Inspection on 14/06/05 for SCIC - 26 Glebe Road

This inspection was carried out on 14th June 2005.

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

SCIC - 26 Glebe Road 17/10/07

SCIC - 26 Glebe Road 10/03/07

SCIC - 26 Glebe Road 07/12/05

SCIC - 26 Glebe Road 04/03/05

SCIC - 26 Glebe Road 17/08/04

SCIC - 26 Glebe Road 12/03/04

SCIC - 26 Glebe Road 16/12/03

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Polesworth Group Pooley Heights

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Polesworth Group 70 Long Street

Breme

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Polesworth Group 68 Long Street

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

CARE HOME ADULTS 18-65 SCIC - 26 Glebe Road 26 Glebe Road Stratford on Avon Warwickshire CV37 9JU Lead Inspector Kevin Ward Unannounced 14 June 2005 08:30 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 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 Stationary 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. SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service SCIC - 26 Glebe Road Address 26 Glebe Road Stratford On Avon Warwickshire CV37 9JU 01789 298709 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Stratford and District Mencap Mrs Alexandra Louise Arnold PC 4 Category(ies) of LD 3 registration, with number LD(E) 1 of places SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Manager achieves qualifications in both management and care including the Registered Managers Award, by 2005. Date implemented: 28/07/2003 2. The Registered Manager pursues a professional qualification in the field of learning difficulty by undertaking the Learning Difficulty Award Framework level 3 by 2004. Date implemented: 28/07/2003 The Registered Manager to notify the National Care Standards Commission upon successful completion of the above and immediately in the event that the Registered Manager fails to achieve it or that the Registered Manager ceases, for whatever reason, to undertake the stated training. Date implemented: 28/07/2003 People admitted to the home must be in age range of 18 to 64 years. Date implemented: 08/01/2004 3. 4. Date of last inspection 04 March 2005 Brief Description of the Service: Glebe Road is a semi-detached house, which offers long-term accommodation for four adults who have learning disabilities. The current service users are men. The property is rented from a housing association, with staff being provided by Stratford and District Mencap. It is not distinguishable as a care home from the other properties in the road. Car parking is limited. There are gardens to the front and rear of the property. Neighbours have right of way across the back garden, which it was advised does not impact on the service users safety. On the ground floor there is a lounge, kitchen and separate dining room, shower room/toilet, sleeping-in room/office. On the first floor there are four single bedrooms and a bathroom. The house is on the outskirts of Stratford, which is accessible by a regular bus service. SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection involved looking around the home and chatting with two people before they went out for the day and meeting with people in the evening when they had returned from their day service. The inspection also involved meeting with the manager and speaking to staff during the course of the day. A sample of staff recruitment files were examined at the organisation’s head office. Service users care plans were examined and a number of policies and procedures were looked at during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Work has started to devise new care plans for service users that include greater details about their preferences and leisure interests, however there is a need for this work to be completed and for people to be provided with a SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 Page 6 summary of their new plan. Staff have been provided with adult abuse training and procedures are in place for them to follow when reporting any incidents that come to their attention. However there is a need to update the contact details of some agencies listed in these procedures so that the correct people are informed if this becomes necessary. The home typically provides one member of staff on duty during the week and there is only one person on duty on some weekend shifts. There is a need to review staffing levels so that service users can get out more often when they wish to do so. A booklet has been devised to help people to consider their wishes in the event of their death and a second booklet is available for people to comment on life at the home. The manager explained that plans have been made for people to receive support to complete this information in the near future. Overall health and safety issues are well addressed at the home however the annual gas safety check is just overdue and there is a need to fit valves to regulate the hot water, so that it stays at a safe temperature for people and so that the hot water in the cylinder is kept hot enough to reduce any possibility of legionella at the home. The manager is in the process of training for the Registered Managers Award, and plans to have completed this course by September this year. This is essential to meet the conditions of registration in place at the home. 