Inspection on 09/11/07 for The Glade

This inspection was carried out on 9th November 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Glade 18/12/08

The Glade 23/05/08

The Glade 16/10/06

The Glade 08/12/05

The Glade 01/06/05

The Glade 12/10/04

The Glade 20/04/04

The Glade 27/11/03

The Glade 15/07/03

The Glade 18/02/03

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

CARE HOMES FOR OLDER PEOPLE Glade, The 32 Lancaster Road Southport Merseyside PR8 2LE Lead Inspector Mrs Margaret Van Schaick Unannounced Inspection 9th November 2007 07:45 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 Glade, The DS0000005322.V346751.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. Glade, The DS0000005322.V346751.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glade, The Address 32 Lancaster Road Southport Merseyside PR8 2LE 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) 01704 566699 01704 566698 Mr David Winston Jackson Mrs Susan Jackson Mrs Antonia M Gillett Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Glade, The DS0000005322.V346751.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 25 in the category of OP The service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection 22nd February 2007 Date of last inspection Brief Description of the Service: The Glade is an older property that has been converted into a care home and is registered to provide personal care and support for up to 25 older people. It is situated in a leafy part of Southport close to public transport and within easy reach of the amenities that serve the area. The home provides accommodation over four floors and has lift access. The communal space contains one large dining room and one large sitting room. Toileting and bathing facilities are located throughout. The home has had adaptations such as handrails, hoists and ramps to suit the needs of the residents. There is a call-bell system throughout the home. The front garden is accessible via a ramp and suitable garden furniture is available for the residents and their visitors. The Glade is part of a small group of homes privately owned by Mr and Mrs Jackson and is managed by Antonia Gillette. Weekly fees range from £365-£446. Glade, The DS0000005322.V346751.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A site visit took place as part of the unannounced key inspection. It was conducted over a two-day period for the duration of 17 hours. Twenty- two residents were accommodated at this time. As part of the inspection process all areas of the home were viewed including many residents bedrooms. Care records and other residential home records were viewed. Discussion took place with many residents, staff and visiting relatives. The inspection was conducted with Mrs Antonia Gillett, registered manager. Discussion also took place with the deputy manager, care staff, cook and with the registered providers Mr David and Mrs Susan Jackson. An Expert by Experience also assisted in the inspection process. An Expert by Experience is a person who, because of their shared experience of using services and/or ways of communicating visits a service with an inspector to help get a picture of what it is like to live in or use the service. During the inspection …residents were case tracked (their care files were examined and their views of the service were obtained). All of the key standards were inspected and also previous requirements and recommendations from the last inspection in February 2007 were discussed. Satisfaction forms “Have your say about….”were distributed to a number of residents, residents and health care professionals prior to the site visit. A number of comments included in this report are taken from surveys and from interviews. An AQAA (annual quality assurance assessment) was completed by the manager prior to the site visit. The AQAA comprises of two self-assessment questionnaires that focus on the outcomes for people. The self-assessment provides information as to how the manager and staff are meeting the needs of the current residents and a data set that gives basic facts and figures about the service including staff numbers and training. What the service does well: The Glade has a friendly and warm atmosphere. Staff were observed interacting freely with residents and their visitors. There approach was noted to be respectful and caring. Residents interviewed stated, “staff are very good-all very good”, “staff seem alright, they are nice to me and seem to be nice to other residents haven’t seen them be nasty to anyone” and “I’ve been here a few years-I’ve loved every minute of it-they are grand people”. Glade, The DS0000005322.V346751.R01.S.doc Version 5.2 Page 6 The manager or deputy visits prospective residents prior to admission and where possible are invited to the home to meet with the other residents. Residents can choose how they wish to spend their day and are provided with varied activities suited to them. Residents interviewed stated, “I do what I want I go out every day to see my friend and we have had exercises this afternoon”. There are many varied activities to suit the residents and residents interviewed confirmed this. Residents and relatives confirmed that they could have visitors at any time. One resident interviewed stated, “I have two girls and they visit me, they visit when they can (at anytime)”. What has improved since the last inspection? The manager has updated the residents’ contracts identifying all costs and terms and conditions. The improved assessment process helps ensure staff can meet the assessed needs of the residents. Residents are able to access all other healthcare professionals where needed. This is evidenced in care files and residents interviewed confirmed regular contact with various health professionals. All staff now signs the