Inspection on 20/03/07 for Glenthorne House

This inspection was carried out on 20th 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Glenthorne House 17/08/06

Glenthorne House 08/12/05

Glenthorne House 18/08/04

Glenthorne House 20/05/04

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

CARE HOMES FOR OLDER PEOPLE Glenthorne House Glenthorne House Dover Street Bilston Wolverhampton West Midlands WV14 6AL Lead Inspector Bhag Jassal Key Unannounced Inspection 20th March 2007 09:00 X10015.doc Version 1.40 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 Glenthorne House DS0000040718.V332331.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 Older People. 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. Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glenthorne House Address Glenthorne House Dover Street Bilston Wolverhampton West Midlands WV14 6AL 01902 491633 01902 491633 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) Mr James Walter Dell Miss Evelyn Thomas vacant post Vacant Care Home 20 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (20) of places Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Maximum of 3 (three) older people within the Dementia (DE) category. Older people with mild dementia only to be accommodated. Date of last inspection 17th August 2006 Brief Description of the Service: The home is a large detached property, situated in a residential area of Bilston. The home is currently registered for twenty older people, of which three older people with mild dementia. It is in close proximity to all local amenities, which includes the Health Centre, library, shops and a market. The area is well serviced by buses and Metro. The home has 16 single bedrooms, two double bedrooms, three lounges/dining rooms, a conservatory, two bathrooms, two showers with WC’s, seven WC’s, a kitchen, a small staff room, the main office, car park is at the rear and garden and patio area. The laundry facilities are located in the basement area. The present Registered Providers - Mr James Walter Dell and Miss Evelyn Thomas have been operating this care home since March 2003. Current charges at the home are from £336.00 to £394.00.per week. Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced visit was a part of an unannounced key inspection and took place on 20 March 2007 and started at 9.00 am and lasted 7 hours and 10 minutes. The home had 18 places occupied and two beds remain vacant. During the course of inspection the assessment information and care plans were inspected for 4 service users. Medication administration was checked. Staff records were seen to check staff rotas, recruitment procedures and training. Various documents were seen in order to check compliance with Health and Safety legislation. A tour took place of the building. Three visiting relatives were spoken to during the inspection and a number of service users were spoken to throughout the day. Discussion took place with 4 members of care staff and the cook. The Acting Care Manager – Ms Carrol Marshall and the Registered Providers Mr James Dell and Miss Evelyn Thomas were present throughout the inspection. On this occasion all the Key Standards of the National Minimum Standards were inspected. Issues raised through a formal complaint against the home’s staff by a member of staff received by the Commission for Social Care Inspection in early March 2007, and Regulation 37 Notifications received from the home were also considered and discussed with the Registered Providers and the Acting Care Manager. What the service does well: Glenthorne House care home is registered for 20 older people, of which 3 old people can have mild Dementia. The home provides a secure and comfortable accommodation for service users. Care is provided by a cheerful and wellmotivated staff team, who are very well led by an experienced, committed manager. During the inspection not all service users were able to express an opinion about the home, but those that did expressed their satisfaction. One person said “I like it here, they are all so nice and friendly.” Visiting relatives also expressed their satisfaction, one saying that the care was “very good” and that they were always kept up to date with their relative’s well being. Full information is provided to prospective service users and their relatives prior to admission. The Acting Care Manager insists on a full and comprehensive Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 6 assessment prior to anyone moving to the home. The specific needs of service users at Glenthorne House are well met, with staff receiving training in the care of people with Dementia. The Manager is experienced, who has a thorough understanding of the needs of her service users. Service users are treated respectfully and their right to privacy is understood and upheld. Social and leisure activities are provided on a daily basis and care is taken to ensure that these are appropriate to the service user group. The food provided at the home is of good quality and choices are always available. The home has a good key worker system in place. There are robust recruitment procedures in place to protect service users. The home takes steps to seek the views of its service users and their relatives through regular meetings and surveys. What has improved since the last inspection? What they could do better: Several care plans had not been updated/reviewed for few months. The home carries out regular reviews, but they must ensure that the care plans are accordingly reviewed on monthly basis and updated to reflect changing needs. Those members of staff who as yet have not received training in safe working practice topics must do so as a matter of priority. The Registered Providers should also consider providing specialist training for staff in Adult Protection from Abuse. This training would enable staff to improve further their care practices and professionalism. The carpets in the communal areas must be professionally steam cleaned. The annual Quality Assurance monitoring for the Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 7 year 2007 must be implemented as a matter of priority. The Registered Providers must take swift action to ensure that the home has a registered manager in post, so that the service users are protected and appropriately cared for, and staff are supported and supervised. The Inspector wishes to thank the Acting Care Manager, Registered Providers, service users, their relatives and staff for their assistance and co-operation on the day of inspection. 