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. SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These Standards were not assessed at this inspection. EVIDENCE: SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 9 The needs of people are being reassessed but need to be fully reflected in the home’s new care plans. Risk assessments are in place to reduce the risks of everyday living and to support people to develop more independence. EVIDENCE: Reviews of social work care plans have recently been carried out, with a view to the organisation agreeing new funding levels with Warwickshire Social Services for people placed at the home. The manager explained that she had delayed reviewing the home’s own care plans, other than for essential changes, whilst the social work reviews were completed, so that both plans are consistent with one another. However the manager was able to demonstrate that the review of the homes care plans had now started and new draft care plans were seen on the managers’ computer. The new care plans are being revised to provide pictures and illustrations to help make the information more accessible to service users. The new care plans also include a helpful index to direct staff to the essential information and risk assessments that they need to consider when undertaking specific tasks, e.g. Personal care or community access. Information contained in service users records indicates that the home SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 Page 10 is seeking the advice and support of relevant professionals to help to address and monitor people’s healthcare needs. Good work has taken place to develop a range of risk assessments to respond to the needs of service users and environmental hazards that people may encounter. A comprehensive package of information has been produced to assist one person to spend time alone safely. The manager confirmed that the time this person spends alone would be increased gradually and closely monitored and reviewed by the home and other relevant professionals, to ensure the safety of the person concerned. SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,16 and 17 There is limited the scope for people to undertake a wide range of leisure activities in order that they might experience a more varied social life and enjoy a holiday. The home respect people’s rights and encourages people to take responsibilities in order to promote their independence. A varied menu is provided that is based on people’s preferences so that service users receive balanced meals that they enjoy. EVIDENCE: 3 people attend a day service between Monday and Friday each week and one person prefers to stay at home. Conversations with people living at the home indicate that they currently enjoy the activities provided at the day service. During the week service users attend some organised activities, e.g. get away club, however there is limited scope for people to go out most evenings other than as a group (this depends on everyone being an agreement). An examination of recent rotas confirmed that the manager endeavours to increase the staffing at weekends, where possible, or arranges for a volunteer to help support people to go out, e.g. shopping or car boot sales. However it is SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 Page 12 not always possible to achieve this. Two people are able to travel independently locally. Comments made by service users and staff confirmed that people go out on occasional outings together and supported to shop for clothes and toiletries. Service users also make use of the local community hairdressers. The manager stated that there are currently no plans to take service users on holiday this year due to staffing availability for this task but that there are plans being made to take people on a number of outings. People living at the home are encouraged to take part in everyday tasks such as food preparation, shopping, cleaning and washing up to support their independence and encourage their involvement in their home. Two service users currently hold a front door key and everyone has previously been issued with a key to their bedrooms. Comments made by a member of staff and the manager explained that service users are given their mail to open and offered support to read it as required. Service users receive assistance to manage their money. Service users have accounts in the own name, however large cash withdrawals are held for safekeeping and service users are issued with money as required. The small group size promotes an informal and relaxed atmosphere within the home. Since the last inspection work has recently taken place to implement a 4 weekly menu plan based on people’s food preferences so that people living at the home receive a consistently balanced and varied diet. An examination of the home’s “food taken” records confirms that there have been improvements to the pudding menu, so that people now get a greater variation of puddings. Comments made by service users and staff confirmed that service users are encouraged to participate in grocery shopping for the home. Comments made by service users indicate that they are able to access snacks if they become hungry between meals. Suitable dining furniture is in place for service users to eat together. SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19, 20 and 21 Staff support and advice is available so that service users receive the help they require to meet their care needs. The home supports service users to make use of community health services so that their health needs are assessed and addressed. Staff are provided with suitable training and procedures to ensure that service users’ medication is held and administered safely. There is an outstanding need to ascertain the wishes of service users (and their relatives) in the event of their death in order that their wishes can be respected in this regard. EVIDENCE: Comments made by service users and staff confirm that people are able to go to bed and rise when they choose. The 4 people who live at the home are independent in most aspects of personal care and do not require practical support in this regard. Service users confirmed that they are supported to make use of the local community hairdressers and to shop to choose their clothing. Three male staff are employed in the staff team, providing opportunities for the four men living at the home to have some contact / support from other men, where they wish to do so. SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 Page 14 Information contained in service users’ records confirms that they are being provided with support to access community health services. 