Care Home: Glasson House

What the care home does well There are many positive features about this service. There is good leadership. The registered manager is experienced and competent and brings a confidence and expertise to her role. She also brings relevant knowledge and skills from her work as a lecturer and researching within the mental health field. The staff team are also experienced at the home. Staff retention is good with many staff having worked at the home for a number of years. Staff have received relevant training including NVQ and other qualifications. There is an understanding of residents needs, particularly of mental health needs but also of additional matters such as physical disabilities and of empowerment. Staff are motivated and like to see success such as residents developing new skills. Care planning is good with records held of weekly work with each resident arranged through the keyworking system. There are good links with health care and other professionals. Initiatives, to further improve the service, to add to the quality of residents` lives and to address equality and diversity issues, are followed. Similarly, the quality assurance processes involve residents and seek to make improvements to the service where possible. The physical standards are good. The home is in an attractive building in a pleasant street and neighbourhood. The building is well maintained and clean. Good facilities are provided for residents. Health and safety is properly taken account of and the building is kept safe. What has improved since the last inspection? The good standards identified at the last key inspection have been maintained. New initiatives have been added such as the introduction of new tools to develop the care planning and quality systems. For example, the use of the "Creating Better Lives" tool, which has the aim of improving the quality of each aspect of residents` lives. The new electronic care planning system should also bring benefits for residents and staff. The registered manager has been able to bring expertise from her academic work to the home, which has benefited staff training as well as the overall care arrangements. What the care home could do better: The service is doing well in each aspect of care delivery. The only area identified in this inspection requiring development was that of the frequency of staff supervision sessions. However, the registered manager should be able to increase the frequency in the last few months of the year. CARE HOME ADULTS 18-65 Glasson House 93 Belmont Avenue Cockfosters Barnet Hertfordshire EN4 9JS Lead Inspector Duncan Paterson Unannounced Inspection 4 & 9 September 2008 9:40 Glasson House DS0000010444.V372091.R03.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 Glasson House DS0000010444.V372091.R03.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. Glasson House DS0000010444.V372091.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glasson House Address 93 Belmont Avenue Cockfosters Barnet Hertfordshire EN4 9JS 020 8449 7808 020 8364 9257 debohuncare@aol.com 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) De Bohun Care Limited Ms Patricia Shanahan Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Glasson House DS0000010444.V372091.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Mental Disorder, excluding learning disability or dementia - Code MD The maximum number of service users who can be accommodated is: 5 5th September 2006 2. Date of last inspection Brief Description of the Service: Glasson House is a care home providing personal care and accommodation to five adults with mental disorders. De Bohun Care Ltd run the home. The home is set in a quiet residential road. There are good shopping and transport facilities nearby. Each resident has a single bedroom, which meets the required minimum standard of bedroom size. The home provides three bathrooms with toilets and a separate toilet on the first floor. The kitchen and the dining room are on the ground floor. The staff support residents with their medication, personal care, social and recreational activities, and with cooking. The service has a copy of the last inspection report and the home’s purpose and function document in the manager’s office for prospective residents to view. The services fees range from £522.79 to £1150.32 per week. Glasson House DS0000010444.V372091.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. This key inspection took place on 4th and 9th September 2008. The inspection involved speaking with the people using the service, the staff on duty and the registered manager. A standard form, the Annual Quality Assurance Assessment (AQAA), was taken into consideration, as were surveys which were returned from residents and staff. The inspection also involved the case tracking of residents’ care, the assessment of a range of the home’s records, procedures and forms as well as observation and a tour of the premises. What the service does well: What has improved since the last inspection? Glasson House DS0000010444.V372091.R03.S.doc Version 5.2 Page 6 The good standards identified at the last key inspection have been maintained. New initiatives have been added such as the introduction of new tools to develop the care planning and quality systems. For example, the use of the “Creating Better Lives” tool, which has the aim of improving the quality of each aspect of residents’ lives. The new electronic care planning system should also bring benefits for residents and staff. The registered manager has been able to bring expertise from her academic work to the home, which has benefited staff training as well as the overall care arrangements. 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. Glasson House DS0000010444.V372091.R03.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 Glasson House DS0000010444.V372091.R03.