Inspection on 12/03/07 for Pembroke Lodge

This inspection was carried out on 12th 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Pembroke Lodge 08/12/09

Pembroke Lodge 05/11/07

Pembroke Lodge 03/10/05

Pembroke Lodge 21/04/05

Pembroke Lodge 04/10/04

Pembroke Lodge 08/07/04

Pembroke Lodge 09/03/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Glenside Centre for Brain Injury Assessment & Rehabilitation South Newton Salisbury Wiltshire SP2 0QD Lead Inspector Karen Mandle Key Unannounced Inspection 12th March 2007 09:30 Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.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 Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.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 Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glenside Centre for Brain Injury Assessment & Rehabilitation South Newton Salisbury Wiltshire SP2 0QD 01722 742066 Address 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 Anita Diane Smith Care Home 14 Category(ies) of Physical disability (14) registration, with number of places Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The staffing levels set out in the Notice of Decision dated 18 November 2002 must be met at all times 3rd October 2005 Date of last inspection Brief Description of the Service: Glenside Centre for Brain Injury Assessment and Rehabilitation is a 14-bedded nursing assessment and rehabilitation unit for younger adults with acquired brain injury. The centre is also known as the ARC. The ARC is a care facility based on rehabilitation however several service users are currently being provided with long term care due to complex nursing needs. Following rehabilitation, the Service User will move to another appropriate facility or home. The building was purpose built for the client group. All bedrooms and living facilities are on the ground floor, with wide corridors. The bedrooms are single all with an en-suite facility providing a good standard of accommodation. A team of nursing staff, physiotherapists, occupational therapists and rehabilitation assistants provide care and support to the Service Users group. The ARC is one of six registered care homes on one campus which are owned by Glenside Manor Health Service Ltd. Mr Andrew Norman is the nominated responsible individual and Mrs Anita Smith is the Registered Manager of the home. Glenside Manor Health Services are situated in the village of South Newton, on the A36, five miles north west of Salisbury. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.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 12th 2007. The inspection commenced at 9.30am and was completed at 3.45pm. The manager Anita Smith was not available for the inspection. The nurse in charge who assisted with the inspection was Jenny Davies, who was open to the inspection process and very helpful through out the day. The inspector was able to freely visit each service user and talk with staff. During the visit, the inspector observed staff interacting and caring for service users. Many service users living at the Arc have very limited communication, however a service user who was able to communicate said, “I am really happy here and doing well”. A number of records were reviewed such as care plans, medication records and health and safety records. Six requirements had been made at the previous inspection, which had been met. Six requirements and one good practice recommendation were made following this inspection. The judgments contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experience of people using the service. What the service does well: What has improved since the last inspection? The range and amount of social activities provided has increased, however with many of the service users currently living at the Arc, participation in activities is limited or impossible. All food supplements were in date and monitored. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.R01.S.doc Version 5.2 Page 6 Food stored in the fridge was dated. The menus have been revised to suite the range of service users. All staff have now undertaken a Criminal Record Bureau check. Two written references, including a reference to the person’s last period of employment, have been obtained for all new staff. Details of any criminal offences of which a staff member has been convicted are now being risk assessed. The manager is now being involved in interviewing potential staff members. What they could do better: 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 Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.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 Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.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. An admission procedure is in place. Prospective service users are assessed prior to admission to ensure that the service is able to meet their needs. EVIDENCE: All prospective service users are fully assessed by the registered manager, Anita Smith or Helen Pessell, operations manager, with usually another member of the team such as a therapist. The assessment is conducted to ensure that the home can meet the nursing, social care and the rehabilitation needs of the individual service user. The pre admission assessments of two service users were seen which contained relevant information relating to all aspects of care required by the service user. Due to the complex and high dependency needs of the service user group, further information where possible will be obtained from the care manager, transferring hospital and families. A record of the assessment is kept on the service users’ file and used towards implementing a care plan and rehabilitation pathway. A baseline assessment is also conducted at the time of admission. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.