3 service users have their needs and medication monitored by a consultant psychiatrist and a community nurse specialist has been used to provide guidelines to support one person. Health plans have been completed with the help of a community nurse based on well person checks and information provided by staff. Information contained in people’ health records confirms that people are being supported to gain access to routine dental checks, chiropody, and eye tests as required. Suitable procedures are in place for staff concerning the safe administration of medication. A suitable lockable cabinet is used for the safe storage of people’s medication. A sample examination of recent medication records identified no anomalies, indicating that staff are properly signing and accounting for people’s medication. Audits are also carried out by the manager to ensure that medication records are properly completed by staff. A book is in place for recording returns of medication to the chemist that has been appropriately signed by staff at the home and the pharmacist, to verify that unused medication has been appropriately returned. Booklets are available at the home for use with service users to help them to make choices regarding their wishes in the event of their death. The manager explained that service users would be supported to complete the booklets in the coming months. SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Service users are provided with information and support to raise comments and concerns so that there views can be acted upon. Procedures and training are provided so that staff are equipped to appropriately respond to any suspicions of abuse, however there is a need to amend the contact details of agencies in the homes procedure. EVIDENCE: The manager explained that there have been no complaints at the home since the last inspection. A complaints log is in place at the home for effectively recording and tracking complaints made at the home. A complaints procedure is available for staff and service users have been issued with more accessible information informing them how to complain. Each service user has their own copy of a complaints form (in an accessible format), which can be posted to a senior manger if they do not wish to share concerns with staff at the home. Two letters from people’s relatives were seen, confirming they had received a copy of the homes complaints policy recently. The letters also included positive comments about the home. Service users’ meetings also take place at the home, which includes an opportunity for service users to raise any concerns. An adult abuse procedure is in place at the home as well as a copy of the local joint agency procedure. The home’s procedure is generally informative but requires amending, to update the contact details of the agencies to be informed in the event of a suspicion of adult abuse. A whistleblowing procedure is also in place that has been seen by staff. Information in training records and comments made by staff confirmed that they have been provided with adult abuse training. There have been no adult abuse investigations at the home since the last inspection. SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30 26 Glebe Rd provides comfortable, clean and homely accommodation for people to live in. Policies and risk assessments are in place so that people are able to live in a clean, hygienic home. EVIDENCE: 26 Glebe Rd provides comfortable well maintained accommodation in a normal house that is of similar design to other homes in the street. Since the last inspection positive action has been taken by the home to repair the garden fence and to provide lampshades where they had been previously removed whilst decorating was completed. The hall, stairs and landing have been redecorated during the last year and new attractive curtains have been fitted. A new tiled floor has been laid in the kitchen and the bathroom has been fully refurbished. A new carpet has been provided in the lounge and improvements have been made to the fire alarm which now includes red flashing lights as well as alarm bells. The home is not designed to meet the needs of wheelchair users or people with significant disabilities. All the people currently living at the home are ambulant and able to climb the stairs. Good work has been undertaken to make the home comfortable and homely and the people living at the home have been supported to personalise their bedrooms. Comments SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 Page 17 made by service users confirmed that they have been involved in choosing the colours for their rooms. The home has a laundry room that is situated well away from the kitchen and dining area so there are no risks presented by soiled laundry being transported through these areas. The needs of the people living at the home are such that there is not currently a need to manage any continence laundry. The home has a suitable infection control policy in place and risk assessments to take account of service users needs. Infection Control Training is planed to take place next month, July 05. SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34 and 35 There is a need to increase the number of staff hours allocated to the home to enable people to enable people to get out more freely and to pursue personal leisure interests. The organisation carries out appropriate vetting procedures to ensure that staff employed at the home are suitable to work at the home. Staff are provided with a good range of training so that they are suitably equipped to carry out their work at the home. EVIDENCE: As previously noted there is typically one person on duty during the evenings and an extra worker/volunteer is being provided on some weekend shifts, dependent on staff availability. Hence the current levels of staffing can limit the scope for people to get out or make spontaneous decisions to go places. The staff team for the Glebe also provide care at another home run by the organisation and to service users living in three “supported living houses”. Since the last inspection there have been three new staff employed in the team. The recruitment information contained in these people’s files was found to be complete indicating that the organisation follows appropriate recruitment practices for safeguarding vulnerable adults. Two reference and Criminal Record Bureau Checks are taken up for new recruits prior to them commencing work at the home. SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 Page 19 An examination of staff training records and `comments made by staff indicates that staff are well trained in the full range of health and safety related practices, such as fire safety, first aid, food hygiene. Medication training and hygiene and infection control is planned to take place shortly. Staff are also being provided with training related to good care practices, e.g. 5 staff have completed LDAF training and 7 staff have undertaken NVQ level 2/3 training. 