Inspection on 05/06/07 for Glow Rest Home

This inspection was carried out on 5th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Glow Rest Home 03/04/06

Glow Rest Home 05/04/05

Glow Rest Home 23/11/04

Glow Rest Home 26/08/04

Glow Rest Home 16/12/03

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

CARE HOMES FOR OLDER PEOPLE Glow Rest Home 58 Villiers Avenue Surbiton Surrey KT5 8BD Lead Inspector Barry Khabbazi Key Unannounced Inspection 5th June 2007 9:30am 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 Glow Rest Home DS0000013416.V342515.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. Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glow Rest Home Address 58 Villiers Avenue Surbiton Surrey KT5 8BD 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) 020 8399 2614 F/P 020 8399 2614 alomaglowacki@yahoo.co.uk Mrs Aloma Glowacki Mrs Aloma Glowacki Care Home 3 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (3) of places Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd April 2006 Brief Description of the Service: Glow Rest Home is registered with the Commission for the provision of residential care to a maximum of three service users. The home is situated within easy reach by car or public transport of both Surbiton and Kingston town centres. On-street parking outside the property is limited, but the home has sufficient hard standing to provide parking for up to four vehicles. All service users bedrooms are on the first floor of the property. The building does not have an elevator or stair lift. To the rear of the property, a mature garden. The fees are currently from £357 to 400 per week Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and started at 9.30 a.m. The inspector was able to speak to all the residents as with the last inspection. At this inspection a friend of one of the residents was also visiting. During this inspection the manager/owner was interviewed. Records, care plans, policies, and the building were examined, as were all the residents’ bedrooms. Although requirements remain from the last report, progress towards meeting these had been made. Although reviews and staff supervision were occurring, the existing requirements refer mainly to these being documented more regularly . The timescales for implementing these requirements have therefore been extended. The care of the residents remains to a high standard. This has been consistently confirmed by residents themselves and by the Commission’s communications with relatives. What the service does well: This is a home for older people where the residents experience a caring family like environment. All the residents have consistently commented about liking living in the home, and liking their rooms, meals and how they are treated. Bedroom sizes exceed those required under the National Minimum Standards, which gives more personal space for the residents. Communal sizes exceed those required under the National Minimum Standards, which gives more shared space for the residents. It is seen as good practice that the home supports relatives’ wishes to maintain contact with the home following bereavement. It is seen as good practice that the home does not manage any residents’ money and it is to be commended for pursuing alternative solutions. This home is very well maintained. It was reassuring to see that the home was as particularly clean and hygienic, as it was at previous unannounced inspections. Relatives and residents have all consistently confirmed this in communications with the inspector. This standard is currently exceeded. Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The Statement Of Purpose and the Service Users Guide do not contain all the information required. This means that potential new residents and those making placements are not provided with all the information they need to make an informed decision about moving in to the home. Although not finalised, the Statement of Purpose and Service User Guide have been updated and are awaiting printing Reviews were not occurring with a satisfactory frequency. This could affect the staffs’ knowledge of the changing needs of the residents. Although reviews are now occurring these need to be on a monthly basis to fully meet the standard required. Although progress has been made with regards to the frequency of recorded staff supervision, this still does not meet the required frequency. This area therefore remains unsatisfactory as it could affect the quality of the work that staff do. The 5 year electrical wiring certificate and portable appliance testing certificate were out of date. This is not currently of serious concern as the home is generally very well maintained and the last certificate had only just become out of date, but it does need to be done to ensure that wiring remains safe. In addition evidence of these tests being booked was presented at this inspection Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Glow Rest Home DS0000013416.V342515.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 Glow Rest Home DS0000013416.V342515.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): Standards 1, 3, and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Potential new residents and those making placements are provided with most, but not all the information they need to make an informed decision about moving in to the home. The initial assessment now covers all the elements of Standard 3. This will result in more detailed and relevant assessments of a resident’s individual needs and a better understanding of needs by staff. This home does not provide intermediate care with a view to return to the community and Standard 6 is therefore not applicable. EVIDENCE: Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 10 The last report recorded that, ‘The home’s Statement Of Purpose is made up of the brochure and additional documents. The Statement Of Purpose was mixed in with procedures in the procedures file and therefore could not be presented to those making placements. In addition, these did not include all the information required, for example, the qualifications and experience of staff. The following requirement is now set to address this shortfall: The Statement Of Purpose must contain all the information required under Schedule 1 and be in a format that can be given to those making placements.’ The manager had done work on this by the time of this inspection but the document had not been completed. The last report also recorded that ’The Service Users Guide was also made up of the brochure and additional documents. However these did not include all the information required, for example, the views of the residents and the qualifications and experience of staff. The following requirement is now set to address this shortfall: The Service Users Guide must contain all the information required under Standard 1 including the views of the service users. The manager had also done work on this by the time of this inspection but the document had not been completed. The home uses ‘Standex’ medical assessment forms, which while being comprehensive from a clinical perspective, do not cover any social needs. The manager has since therefore amended both care plans and assessments to cover all the additional elements of Standard 3.3, and in particular a history falls, oral health, mobility, social interests, religious and cultural needs and carer and family involvement and other social contacts. The initial assessment now covers all the elements of Standard 3. This will result in more detailed and relevant assessments of a resident’s individual needs and a better understanding of needs by staff. This home does not provide intermediate care with a view to return to the community and Standard 6 is therefore not applicable. Glow Rest Home DS0000013416.V342515.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, 10, and 11. Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. Plans of care are now more holistic but records of the reviews need to be recorded more frequently . This will help staff know all a resident’s needs and how to meet them. Residents’ personal care needs and physical and emotional health needs are met well by this home. This ensures that the residents’ physical and emotional health is well maintained and therefore the quality of life experienced is also maximised. Residents’ medication is also well managed to ensure maximised good health. The residents’ needs regarding terminal care and following death are met well and this Standard is exceeded. Good practice has been identified in treating residents and relatives with respect and sensitivity at times of illness and death. EVIDENCE: Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 12 Care Plans now cover all the elements of Standard 3.3. {See Standard 1}. While examining the residents’ files at the last inspection, it was ascertained that reviews were not occurring monthly as required under Standard 7. The following requirement was then set: Reviews must occur on a monthly basis. Although these are now more regular they are not being all recorded as required under this Standard. This requirement will therefore remain in force until fully met. Pressure sore avoidance procedures include hygiene and regular toileting, nutritional and fluid monitoring and supplements, and activities to promote mobility. The nutritional needs of service users are also closely monitored. Residents’ weights are monitored and recorded where dietary concerns exist. Service users remain registered with their own family General Practitioner whenever it is practicable to do so. The owner has stated that a chiropodist visits the home approximately once every six weeks at no charge to service users although private services are also available. The GP has been visiting regularly to review medication as has the pharmacist. Medicines are currently stored in a metal cupboard attached to the wall in each individual’s bedroom. This system is being changed to one metal cupboard attached to the wall in a communal area. Residents can self medicate subject to a risk assessment and all have lockable cabinets in their rooms to facilitate this. Staff were observed to interact with service users with respect and dignity and demonstrated a good relationship with them. This was confirmed through discussions with residents and relatives. Personal care needs were addressed promptly, and in a fashion that maintains the respect and dignity of service users. There are flexible visiting hours and relatives, friends and visiting professionals can meet residents privately in their own rooms or in a separate room. There are no shared rooms at this home. Procedures are in place for death and dying and evidence for preparation for this was observed. The procedure includes recording the service users’ wishes regarding terminal care and arrangements after death. Residents are able to spend their final days in their rooms and specialist medical care is brought in if required and appropriate attention to pain relief given. The following evidence of good practice was presented: The home provided evidence of supporting relatives’ wishes to maintain contact with the home following a bereavement. Glow Rest Home DS0000013416.V342515.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): Standards 12, 13, 14, and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s policies support visits to the residents from relatives and friends. Residents are provided with opportunities to remain part of the local community and are able to take part in appropriate activities. Dietary needs are well catered for and a well balanced diet is provided, to ensure health and enjoyment of food. The daily routines and the home’s policies promote the residents’ choice and rights, to ensure equality and that all rights are enjoyed by all residents. EVIDENCE: The routines of daily living and activities are made as flexible as possible, for example there is no set bed time or getting up time and service users can change the bathing day wanted. The inspector was able to speak to all the residents at the last inspection, at this inspection two residents were sleeping in late and the third was awake. It was good to see that the residents themselves were able to choose when to get up when they wanted and not when it suited staff. Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 14 Group activities included: ball games, skittles, and the home also has links with other similar services in the area and service users are encouraged to maintain social contact with their peers through open coffee mornings in the home. Individual activities also occur and events and birthdays are also celebrated. The owner/ registered manager provides transport, if required, to enable residents to undertake visits to places of interest locally. Residents are encouraged to receive visitors at all times, although the home requests that visitors are requested to avoid mealtimes unless invited to share a meal with residents. Visitors were present at 3 out of the last 4 inspections. Community interaction includes the local town centre’s resources and shops. Residents are able to attend church should they wish to do so. The owner reported good relationships with neighbours. The home is run in a manner that promotes choice and independence and this was confirmed through service users’ comments, policies, and observation. Residents can take meals, and particularly snacks, at times and places to suit them and have a choice of meals and alternatives. Residents can bring