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 adequate. This judgement has been made using available evidence including a visit to this service. Service users are provided with comprehensive care plans, which are reviewed monthly, however not all care needs identified are fully met in practice. Due to the high dependency of the service users, decision-making is limited, as is an independent lifestyle at this stage of rehabilitation. EVIDENCE: Each service users is provided with a care plan. The inspector reviewed 4 care plans following visits with the service users. The care plans provided detailed information relating to support, rehabilitation needs and goals of the service users, health care needs and social background. Evidence was seen of monthly reviews taking place and when a change in care needs occurred. Appropriate risk assessments were in place such as tissue viability, nutritional assessments and manual handling assessments. Service users and families are involved with care planning where possible. Following a visit with a high dependency Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.R01.S.doc Version 5.2 Page 10 service user, it appeared that a care need had been identified in the care record, which was supported by providing clear instruction to care staff on how to meet the care need but was not being fully addressed in practice. High dependency daily monitoring charts were in place, however the instructions of how care should be provided according to the high dependency charts was again not being fully provided. The degree of decisions making that service users at the Arc can make is extremely varied due to their individual complex health needs. Through observation of the staffs’ interaction with service users, it was evident where possible that the staff tried and supported service users to make decisions and choices. A service user with limited communication was observed making decisions at lunch time, as to where to eat his meal and what to eat with a member of staff, who’s approach was very supportive and unhurried. A service user who was able to communicate said “ I can spend most of the day doing as I wish, apart from when I am receiving treatment”. Due to the complex brain injuries that the majority of service users had experienced, taking risks as part of an independent life would be limited but would be considered as part of the rehabilitation plan of care, which aims to provide an outcome where possible that service users will regain an independent lifestyle. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.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 able to participate in a range of activities according to their needs. Service users are supported to maintain links with family and friends. Service users are treated with respect and their dignity maintained. Service users are provided with a varied and balanced diet. EVIDENCE: The Arc is a rehabilitation unit therefore the majority of activities provided are centre around the rehabilitation of the service user. Each service user had an individual daily activity programme, which correlates with their rehabilitation needs, combined with social care needs. During the morning of the inspection a Yoga class took place in the communal lounge which one service users was able to participate in. The service user said following the class “I really enjoyed that, it was fun and good for me”. Other activities include church services, social groups and where appropriate home visits. Service users also had radios and TV’s in their rooms, some with DVD’S. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.R01.S.doc Version 5.2 Page 12 As part of the ethos of the Arc, service users are supported and encouraged to regain the skills and confidence to be part of the local community. Where possible service users go to the local theatres, cinemas and shopping trips. Service users are supported to maintain links with family and friends. Again the ethos of the home is to encourage and support families to be part of the rehabilitation programme, as this would be regarded as an important part of the programme. A visitor was spoken with during the morning that said, “I’m really pleased with the care here”. Family and friends can visit the home at any reasonable time, which was evidenced through the visitors signing in book. A service user was also observed going out in a car with family during the afternoon. Staff were observed and heard approaching service users in a respectful manner. Staff were observed knocking on bedroom doors before entering and identifying themselves to those service users with high dependency needs. Whilst care was being provided, staff could be heard informing the service users what they were going to do next and how, whilst respecting their dignity. The staff was observed interacting well with service users and even when communication was limited, the staff worked hard to understand the wishes of the service users. The menus for all six homes have recently been reviewed and changes made to consider dietary needs and the range of people living there. Only five service users were able eat a normal diet. The others due to swallowing difficulties were fed via a gastric feeding tube, with all appropriate systems in place to support this method of feeding. The inspector sat with the service users at lunchtime who were complimentary of the food provided. A service user who wished to have her hot meal in the evening was given a sandwich at lunchtime and the carer saved her hot meal for the evening. The weights of service users are monitored and nutritional risk assessments are in place. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.