9 staff have also completed dementia training, which is important given the increasing ages of the people being supported by the organisation. SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 39 and 42 Whilst overall the home is run effectively there is an outstanding need for the manager to complete the Registered Managers Award in order to meet the home’s conditions of registration. Satisfactory arrangements are in place for the home to identify and respond to the concerns of service users however there remains a need to consult with people about the running of the home and to ensure that Regulation 26 visits are carried out consistently. There is a need to address hot water temperatures and gas maintenance to ensure that people’s welfare is protected. EVIDENCE: The manager is in the process of completing the Registered Managers Award. The manager has failed to meet the conditions of registration that require her to be appropriately trained by 2005.The Responsible Individual for the organisation states that delays in achieving the Registered Managers Award have been due to difficulties faced by the training providers in identifying external assessors to evaluate the work completed by the manager. The SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 Page 21 Responsible Individual explained that it is intended that the manager will have completed the Registered Manager’s Award by September 05. The Responsible Individual also explained that the manager initially completed LDAF, induction and foundation training following here appointment at the home before commencing the Award in January 2004. The manager confirmed an intention to complete the Registered Managers Award by this September. Service user meetings are being carried out at the home to provide people with the opportunity to express their views / concerns. The manager shared a new agenda format that is being introduced to these meetings so an increased variety of subjects are covered that are likely to be relevant to service users. New booklets have been devised for eliciting service users views about the home. The manager explained that service users would be assisted by the manager of another service to complete this information shortly. The small size of the home enables service users concerns to be identified and acted upon informally on a daily basis. An examination of recent Regulation 26 reports, of visits carried out on behalf the Responsible Individual, indicates that three visits have been undertake and two visits have been missed this year for February and May 05. These visits are important for providing the Responsible Individual with an independent perspective of the home. An examination of the homes fire safety records confirmed that fire alarms and emergency lights are being tested at the correct frequencies and that fire drills are being carried out at the home. A lockable cupboard is in place for cleaning fluids and detergents so that service users are not placed at risk by these products. An examination of hot water temperatures and comments made by staff indicate problems in striking a balance between keeping the hot water temperature at a safe level for service users and ensuring that water in the cylinder is hot enough to prevent any risks of legionella. Gas safety records and comments made by the manager confirmed that a gas safety check is now due by the housing association responsible for the building. SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 2 2 x 3 3 Standard No 31 32 33 34 35 36 Score x x 2 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 SCIC - 26 Glebe Road Score 3 3 3 2 Standard No 37 38 39 40 41 42 43 Score 2 x 2 x x 2 x E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 Page 23 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. 2. Standard 6 13 & 33 Regulation 15 18 (1) (a) Requirement Complete the work that has started to devise new care plans. Review staffing levels to enable people to get out more spontaneously and to develop a greater range of social activities and personal interests. Work is required to establish the wishes of service users (and their relatives) in the event of their death.(outstanding requirement from the last inspection timescale - 30/6/05) Update the current contact details of agencies (in the homes adult abuse policy)to be informed, in the event any incidents of abuse are brought to the attention of staff. The manager must complete the Registered Managers Award. (This is a condition of the homes registration). Make arrangments for Regulation 26 visits on behalf of Responsible Individual to be carried out consistently each month. Make arrangments for hot water temperature regulator valves to be fitted to hot water outlets, so Timescale for action 14/7/05 31/8/05 3. 21 15 (1) 31/8/05 4. 23 13 (6) 30/7/05 5. 37 9 (2) (b) (i) 33 31/9/05 6. 39 30/7/05 7. 42 13 (2) (4) (c) 30/7/05 SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 Page 24 that the hot water may be kept at a safe temperature for service users and any possible risks of legionella are addressed. Arrange for an annual gas safety check to be carried out. 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 14 Good Practice Recommendations The Responsible Individual is strongly recommended to help the home to find a means of enabling service users to go on holiday. SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 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 SCIC - 26 Glebe Road E53 S4468 SCIC - 26 Glebe Road V233031 140605 stage 4.doc Version 1.30 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!