medication sheets. All areas discussed at the last inspection with regard to the environment have now been improved. The fire escape exit and fire door exits have all been refurbished therefore ensuring easier evacuation of premises. The recommendations made by the visiting fire officer have been carried out. The training programme has improved therefore ensuring staff have the skills needed to care for residents. All new staff now receives induction training. Staff are now attending training dates that have been set up. Staff have now received infection control training. Staff interviewed stated, “I feel happy with the training”. The home has also exceeded the standard for NVQ training with 99 having gained the Level 2. Dressings and treatments are now applied to residents in their bedrooms thus ensuring residents dignity is maintained. Risk assessments and the management of residents who smoke in their bedrooms is now documented. A laundry person is now employed. Glade, The DS0000005322.V346751.R01.S.doc Version 5.2 Page 7 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. Glade, The DS0000005322.V346751.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 Glade, The DS0000005322.V346751.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): OP 2, 3,4 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The improved assessment process helps ensure staff can meet the assessed needs of the residents. EVIDENCE: The manager has updated the residents’ contracts and some have been sent out to families for them to sign and agree the conditions. Contracts seen evidenced the terms and conditions of residency including a breakdown of fees. Contracts viewed evidenced signatures of family or resident. The manager or deputy visits prospective residents prior to admission and where possible are invited to the home to meet with the other residents. New residents confirmed through discussion with the inspector that they had a visit at home from the manager prior to taking up residency. A resident interviewed stated, “Sara (deputy) came to visit me at the home I was in” and one resident confirmed through discussion that someone came to the house from the home and discussed the care she would get. Copies of social work assessments are also evidenced in some files. The assessment process has Glade, The DS0000005322.V346751.R01.S.doc Version 5.2 Page 10 improved since the last inspection. The information gathered prior to admission is much more detailed. Each new resident’s documentation evidences an assessment has been carried out. Residents already under the care of staff have had their needs reassessed during their stay when their individual care needs have changed. Care records evidence these changes and intervention sought from other agencies where needed. Copies of the new assessment are in place in care files. Glade, The DS0000005322.V346751.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): OP7,8,9,10 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plan documentation has improved but medication procedures place residents at risk. EVIDENCE: As part of the case tracking process two residents files were viewed. One residents care plan does not fully identify their care needs despite an assessment of their needs being carried out prior to admission. Care needs identified on assessment were not always recorded in the care plan, though the resident confirmed during discussion that their care needs were being met by staff. Care plans are reviewed monthly or sooner if needed. Changing needs and management of them were reflected in their individual care plans. Health professional advice has been sought where needed to offer support and intervention. One resident needed medical intervention and all care documentation reflects the changing needs of the resident and the interventions taken. Residents care files evidence regular input and visits from other health professionals including GP’s chiropodists, opticians, district nurses and community psychiatric nurses. Residents interviewed confirmed this Glade, The DS0000005322.V346751.R01.S.doc Version 5.2 Page 12 stating, “the chiropodist comes in every 4-5 weeks”, “they get the Dr in if I’m poorly and I saw the chiropodist yesterday”. . Residents interviewed confirmed that they regularly attend hospital for appointments. Resident interviewed were generally positive about their stay in the Glade and the care provided. Residents’ comments about their care include: “staff are good, “the staff are helpful, the care is good”, “Antonia (manager) is very helpful-she makes sure you don’t miss appointments and things”, “I think it is good care” and “sometimes I want to lay on my bed and I have to wait sometimes for ages”. Residents are encouraged to maintain their independence and risk assessments are in place where needed. This includes assessments for manual handling and skin integrity. Pressure relieving equipment was seen to be in place is in place for residents who need it. Other care documentation evidenced that the record keeping is generally of a good standard however one date viewed had no day or night report recorded. The manager also needs to ensure that all accidents are recorded in the formal accident book and relatives are notified and kept informed as soon as possible. A lack of accurate records may place residents at risk. New falls monitoring documentation is now in place so that residents at risk are clearly identified and monitored more often Relatives’ comments include: “In the years my ….. was a resident at the Glade Care Home, they never once complained about their treatment etc. to us. They were always happy to be with people and to be so well cared for”. Health professional comments include: “If any individual I treat needs further follow-up, i.e. a GP visit or if I ask for a situation to