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 adequate. This judgement has been made using available evidence including a visit to this service. The nursing and care needs of some high dependency service users had not been fully met. The medication system was safe, however care plans should be in place to support the use of some medications. EVIDENCE: The majority of the service users require full support in meeting their personal care needs, from two members of staff. A team of physiotherapists, occupational therapist, speech therapists and psychologists are employed for the site that work with the care team. It was observed that the physiotherapists provide good clear instructions on how to position high dependency service users whilst in and out of bed and instructed as to what equipment to use. Through observation it was evident that the instructions were being followed. The appearance of service users was good, giving consideration that some service users find being provided with personal care very difficult and can trigger out bursts of inappropriate behaviours. All Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.R01.S.doc Version 5.2 Page 14 personal care was provided in the privacy of the service users bedroom or bathroom. Service users are registered with a local GP who visits the home weekly or more if requested. Clear records are kept of GP visits and other health care professionals who are involved. As stated under Standard 6 of this report, the high dependency service users had a high dependency care chart for monitoring change and frequency of position, frequency of mouth care, fluid input and output. However the frequency of care instructed by the chart was not being fully put in to practice, service users were not being repositioned as frequently as the chart recommended or in one case as recommended in the service users’ care plan. Evidence was seen of other health care professionals being contacted, when health care needs changed. The medication procedure was assessed. The medication was stored correctly, as were the controlled drugs. The medication records were up to date. The controlled medication register was correct. The disposal of medications procedure was in line with current legislation. At this point of rehabilitation service users were not able to self medicate. A prn medication or “as required” had been prescribed but it was not clear as the reason for the medication. Care plans should be in place to support the use of the prn medication and to provide instruction to the staff when the medication should be used and frequently review the use of the medication. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.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 adequate. This judgement has been made using available evidence including a visit to this service. A clear complaints procedure is in place and openly displayed in the home. There are policies and procedures provided by the company to ensure that service users are protected from abuse, however a clear understanding of the procedures is lacking within the unit. EVIDENCE: A good, clear complaints policy is in place for all six homes on site. The complaints policy is available in all the units, openly displayed in the entrance halls. Each home keeps a log of complaints and outcome to the complaints. The manager was not available for the inspection; therefore the log was not viewed on this occasion. The majority of service users would be unable to make a complaint due to their very complex needs, however systems are in place for families and representatives to make a complaint. The Glenside Group have a clear policy and procedure relating to the protection of vulnerable adults, which was seen. Following a discussion with a staff member, it was evident, although having been provided with training that the chain of referral, in line with local policy and guidelines, was not fully clear posing a risk to service users. A vulnerable adults issue is currently being investigated, however the referral was delayed. It will be required that all staff working on the Arc receive further training in this area to fully understand the homes’ and local procedures ensuring the safety of service users. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Arc provides a good standard of accommodation, which is well maintained. The bedrooms had been personalised offering a homely environment for service users to live in. The home is well equipped and offers a range of treatment rooms to support rehabilitation programmes. EVIDENCE: The Arc is a purpose built unit designed to meet the needs of the service users group. The Arc is spacious, providing good communal space, a separate dining area and rehabilitation treatment rooms, which can also be used for other service users living on site. The furnishings are domestic and homely. The corridors are wide to suit the needs of wheelchair users. The bedrooms are again spacious, which all have an en suite facility. Service users and families are encouraged to personalise their bedrooms, which creates a homely feel. The home is well equipped with a range of equipment to Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.R01.S.doc Version 5.2 Page 17 meet the needs of the service users. All the beds are good profiling beds with protective, specialised mattress to meet the assessed needs of the individual service user. The home was clean to a good standard throughout and infection control measures in place. However according to the staffing rota, the housekeeper was on annual leave the following week and was not being replaced. Discussion with the maintenance department indicated that while industrial carpet cleaners were available, there were not enough for each registration. This also applied to the weighing scales. Joint use of equipment across the campus needs to be reviewed, as while it is appreciated that sharing of equipment between units may be necessary, such sharing may also involve a range of risks to health and safety and spread of infection. These need to be fully considered. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.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 qualified staff that understand the complex needs of the service user group. Training is provided to ensure that staff are competent to meet the needs of the service users. The Glenside Group’s recruitment procedures protect service users. EVIDENCE: The Arc is registered to provide nursing care; therefore the home operates the staffing levels in line with a condition of registration. A qualified nurse is on duty at all times supported by a team of carers. Service users are also provided with support from occupational and physiotherapists. The home was busy at the time of the inspection with staffing levels lower then normal. However the rotas seen provided evidence that the staffing levels were usually always maintained. Several of the care staff had worked on the unit since it had opened and were obviously experienced in the care needs of the service Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.R01.S.doc Version 5.2 Page 19 user group. Agency staff are not used, as the staff will cover extra shifts if needed. 