are provided with comprehensive care plans, which are reviewed monthly. The staff support service users in making decisions where possible. The manager and staff have established an excellent balance between independence and care needs. EVIDENCE: The care records of four service users were seen. The care records were comprehensive and provided clear instructions to the staff on how to meet all areas of care required by the individual service user. Due to the mental health needs of the service users group, behavioural issues had been well addressed. An integrated care pathway, which is a 12-week assessment tool, was in use for a service user with difficulties, used to provide staff and therapist of triggers that can create behavioural problems. The care records were reviewed monthly or when care needs change. All service users have a primary nurse who is responsible for the care records. Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 10 Due to the high and complex mental health needs of the service user group decision-making could be very limited. However through observation of the staffs’ interaction with service users, it was evident how well the staff supported and encouraged service users to make decisions about their daily life within the home such as what they would like to eat, what activities they may wish to participate in and how they spent their day. The staff also were able to advise and guide service users when they needed support with a decision, which may of not have been be quite appropriate without being dictatorial. The manager and staff have established an excellent balance between independence and care needs. Following detailed risk assessments, service users are encouraged to takes walks independently around the campus, one service user is responsible for delivering all the post to the six units on site, other’s use the lift independently even though they may have some mobility problems to access their bedrooms when they wish. Given the complex mental heath needs of the service users these steps of independence are good. Two service users have recently been rehabilitated and discharged from the Old Vicarage, as this level of care was no longer required. Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with appropriate activities to meet their social needs. Service users are encouraged to maintain links with family and friends. The staff respect the rights of the service users. New menus are in place, providing a range of nutritional meals. EVIDENCE: During the morning of the inspection, an Occupational therapist was providing and arts and craft group session. Service users appeared to be enjoying the session, with one saying “I enjoy these classes and making things”. The OT reported that she spent a lot of time with the service users at the Old Vic and has arranged trips out for the day, with the service users input. Other activities provided are social groups, home visits, the gym and trips to the theatre and cinema. Service users also had TV’s and DVD’s in their bedroom. A TV is provided in the main communal space and a pool table is situated in another Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 12 large communal room. The home provides good spacious communal areas, which the manager said were always used as the service users often needed space from each other. Service users are supported to maintain links with family and friends. Some service users have weekend home visits. Service users can receive visitors at any responsible time; this was evidence through the visitors signing in book. A visitor spoke with the inspector who said, “I am very happy with the care here and Shelia is marvellous”. The approach of the staff and routines of the home are flexible supporting the rights of the service users. At the commencement of the inspection service users wishing to remain in bed did so and could receive their breakfast where they wished. The staff were observed knocking on bedroom doors before entering and identifying themselves to service users. The staff were observed interacting well with service users and even when communication was limited, the staff were able to understand the service users’ requests. If the requests was inappropriate, staff would try and divert the service user but with respect. Mrs Pickering has been leading the menu change across the six homes. The menus have been changed to cater for the wide range of age groups living at Glenside. Mrs Pickering is now also going to introduce pictorial menus, so service users with limited communication or reading skills, can choose from the menus. The main hot meal of the day was served at lunchtime, which provided a good choice of food. The majority of service users had their meal in the dining area. The staff supported service users with their meal where needed. A service user said, “I like the food here” and another “They feed us well”. A service user with swallowing problems, was fed by a gastric feeding tube, all appropriate systems were in place to support this. Each service user had a nutritional risk assessment in place and weights were monitored monthly. Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a good standard of personal and nursing care. The medication procedure was safe and medications were frequently reviewed, with service users taking minimum amount of medications. EVIDENCE: The care staff work hard to provide a good standard of personal care, which was evident through the well presented appearance of the service user. Consideration should be given, that providing personal care to service users with challenging behaviours, due to mental health care needs can be difficult to achieve. All personal care is provided behind closed doors, either in the privacy of the service users’ bedroom or bathroom. A service user was observed being encouraged to place his dirty laundry in the appropriate place, again trying to promote independence. Evidence was seen in the care records of health care needs being closely monitored by the nursing staff and prompt, appropriate action being taken Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 14 when changes in health care needs occurred. All service users are registered with a local GP who visits the home weekly and when requested. A record of all visits is kept. A physiologist is employed by Glenside manor who is also involved with the care of the service users. Physical nursing needs are also fully monitored and appropriate action taken, supporting tissue viability needs, continence management and mobility. The medication procedure was safe. The medications were stored correctly, as were the controlled medications. The controlled medication register was correct. The disposal of medications was in line with current legislation. The medication records were up to date. It was evident that medications are frequently reviewed and service users were taking minimum amounts of medication. Service users were not able to self medicate. Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This is judgement has been made using available evidence including a visit to this service. A complaints policy and procedure is in place and available to service users. There are polices and procedure in place to protect service users and the staff receive training in abuse awareness. EVIDENCE: A complaints policy and procedure are in place. The complaints procedure is openly displayed in the entrance of the home. A record of complaints is maintained along with the outcome of the complaint and what action (if required) was taken. Through discussion with the manager, it was evident she had an open and positive approach to complaints. A service user was asked who they would talk to if they had any concerns of complaints, the response was “I would talk to Shelia as she is in charge”. Glenside provides annual training in abuse awareness and vulnerable adults to all levels of staff and is part of the induction programme. Through discussion with the manager it was evident Mrs Pickering had a good understanding of how to make a vulnerable adults referral, if an allegation of abuse was reported to her. The employment procedure for the Glenside homes is robust and protects the service users as much as possible. Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a good standard of accommodation, which is appropriate to the service user group. The home is well maintained, apart from three bedroom carpets. The sharing of equipment across campus will need to be addressed. EVIDENCE: Good improvements had been made to the main communal area of the home since the previous inspection. The communal area had been refurbished and is now decorated in a more appropriate style for the service user group. New flooring has been laid which is easy to clean and maintain, whilst being hard wearing. The home offers two other large communal rooms, plus a conservatory with an enclosed garden to the rear of the home. Some of the armchairs are stained and are unable to be cleaned. The home is well maintained considering the complex needs of the service users living there. A Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 17 smoking room is situated on the ground floor. Bedrooms are situated on the ground and first floor. A communal room is provided for the elderly service users on the ground floor. The inspector was able to visit the majority of the bedrooms. Some bedrooms are very personalised, with photographs of families, small pieces of furniture brought in from home, this depending on the individual service user. All the bedrooms were decorated to suit the age group of the service users. However due to behavioural problems, furniture and personal items had been destroyed. In one case the manager was trying some very hardwearing bedroom furniture, which she hoped could not be destroyed. The elderly service users all had very cosy and personalised bedrooms, which suited their needs. A weighing scale suitable for wheelchair users is provided across the campus, for use by all homes on site. Discussions with the maintenance department also indicated that while industrial carpet cleaners were available, there were not enough for each registration. Joint use of equipment across the campus needs to be reviewed, as while it is appreciated that the sharing of equipment between units may be necessary, such sharing may also involve a range of risk to health and safety and spread of infection. This needs to be fully considered. Communal toilets situated off the large communal area had raised toilet seats, which were in poor condition and again could pose a risk of cross infection. The home was clean through out, apart from the flooring in three bedrooms, which was due to continence issues and did present with an odour. The carpet will need to be replaced. Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by competent and qualified staff. The systems for recruitment of staff protects the service users. Service users are protected by the extensive staff training programmes. Staff are fully supported and supervised. EVIDENCE: The Old Vicarage is staffed by a team of qualified nurses, either registered mental nurses or registered general nurses who are supported by a team of carers. The home benefits from a stable staff group who have worked at the home for several years and have a good understanding of the complex needs of the client group. Agency staff had not used as staff are prepared to cover shifts when needed. The senior management team of Glenside also support the home, as do the maintenance and catering teams. Staff have been trained in a wide range of skills to meet service users needs. The Glenside Group has a training department, which is managed by a qualified trainer. All staff, at all levels, undergo a standard induction Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 19 programme when they take up their posts. This includes all relevant areas such as manual handling, health and safety, fire safety and infection control. Newly employed staff are issued with a standard induction booklet, which they and their trainer/mentor sign, once they have been fully inducted into each area. The Glenside Group supports NVQ training and approximately 80 of care staff are trained to NVQ 2 or above. Staff who work in the brain injury service receive additional training in the area, to enable them to fully support service users and be aware of the range of service users needs and therapies involved. All staff also undergo annual resuscitation. Additional training to meet service users needs also is provided in a range of other areas, for example prevention of pressure damage and diabetic care. Home managers are responsible for ensuring that their staff receives mandatory training. Information is freely available in each registration to show which members of staff need to attend training. The Glenside Group has a central human resources (personnel) department, which handles all applications for employment. Much improvement has been made since the previous inspection in a range of areas relating to employment of staff. All staff have a criminal records check and are checked against the vulnerable adults list. If positive results are identified, their suitability for their role is assessed and a risk assessment performed. All prospective staff complete an application form and health status questionnaire. At least two suitable references are now always obtained prior to employment. All staff are interviewed, using an interview tool. There is a clear system for regular staff supervision. All staff spoke with confirmed that they had received supervision at least six weeks and annual appraisal. Records relating to supervision and appraisal were seen on staff files. Supervisions and appraisal were individual in tone and issues relating to training and development were consistently included. Records showed that supervisions were also performed when it was considered that a member of staff needed additional support in a particular area. Supervision and appraisal records cross-referenced to training records, so that it was clear that where a member of staff has requested, or was assessed as needing training in a particular area, arrangement had been made for the person to attend training in a timely manner. Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The manager is competent and provides very good leadership to the home. Quality assurance systems are in place. The home is well maintained providing a safe environment for service users to live in. EVIDENCE: Mrs Shelia Pickering is a qualified registered mental nurse who has much experience in caring for service users with brain injury and dementia care. Shelia is currently studying for a master degree in this area to further her own professional development and knowledge. Shelia has obtained the managers award. Shelia fully understands her role and responsibilities as manager and provides good leadership to the home, whilst creating a relaxed atmosphere for service users to live in. Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 21 Quality assurance systems are in place with audit visits from the senior management regularly taking place. Residents surveys are conducted, however Mrs Pickering stated that the service users are not keen to use them. When the menus across the campus were changed, Mrs Pickering conducted surveys for all service users who were able to comment prior to changing the menus, gaining their views of changes to be made and what they would like to see on the menu. The Glenside Group has systems to ensure that staff are trained as required in a range of matters relating to health and safety. A recent fire safety audit had taken place across service on site. At present night staff are trained in fire safety twice a year. The home is advised that, as fire officers consider the risk to service users at night, when there are fewer staff, to be higher, that all staff who work nights need to be trained in fire safety four times a year. A review of maintenance records and discussions with the maintenance manager showed that other area relating to health and safety, such as lifts, hoists and boiler servicing, fire safety checks and water temperatures testing takes place at the regularity advised. Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 3 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 4 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 4 X 3 X X 3 X Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 23 NO 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. 2. Standard YA25 YA30 Regulation 23 23(2n) Timescale for action The registered person will ensure 30/05/07 that bedrooms number 6, 15 and 19 have new flooring provided. A policy and procedure on 30/06/07 equipment shared across the site must be put in place to ensure that adequate equipment is provided. This must conform to health and safety and infection control guidelines Requirement RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA30 YA30 Good Practice Recommendations The raised toilets seat in the communal toilets should be replaced to reduce any risk of cross infection. The management should consider replacing the arms chairs, which are now stained. Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Glenside Manor - Old Vicarage Wing DS0000015910.V329133.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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