be monitored it is always done. If an individual has a sudden unexpected need for treatment, or is a new admission in urgent need I am contacted, and requested to visit. In respect of my scope of practice residents’ needs are always met. The caring is excellent. Another visiting health professional commented, “This is the best home in the area”. Medication storage and records were viewed. Medication records show staff signatures for all medication rounds. The total amount of medication in stock is not always recorded at the start of the medication sheet therefore making it more difficult to audit. Medication practices were noted to be poor during the administration of medication with medication being left out for staff to administer at a later time Glade, The DS0000005322.V346751.R01.S.doc Version 5.2 Page 13 and some tablets were reported as missing previously. This places residents at risk and staff responsible for administering medicines should have their competency checked before being allowed to. Staff were observed to be patient and caring in their approach to residents. Residents interviewed confirmed that staff ask permission prior to entering a residents bedroom. One resident stated, “staff always knock on my door when they want to see me. In general feedback from residents and relatives confirmed that residents dignity is maintained. A visiting health professionals comments include, “as far as I am aware residents privacy and dignity is respected”. Residents can meet their relatives in private or in the communal rooms if wished. Glade, The DS0000005322.V346751.R01.S.doc Version 5.2 Page 14 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): OP12,13,14,15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can choose how they wish to spend their day and are provided with varied activities suited to them. EVIDENCE: Residents and staff interviewed were able to discuss the various activities on offer, which include bingo, gardening club, beauty therapy, quizzes, musical entertainment, chair exercises and videos. The gardening club continues to be popular with residents becoming involved in preparing plants in pots for their garden. Residents interviewed were concerned that they had not been out on any trips recently on the mini bus. Mr Jackson was trying to resolve this. Residents’ comments with regard to activities include: “we have keep fit, gardening club, a quiz (done by staff), a man comes in to sing from Preston-Hugh Dent, we had him last week for Halloween again”, “I had my nails done today, we have the hairdresser on Thursday”, “I join in the exercise class”, “we have entertainment and bingo this afternoon, I go out every day to see my friend and we have had exercises this afternoon. Other residents regularly go out to meet up with friends and one resident attends Glade, The DS0000005322.V346751.R01.S.doc Version 5.2 Page 15 their local club on a weekly basis and attends functions also. Relatives also commented that residents had various activities they could attend. Some of the local churches visit the home on a regular basis. One resident stated, “they also come from the Roman Catholic Church, they visit every Wednesday morning and they come from St James at Easter and Christmas. One resident stated, “I’ve had Communion from the lady this morning”. Residents interviewed confirmed that they were generally able to live their lives as they pleased. Residents are able to retire to bed when they wish and get up when they wish to. Where restrictions are in place it is identified in care plans. Residents are also happy with the support they receive from staff with personal care needs. Residents interviewed stated: “I like to get up laterabout 10am”, “I prefer the girls to care for me-it’s always a girl who does the care”, “7.30 I get up as I like to take my time, have a good wash-I wouldn’t like to stay in bed longer” “I do what I want, I go upstairs to watch TV, I don’t know about the other residents if they don’t want to come down in the day, they don’t need to”. Residents and relatives confirmed that they can have visitors at any time. Residents interviewed stated, “my sons come and friends can come when they want to there are no restrictions” and “I have two girls and they visit me, they visit when they can (at anytime)”. The menu for today is written on the board in the dining room. The regular 4 weekly menu was viewed. Some days there is a choice recorded but on other days there is not although residents interviewed confirmed they have a choice. A tour of the kitchen and storage areas evidenced a fridge and freezer full of foods such as frozen meat joints and vegetables. There was also a supply of tinned and dried foods. Fresh fruit and vegetables were also in evidence and they are delivered three times a week. Fresh meat is delivered weekly. The cook was observed speaking with the residents to ask what they would wish for their lunch and tea that night with choices on offer. Residents later confirmed that they could always have something else prepared for them if needed. Residents interviewed stated, “personally I’m not that keen on the food, not enough choice-that’s what I think”, “the food is very good, yes you have a choice”, “the food is good, not bad at all, nice cake, nice sandwiches, I get enough to eat”, “the food is excellent” and “we have a choice-they always make me something else if something is on that I don’t want”. Glade, The DS0000005322.V346751.