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 programme when they take up post. 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 fully completed into each area. The Glenside Group supports 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 user need and therapies involved. All staff undergo annual resuscitation training. Additional training to meet service user 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 receive mandatory training. Information is freely available in each registration to show which members of staff need to attend which 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 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 completes an application form and health status questionnaire. At least two suitable references are now obtained prior to employment. All staff are interviewed, using an interview assessment tool. These were fully completed on an individual basis. Staff files showed that there were systems for management of performance, including absences. Where issues were identified, these were followed up with the individual staff member. The Glenside Group has a clear system for regular staff supervisions. All staff spoken with confirmed that they had received supervision at least every six weeks and an annual appraisal. Records relating to supervision and appraisal were seen on staff files. Supervisions and appraisals were individual in tone and issues relating to training and development were consistently included. Records shoed 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-references 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, arrangements had been made for the person to attend training in a timely manner. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.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 adequate. This judgement has been made using available evidence including a visit to this service. Staff require more supervision and guidance from the manager to ensure that all care needs are fully met. Quality assurance and reviews of provision are in place. The health and safety of service users is promoted and protected. EVIDENCE: Mrs Anita Smith is the registered manager of the Arc who unfortunately was not available at the time of the inspection. Mrs Smith is a qualified nurse who has worked with brain injury clients for several years and understands the nursing care needs and rehabilitation programmes. However it would appear that more direct clinical supervision of staff is necessary ensuring that all care needs are being met in line with the care plans, especially the high dependency Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.R01.S.doc Version 5.2 Page 21 service users. A more active response to vulnerable adults issue, ensuring the safety of the service users in her care is necessary. Quality assurance systems are in place across all six homes, with surveys being conducted for families and service users. The senior management conduct good quality audits of each unit on a regular basis and remain very much in touch with each service. A large protect has recently taken place to improve and change the menus to suit the range of service users. 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 services on site. At present night staff are trained in fire safety twice a year. The home is advised that, as fire officers consider that the risk to service users are 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 areas relating to health and safety, such as lifts, hoists and boiler servicing takes place. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.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 2 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 2 ENVIRONMENT Standard No Score 24 4 25 3 26 X 27 X 28 X 29 4 30 3 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 DS0000047643.V329068.R01.S.doc 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 x 2 X 4 X X 3 x Version 5.2 Page 23 Glenside Centre for Brain Injury Assessment & Rehabilitation NO Are there any outstanding requirements from the last inspection? Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.R01.S.doc Version 5.2 Page 24 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 YA19 YA19 Regulation 12 12 Timescale for action The registered person will ensure 02/05/07 that all identified care needs are fully met. The registered person will ensure 02/05/07 that if a high dependency care chart is used that the care provided is in line with the guidelines on the chart unless assessed and documented reason for not following the charts. Where service users are 02/05/07 prescribed a medication on an “as required” (prn) basis, a care plan must be drawn up to direct staff on the indicators for use of such medication. All members of staff will receive 02/06/07 further training in the homes’ and local vulnerable adults procedure. 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. The registered manager will 02/06/07 ensure that staff are supported and supervised to ensure that the aims and objectives of the home are met. Requirement 3 YA20 13 4 YA22 18 (C1) 5 YA30 23 6 YA37 9 (2,b) Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.R01.S.doc Version 5.2 Page 25 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 YA30 Good Practice Recommendations The home should be provided with housekeeping support during periods when the permanent person is on annual leave. Glenside Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.R01.S.doc Version 5.2 Page 26 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 Centre for Brain Injury Assessment & Rehabilitation DS0000047643.V329068.R01.S.doc Version 5.2 Page 27 - 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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