in their own possessions and furniture if they wish and this was observed in their rooms, which had been individualised. The home has demonstrated good practice by not taking responsibility for the control or administration of any resident’s finances. Where an individual may not be able to exercise control in this area the home will liase with relatives or independent advocates, for example solicitors. Meals can be taken in the dining room or conservatory, which had room for all residents to be seated. The home menus are based on the likes and dislikes of the home’s residents. These were examined and appeared nutritious and varied. Meals can be taken separately to the main dining room if wanted. Additional drinks and snacks are available at any time. The inspector was invited to take a meal with the residents at the last inspection and would like to thank them for their hospitality. The meal was pleasant, nutritious and served in a congenial environment. Staff provided assistance to service users discretely where necessary. Residents have previously described the food as “lovely”. At the last inspection all the service users also commented positively about the meal and all seemed to eat well. Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 15 Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 16 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): Standards 16 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints are generally managed well which should ensure that residents’ and relatives’ concerns are listened to. The home’s policies and procedures help generally protect residents from abuse and help staff if they need to tell someone about any bad care practice they may see. EVIDENCE: The home has not received any complaints over the last 48 months. The complaints procedure was clear and contained all the elements required including a written maximum response time of less than 28 days and details of how to contact the Commission. The home has a copy of the local Adult Protection procedure. The home has Violence at Work Policy that gives guidance regarding restraint. The home also has a Whistle Blowing Policy and an Abuse Policy. The Gifts Policy was updated during last year’s inspection to also preclude staff from being involved in the making or being the beneficiary of service users’ wills as required under this Standard. The home does not handle any service users’ money and there are lockable spaces in service users’ rooms and a safe for secure holding of valuables. The manager is currently updating a number of policies. Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 17 These include the restraints procedure. The following recommendation is set to support this. The manager should continue with the current updating of policies. Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 18 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, 20, 23, 24, 25 and 26. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is in very good condition externally and internally, and is well decorated in a homely fashion and very well maintained. This creates a pleasant environment that promotes the residents’ dignity and emotional wellbeing. Bedroom sizes and communal area sizes exceed the National Minimum Standard providing extra space for the residents. Residents’ rooms contain all the furniture required under the National Minimum Standards unless recorded choice or risk assessment shows otherwise. This will ensure that the residents have all the furniture they are entitled to supplied by the home, unless they do not want a particular item. The home is particularly hygienic and clean, homely and comfortable; this environment therefore promotes a pleasant environment, the residents’ health, and emotional well-being. Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 19 EVIDENCE: The home has a lounge and dinning room, which are both large enough for all the service users to sit together if they wished. In addition, there is a new conservatory. Communal sizes exceed that required under the National Minimum Standards, which gives more shared space for the residents. The home accommodates three service users in three separate rooms. Bedroom sizes exceed that required under the National Minimum Standards, which gives more personal space for the residents. The 2003 inspection report contained the following requirement: All windows from which there is a risk of falling must be fitted with appropriate restrictors. This has now occurred and this requirement is now met. All the residents’ bedrooms were seen at this and this and the last unannounced inspection. Bedrooms were decorated to a high standard. The bedrooms were highly personalised and reflected the individual tastes and preferences of their occupants. Residents spoken to during the inspection confirmed that they had been able to bring items with them on admission, including photographs, ornaments and in some cases items of furniture. Service users also confirmed that they liked their rooms. The home always gives the impression of a very clean and hygienic home. The building was clean and tidy and rooms were free of offensive odours. This has been the case at all announced and unannounced inspection visits. Laundry facilities have easily cleanable floors and walls. The home has policies covering storage, infection control and dealing with spillages. Hand washing facilities and protective clothing are available where required. At all inspections, announced and unannounced, it was reassuring to see that the home was particularly clean and hygienic. This is an area of good practice commented on by residents during inspections and by relatives in recent surveys. Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 20 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): Standards 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff numbers are of sufficient quantity to meet the residents’ needs and provide consistency. The residents are not supported by a staff group where 50 or more have the required qualifications. Achieving this will raise the quality of staff, their knowledge and their practices. The staff vetting procedure is now much improved, although refarances are also needed for staff known to the manager to meet the National Minimum Standards fully. This should help protect the residents from undesirable staff. Induction and foundation training to National Training Organisation’s specifications is now in place EVIDENCE: Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 21 Last year’s unannounced inspection report specifically examined staff numbers and quantity and found that they met the residents’ needs and provided consistency. See that report for details. In addition to the registered manager’s 42 hours there is a