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): OP16,17 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure is not robust to ensure complaints are dealt in a timely manner. EVIDENCE: Policies and procedures are in place for the complaints process. Residents and relatives were mostly aware of how to make a complaint. Residents commented, “any complaints I usually have a word with staff who are very good at sorting” and “in the 10 years my sister was a resident at the Glade Care Home, she never once complained about her treatment etc. to us. She was always happy to be with people and to be so well care for”. Although positive comments have been received concerns have been raised with the Commission regarding the providers handling of complaints. The providers’ response to complainants was not always within the 28 days timescale with no record of explanation for the delay. The Aqaa stated that 2 complaints had been received and both were upheld. They are both logged in the complaints record. An anonymous concern has been raised with the Commission and this has been addressed during the inspection visit. The financial records of 2 residents were viewed. Both records were clear with residents’ signature evidenced and receipts held for financial transactions. One resident interviewed confirmed there were no problems with their finances. Glade, The DS0000005322.V346751.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP19,26 were assessed. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager needs to improve the plan of action it has in place in the event of a lift breakdown, this will ensure residents health and safety are managed better. EVIDENCE: The home is decorated to a pleasing standard with residents bedrooms personalised with their belongings. Residents interviewed stated, “they tell you to treat it as your home-I have brought some of my stuff into the home” and “it’s warm enough and I have 2 radiators in my room”. There is a large sitting room and separate dining room, which are pleasantly decorated. Residents were pleased with their surroundings. The work to the fire exits and fire escape has now all been carried out. Exits were checked at random during the visit and ones checked were easy to open. A fire risk assessment of the building was carried out earlier this year and recommendations made have been have been carried out. Fire bell checks have been varied and recorded. Glade, The DS0000005322.V346751.R01.S.doc Version 5.2 Page 18 Hot water records are recorded weekly and bath temperatures are checked and recorded prior to the individual residents bath time. These were viewed. The home is due to receive a grant for improvements to benefit the residents and this is being spent on refurbishing two of the bathrooms. Quotes have been requested for a Parker bath to be fitted to first floor and a shower room to the ground floor. This will increase residents’ choice. Recommendations with regard to some of the environment have been carried out including the repair of broken tiles on the front steps. Some areas of the home need redecoration including the laundry where pipes need to be boxed in to ensure easier cleaning as many around the room are very dusty. The laundry sink, kitchen cooker, lift floor were very dirty and in need of cleaning. The main concern for the home has been the repeated breakdown of the lift throughout the year. The inspector viewed the records to find that each time a breakdown had occurred the service engineers had been contacted and resolved the situation. It is however a worry that the lift is breaking down on a regular basis. The manager has now formulated an action plan in the event of any further breakdown. The inspector viewed this and advised that further information needs to be recorded to ensure residents are safe and that families are kept fully aware. Glade, The DS0000005322.V346751.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP27,28,29,30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager needs to ensure all pre employment checks are in place to ensure residents are protected. The homes training programme has improved therefore ensuring staff have the skills needed to care for residents. EVIDENCE: The staff rota evidence all staff employed in the home including cook, kitchen staff and laundry staff. There have been occasions when the home has been short staffed in particular this seems to occur at weekends. There is just two care staff on duty for the evening shift from 5-8pm. This need to be reviewed in particular when residents are having to wait a long time before staff can assist them to bed. One resident commented, “sometimes I want to lay on my bed and I have to wait sometimes for ages”. Health professional comments: The staff always seem supportive giving appropriate advice where necessary. As far as I can see staff have the skills and experience. They make the Glade ‘home’ for their residents, the staff are all of a pleasant caring demeanour”. Some of the staff were interviewed during the inspection and their comments include, “staff are fine, friendly, I am supported and am able to speak to the senior staff”, “I have no worries-I wouldn’t work here if I did”, “we have time to do things properly” and “I’m very worried about the attitude of some staff towards residents”(this was passed to the managers attention). Glade, The DS0000005322.V346751.R01.S.doc Version 5.2 Page 20 Residents’ comments include: “Most of the time some of the girls are very good some I wouldn’t ask to do things”, “staff are very good”, “staff are nice to me and seem to be nice to other residents I haven’t seen them be nasty to anyone”, “staff are nice except one or two”, “I’ve been here a few years-I’ve loved every minute of it - they are grand people”. Relatives’ comments include: “there is always enough staff on duty but the care given depends on who is on duty sometimes”, “the main tasks that fall to the staff are to attend to personal hygiene, tempt their appetite, keep them neat and tidy and ensure that they are made as comfortable as possible. I am happy that the duties are carried out and carried out well” Staff interviewed confirmed that they