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. Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 (Standard 6.is not applicable). Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Glenthorne House provides clear information to prospective service users and their families to enable them to make decisions about whether or not they wish to live at the home. All prospective service users receive a full needs assessment prior to admission to ensure that their needs will be met. EVIDENCE: Admissions are not made to the home until a full needs assessment has been undertaken. The home is then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the Statement of Purpose. For people who are self-funding and without a care management assessment, they always receive assessments by the care manager. Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 10 Four service users’ files/care plans were inspected which contained preadmission assessments of the service users’ needs, both from assessments by the home’s staff and other relevant professionals. Observations and discussions with the service users, The Acting Care Manager and staff on duty indicated that the home continues to meet the individual needs of all the service users accommodated at the home in a satisfactory and sensitive manner. A service user spoken with stated that she was satisfied with the information she and her family had received prior to admission and since living at the home. Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10. Quality in these outcome areas is Good. This judgement has been made using available evidence including a visit to this service. All service users have individual plans of care, which ensure that their personal, healthcare and social needs are met. Some of these care plans are in need of monthly reviews and updating. Medication is administered and stored in a manner that safeguards service users. Service users are treated with respect and dignity and their right to privacy is understood and upheld. EVIDENCE: All service users undergo an assessment of their needs prior to admission to the care home. A Care Plan is produced, which is based on the assessment of needs. The home operates a key worker system, which helps to ensure that the recommendations arising from the care plan reviews are implemented. Four service users care plans were examined in detail and it was noted that the short-term and long-term goals, aims and objectives are clearly identified and Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 12 appropriate interventions required to put them into action to meet the individual service users’ needs. It was noted that the care plans are being reviewed on a monthly basis. However, it was evidenced that there were some gaps in recent reviews of the care plans. The Acting Care Manager stated that all the care plans will be reviewed and updated as a matter of priority. The home maintains records of all health checks carried out by doctors, opticians, dentists, district nurses and chiropodists. It was also evidenced that the home ensures that the detailed nutritional screening is undertaken, including a weight gain and loss records are maintained and appropriate action is taken if required. It was observed on the day of inspection that no personal care interventions were undertaken in communal areas. In addition, consultation with health and social care professionals are carried out within the service users’ bedrooms. Visitors are able to meet service users in their bedrooms or lounges/conservatory on the ground floor, which offers privacy when not being used. It was observed that service users were being treated with respect and staff are working both professionally and sensitively in meeting individual needs. The Inspector spoke at some length with several service users and all of them commented positively about their care and they felt that they have everything that they need. Five service users stated that “the carers are very good and kind and they look after us very well”. Two other service users said that the carers are always there to help. Generally the service users appeared to be content, comfortable and happy. The service users were complimentary regarding the quality of their lives and their care they are receiving at the home. It was evidenced from the staff training records and from discussion with the Acting Care Manager that three senior carers have completed their training in safe handling of medication. However, it is the home’s policy that only the senior members of staff would be responsible for the safe handling and administration of medication. Records evidenced medication received, administrated and leaving the home. The photographs of service users have been provided on the medication sheets to avoid any risks of maladministration of medication. Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15. Quality in these outcome areas is Good. This judgement has been made using available evidence including a visit to this service. Service users are able to exercise choice with regard to social and recreational activities at the home. Activities provided meet the needs of the service user group. Relatives and friends are encouraged and assisted to maintain contact with the service users. The food provided at the home is of good quality and choices are always available. EVIDENCE: The home provides an activities programme in accordance with the service users’ choices, preferences and capacities in relation to – social, leisure and cultural interests. However, it was noted that the records of activities enjoyed by the service users are not being recorded consistently and appropriately. The Acting Care Manager stated that the staff would be asked to record accurately in the format provided all the activities undertaken by service users and incorporated into all the individual service users’ care plans. Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 14 Several of the service users spoken to stated that they are in regular contact with their family members and friends, and spoke about their visitors’ involvement and interest in their daily care matters. The visitors’ book kept in the home showed a considerable activity. The relatives of two service users stated that they visit the home at various times of the day as they wish. Three relatives who spoke to the Inspector said they are given warm and friendly welcome by the staff whenever they visit. The service users also keep contacts with the local community – for example, church services, shops, pubs and park. The Acting Care Manager stated that the service users are positively encouraged and helped to exercise their choice and control over their lives and daily living, subject to risk assessments in terms of safety, security and capacity to make certain decisions. A close liaison is maintained with the relatives and representatives, where the service users are not able to make certain decisions. The service users and their relatives are informed of the availability of the Advocacy Service based at the local Age Concern. The information about the Advocacy Service is included in the home’s Statement of Purpose and the Service Users’ Guide. Several service users told the Inspector “the food was very nice and tasty”. The consensus of service users was the range, quality and choice of food provided was very good and the home caters for those service users who have individual preferences and medical needs. The Acting Care Manager stated that the menu is changed on a regular basis in consultation with the service users. The kitchen is well equipped and kept clean and tidy. The catering staff are well trained in food safety and hygiene matters. Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in these outcome areas is Good. This judgement has been made using available evidence including a visit to this service. The overall outcome for this group of Standards is judged to be Good. There is a clear complaints procedure in place, a copy of which is made available to service users and their relatives. This should ensure that any complaints made are listened to and acted upon. The home has an Adult Protection Policy and Procedure to protect service users from abuse. EVIDENCE: The home has a good complaints procedure in place, which is referred to in the home’s Service Users’ Guide and in the Statement of Purpose. There is a system of recording concerns and complaints. It was noted that there has been one complaint made against the staff of the home at the beginning of March 2007 by a member of staff. This was directed to the Commission for Social Care Inspection (CSCI). The Registered Providers are investigating the issues raised by the complainant and will respond in accordance with the Home’s policies and procedures and timescale. Service users, when asked, were certain of how to formally make a complaint but they said they would quite happily talk to one of the staff in charge or the manager. Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 16 The home has not had to report any vulnerable adult issues. The home has good policies and procedures regarding restraint, dealing with aggressive behaviour and prevention of abuse, which includes whistle-blowing policy. The Acting Care Manager stated that adult protection issues are discussed during induction training and supervision meetings. The Registered Providers stated that all members of staff will receive training in protection of vulnerable adults as a matter of priority. Several service users stated that they are satisfied with the service provision, feel safe and well supported by staff that have their protection and safety as a priority. Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in these outcome areas is Good. This judgement has been made using available evidence including a visit to this service. General standard of the environment is good providing a homely and secure place to live. The ongoing cleaning schedule maintains the standard of hygiene throughout the home. EVIDENCE: The home offers a comfortable and well-maintained environment to all service users. The home has ample communal space – two separate lounges and dining areas and a conservatory. The home has a rolling programme of redecoration to maintain good standards. The garden and patio areas are also well-maintained. The home has implemented all the requirements and recommendations contained in the recent inspection reports of the Fire Safety Officer and the Environmental Health Officer. Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 18 The home has provided suitable aids and adaptations in the home to meet the general and specific needs of all the service users. There are adequate number of bathrooms/showers and WCs in the home. It was noted that the bedrooms have been “personalised” by the service users. However, it was noted that the carpets in the communal areas – i.e. lounges/dining areas and corridors on the ground and first floors need professional steam cleaning. During the day of inspection, the home was found to be clean, tidy and free from any unpleasant odour. The home has good policies and procedures in place regarding infection control. It was noted from staff training records that several members of staff have completed their training in infection control. In addition, all members of staff have received induction training and they are made aware of the dangers of cross-infection. Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Glenthorne House is adequately staffed by well - trained staff to meet the needs of service users. There are robust recruitment procedures in place to protect the service users. There is a good training programme in place that ensures staff are competent to do their job. New members of staff receive structured induction training. EVIDENCE: The staff rotas available in the home showed that the home at present is adequately staffed (i.e. a senior carer, two carers during the day and two carers on wakeful duty at night) to care for 18 service users. The home also employs sufficient cooking and housekeeping staff. The Acting Care Manager’s hours are considered to be supernumerary. At least 80 of care staff group have achieved NVQ Level 2. Those that have not yet achieved the award are undergoing the training at present. The home does not employ Agency staff. Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 20 Four staff files were examined in detail in order to check compliance with recruitment requirements. All four files contained copies of 2 written references and a full employment history. There was evidence on files that all four had been subject to satisfactory Criminal Records Bureau and POVA checks prior to being appointed. All staff are given copies of the General Social Care Council Code of Conduct and sign to verify that they have received it. There is evidence on files that staff receive statements of their terms and conditions of employment. There is a staff training and development programme in place. In addition to the mandatory health and safety training (see Standard 38), staff also take part in Dementia Care training. The file of a newly appointed worker showed that she had received full induction training to Skills for Care specifications. Staff spoken to also confirmed that they had received a full induction. Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33,35, 36 and 38. Quality in these outcome areas is Good. This judgement has been made using available evidence including a visit to this service. The Registered Providers have appointed a new Acting Care Manager and attention needs to be given to formalising the position of Ms Carrol Marshall. An application for registration with CSCI must be pursued as a matter of priority. There are satisfactory systems of communication in place to seek views and feedback from the service users and their families/friends. Service users’ monies are kept securely and proper records are maintained. Staff need to be supervised formally at the required intervals. The health and safety of service users and staff are protected by the home’s policies and procedures. EVIDENCE: Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 22 The home is without a Registered Manager. However, the Registered Providers have appointed a new Acting Care Manager. Ms Carrol Marshall appears to be managing the home well. The Registered Providers stated that a formal application to register Ms Marshall would be submitted shortly to the CSCI. There are clear lines of accountability within the home and the Acting Care Manager is well supported by the Registered Providers. The home has a formal staff supervision system in place and the new Acting Care Manager have already begun to implement supervision of staff and meetings with staff and service users are already being held. Observations made and discussions with service users and staff indicated that the new Acting Care Manager is very approachable and operates an open door policy. The service users, who could express themselves stated that they are happy to approach the Acting Care Manager and senior staff with any problems they might have and were confident that they would respond to them. It was noted that the home has a Quality Assurance monitoring system in place, which includes questionnaires to service users, visitors, and relatives to obtain feedback on the quality of service. The feedback from the monitoring report for the year 2006 was generally very positive regarding the home and care received. However, there were comments regarding the quality in some areas – for example lack of activities and choice of meals. The Registered Providers stated that an action plan has been implemented to address all of the issues raised by the service users and their relatives, including a formal programme of daily activities, revision of menus and review of provision of information for service users – i.e. complaints procedure and social and leisure activities in the home and outings/trips. The Registered Providers stated that they are in the process of implementing their annual Quality Assurance monitoring for the year 2007 shortly and hope to complete the process by end of May 2007. Service users’ financial affairs are mostly taken care of by their relatives. The home, however, look after some personal allowances on behalf of service users. The Acting Care Manager does not act as appointee for any of the service users. A random sample of the individual monies and accompanying records were seen at the inspection and all were in order. All monies are kept in appropriate safe keeping. Not all members of staff have received the required numbers of formal supervision meetings over the recent months. The Acting Care Manager stated that she will commence formal staff supervision meetings with immediate effect. Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 23 From staff training records seen and from conversations with care staff, there is evidence that regular training takes place in key areas of moving and handling, health and safety, fire safety, first aid, food hygiene and infection control. The Registered Providers stated that all members of staff who as yet not received mandatory training in safe working practices topics would do so as a matter of priority. The home has good health and safety policy and all staff are aware of their responsibilities regarding these issues and a majority of staff have received training on these issues. Matters pertaining to fire safety and environmental health were found to be satisfactory and all issues identified in the inspection report dated 12 December 2006 of the Environmental Health Officer have been appropriately implemented. All safety systems and equipment are regularly checked and well maintained and records of all checks kept up to date. Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 3 Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP31 Regulation 9 Requirement The Registered Providers must ensure that an application for registration of the newly appointed acting care manager is brought forward as a matter of priority. Timescale for action 30/04/07 2. OP19 23 The Registered Providers must ensure that the carpets in the first and ground floor corridors and lounges/dining areas are professionally cleaned. The Registered Providers must ensure that the service users’ care plans are kept up to date and reviewed on a monthly basis. 30/04/07 3 OP7 15 30/04/07 Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP19 Good Practice Recommendations That the Registered Providers should give consideration that the two double rooms become single rooms fitted with en-suite That the Registered Providers should consider providing specialist training for staff in adult protection from abuse, dementia care, and disability awareness. As a matter of good practice and staff development. 2 OP30 Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Glenthorne House DS0000040718.V332331.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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