total of 35 care staff hours per week The home is managed and run on a day-to-day basis by the owner/manager, with assistance provided by staff. Both the owner and staff members live on site and are therefore available in case of emergency. The owner has reported that, in her absence from the service, she liases with other local homes with which she has links, to make appropriate arrangements for cover. This was also confirmed at the last unannounced inspection. The staff vetting procedure is now much improved and all the required documents were in place except for one reference. This member of staff is well known to the owner/manager and therefore the lack of a reference is not of grate concern. However references are also needed for staff known to the manager to meet the National Minimum Standards fully. The following mew requirement is set to address this: Written references are needed for all staff employed at the home. None of the staff have the required NVQ 2. Whilst recognising that this is a small home and outcomes for service users are positive, the following requirement is now made: 50 of staff must have an NVQ2 qualification. This home’s policies are currently being updated. {See recommendation under standard 18.} Staff files were examined, Criminal Record Bureau checks are sought for staff before employment begins, references and proof of identification were checked and were present for all staff. External volunteers are not currently used at this home. The staff files sampled also contained interview notes, statements of terms and conditions and staff photographs. Staff training meets National Training Organisation standards and specifications. The registered manager had recruited a new staff member at the time of the last inspection. The home had acquired the ‘Training Of Personal Social Services’ induction packs and the new member of staff has started this induction system. Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 22 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): Standards: 31 33, 35, 36, and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a generally well run home although the manager still needs to complete the registered managers award. The home has implemented a quality assurance system and an annual development plan, with both involving residents. This should ensure that the home is run in a way that involves the residents and a way that is in the best interests of the residents. Residents’ financial interests are safeguarded by the home’s policies and practice. Only limited progress has been made with regards to the frequency of recorded staff supervision. This could affect the quality of the work that staff do. Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 23 Although health and safety policies and procedures do generally protect the residents, further checks need to be done to ensure that the electrical systems are safe. EVIDENCE: The manager has many years experience in the field and is a qualified nurse. The manager however is not qualified to NVQ 4 in management and needs this element under this Standard. As the deadline {set under the Standards} for completing this has elapsed, the following new requirement is set. The manager must complete the NVQ 4 registered managers award Quality assurance tools currently include service users questionnaires, service user meetings and a complaints system. These quality assurance tools have been pulled together into an internal quality assurance system, which includes this information in the home’s annual plan where appropriate, and then provides a system of feedback and review involving the service users in the form of resident meetings. This should allow open measuring of achievement in improving quality. The home does not hold savings for, or act on behalf of, service users. Evidence of good practice presented: The home is to be commended for pursuing alternative solutions regarding management of service users’ money. The last inspection report recorded that supervision is occurring but this is not being recorded as required under this Standard. The following requirement was then set to address this shortfall: Formal supervision sessions must occur at least six times a year and must be recorded and cover all the elements of Standard 36.3. This had not occurred yet and the requirement remains in force. All of the health and safety policies and procedures relevant to this Standard have been seen to be present. Fire Safety, First Aid, Food Hygiene, Infection Control, and Handling and Disposal of Clinical Waste policies are all also included in staff induction. Control Of Substances Hazardous to Health policies and data sheets were available and these substances were all locked away. Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 24 All of the procedures and testing of systems required in Standard 38 were also present except an up to date 5 year electrical wiring certificate and the Portable appliance testing certificate. The following new requirement is now therefore set: An up to date 5 year electrical wiring safety certificate and a portable appliance testing certificate must be sent into the Commission. Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 x 3 x x N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 3 4 x x 4 3 3 4 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 2 x 2 Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4[1][C] Requirement The Statement Of Purpose must contain all the information required under Schedule 1 and be in a format that can be given to those making placements. The Service Users Guide must contain all the information required under Standard 1 including the views of the service users. Reviews must occur on a monthly basis. 50 of staff must have an NVQ2 qualification. The manager must complete the NVQ 4 registered managers award. Formal supervision sessions must occur at least six times a year and must be recorded and cover all the elements of Standard 36.3 An up to date 5 year electrical wiring safety certificate and a portable appliance testing certificate must be sent into the Commission. Written references are needed for all staff employed at the home. Timescale for action 01/10/07 2. OP1 5 12[3] 01/10/07 3. 4. 5. 6. OP7 YA30 YA37 OP36 15[2]b 18[1]a 9(2) i 17[2]b 1 8[2] 01/09/07 01/04/08 01/04/08 01/09/07 7. OP38 12[1] 01/09/07 8 OP29 17 01/09/07 Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 27 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 OP18 Good Practice Recommendations The manager should continue with the current updating of policies. Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Glow Rest Home DS0000013416.V342515.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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