had an induction (skills for care) on commencement of employment and attended further training throughout the year. Training provided for staff include manual handling, falls, fire safety, abuse, protection of vulnerable adult, food hygiene, first aid, dementia, medication, report writing, NVQ Level 2 and 3, infection control and health and safety. During discussion with staff they were knowledgeable about the care needs of residents and how the training supported them in their work. Staff interviewed stated, “I feel happy with the training and there are plenty of aprons and gloves, “there is always hoists and equipment available and always courses going on”. The staff training and standards officer is planning to carry out equality and diversity training in the next few weeks as at present there is no specific training in the home. In addition to this COSHH (Control of substances hazardous to health) is being booked in the next weeks. The training programme has improved with most staff up to date with mandatory training. 99 of staff have now gained the NVQ in Level 2 therefore surpassing the standard required. Staff files are well organised and evidence personal details including application forms, start dates, police checks, disciplinary records and training records. It was noted that one reference was missing and this was brought to the manager’s attention. Glade, The DS0000005322.V346751.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): OP31,33,35,38 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager needs to ensure procedures are followed with regard to notifying the Commission of any incident that may affect the wellbeing of the residents. EVIDENCE: The registered manager has recently been awarded the RMA (Registered Managers Award) in October this year. This was viewed. The manager keeps up to date with all mandatory training. The training/standards officer was present during the inspection and discussed proposed supervision for the manager. Staff and residents were complimentary about the manager. Residents interviewed stated, “I get on very well with the manager, If I was worried I’d be able to talk with her”. Staff interviewed stated, “the manager has been helping me with the NVQ”, “I have no problems with the managers, and “I would talk to them if concerned and I’m confident that they would do something”. A regulation 37 (statutory notice advising of an incident) notice Glade, The DS0000005322.V346751.R01.S.doc Version 5.2 Page 22 should have been forwarded to the Commission to advise of the lift breakdown. This was not done. The manager has distributed questionnaires to residents and relatives in July/Aug 07. They were not available during the visit. A residents and relatives meeting was arranged for September this year with no one turning up. The previous meeting was held last year. Staff meetings are held a minimum of 3 times a year with the most recent minutes viewed for the meeting in September. Staff interviewed stated, “I find the staff meeting useful and always read the minutes”. The manager also canvassed the views of visiting GP’s in September and one response was available during the inspection. Their comments included, “each time I have visited my patients at the Glade I have always found the staff helpful. Patients appear to be very happy living at the Glade. My overall impression is that the standard of care is good”. The provider visits the home on a regular basis and monthly reports are kept on file and were viewed during this visit. Mr Jackson speaks with staff and residents with the last report recorded in October this year. A resident interviewed stated, “I have met Mr Jackson-he seems friendly”. Accident records have been completed for residents and RIDDOR (Reporting of Dangerous Disease and Occurrences Regulation) has been completed where needed. The Aqaa states that all servicing of all equipment held in the home is in date and one or two of these were checked at random during the visit including gas, lift, fire and electrical safety checks and equipment including fire exits and fire extinguishers. The most recent fire drill was in October this year. Emergency lighting and various fire alarm points are checked weekly. Glade, The DS0000005322.V346751.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Glade, The DS0000005322.V346751.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 OP9 Regulation 13 (2) Requirement Timescale for action 03/12/07 2 OP16 22 (3) (4) The registered person must ensure that medicines are administered safely and follow the policy for administration of medication. Medication must not be dispensed in advance of the medication round. The registered person must 03/12/07 ensure that all complaints raised are dealt with in line with the homes complaints procedure. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP7 OP8 OP9 Good Practice Recommendations The manager should ensure all care plans are fully completed and residents or their representative signature is included. It is recommended that risk assessments in place should reflect the changing needs of the residents. It is recommended that all staff should have their competency checked with regard to administration of DS0000005322.V346751.R01.S.doc Version 5.2 Page 25 Glade, The 4. 5. 6 OP26 OP29 OP33 medications. It is recommended that the cleaning schedule should be updated to ensure all areas of the home are clean. It is recommended that all pre employment checks should be in place prior to commencement of employment. The manager should hold regular residents meetings with minutes published. Glade, The DS0000005322.V346751.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Glade, The DS0000005322.V346751.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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