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): 12&3 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The admission arrangements carefully introduce residents to the home and involve them fully in the process. Information about the service is clear and informative. Residents can be sure that staff are able to meet their needs, work with them to develop independent skills and promote their interests. EVIDENCE: The statement of purpose was updated in June 2008 and provides a detailed pack of information for people interested in the service. The aims and objectives are woven into the document with separate sections in areas including, the rights of residents, care plans and the environment. In order to assess the assessment arrangements individual residents’ files were inspected and discussions were held with residents, staff and the registered manager. There has been one recent admission to the home and the other residents have lived at the home for a number of years. The assessment information seen was detailed with relevant background information provided by the referring local authority. Residents said that they liked the way they had been introduced to the home and had chosen this home rather than others visited. One resident said, “They’ve made me very welcome here. I like it.” Glasson House DS0000010444.V372091.R03.S.doc Version 5.2 Page 9 The manager was able to describe how placements were prepared for and some documentation relating to recently admitted residents was provided as evidence. This showed that contact had been made with the local authority and previous placements to establish needs as well as address matters such as benefit entitlement. The majority of the residents were spoken with during the two days of the inspection. Some in more detail than others. Surveys were also received from residents. Generally, the feedback about the service was positive. One resident, for example, said, “Nothing could be better”. Another resident, in a survey, said, “I’m happy at Glasson House.” The returned AQAA provided details about equality and diversity initiatives. These included the fact that an accessible bathroom on the ground floor had been installed as well as handrails to assist residents with mobility around the home. Some of the residents have disabilities and the staff were seen to be working very carefully and sensitively with them. The AQAA also provided information about the approach taken. There is an emphasis on person centred care and providing a service that can respond to individual resident’s needs, interests and wishes. For example, a talking newspaper has been introduced for one resident and has been taken up by other residents as well. Similarly, individual residents are supported to take up religious interest and with following interests such as music. There was evidence of good relations and communication between staff and residents as well as a commitment and enthusiasm from staff to work for the benefit of residents. One staff member said that the best thing about working at the home was, “seeing improvements in residents”. Residents were very welcoming and keen to talk about life at the home, introduce themselves and others as well as give a tour of the home including their bedrooms. Glasson House DS0000010444.V372091.R03.S.doc Version 5.2 Page 10 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 8 9 & 10 People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care planning arrangements are good. Staff know residents well, there are effective keyworking systems where staff meet residents weekly and work on goals to develop resident’s independence. Creative ways have been introduced with the aim of improving the quality of resident’s lives. EVIDENCE: In order to assess this set of standards the case tracking methodology was used to sample three resident’s individual case files. In addition, discussions were held with the residents, staff and the registered manager. The registered manager is experienced within mental health service provision and is currently studying and teaching within mental health at a local university. She is able to bring this expertise to the service to plan and deliver care as well as train and develop staff. There is a holistic approach at the home covering all aspects of resident’s lives. The registered manager has introduced a new tool, the “Creating Better Lives” tool, which allows a focus on resident’s all round lives and aims to add value to Glasson House DS0000010444.V372091.R03.S.doc Version 5.2 Page 11 their lives. Residents are encouraged to do things for themselves and work more independently. Residents were observed cooking lunch during the inspection, for example. The care plans seen were well presented and comprehensive. Each care plan objective was accompanied by goals which the residents were working on, with the help of their keyworker. The goals varied and including matters such as extending independence as well as matters such as hygiene and food preparation. There was evidence of weekly meetings having been held with residents. There is an additional file for each person. These files contain documentation from local authorities and health professionals including assessment and review information as well as benefit entitlements. Reviews and risk assessments were being held regularly. During the inspection the manager was able to arrange Care Programme Approach (CPA) reviews for each resident. There had been some difficulty in arranging these beforehand … The manager is in the process of introducing a new electronic form of care plan. Paper records were viewed at this inspection but the introduction of this electronic format will assist in presentation and retention of information. …… From observations and discussion with residents, staff and the manager, it was clear that communication was good between residents and staff. For example, staff knew residents well and were observed to be speaking with them kindly and sensitively all the time. There was a great deal of informal interaction. In addition, residents had a range of opportunities to participate in the running of the home. For example, there were notes of monthly residents meetings which residents confirmed they had attended. There were also notes available of regular meetings residents had with their keyworkers. Risk assessments were discussed with the manager. Evidence was seen of risk assessments which had been drawn up with each individual resident. These were reviewed regularly by the keyworkers. There were also a set of risk assessments relating to the environment as well as matters such as fire safety. An example, was of risk assessing fire and residents smoking. Smoking was now only allowed outside. Records were held confidentially in the office on the top floor of the home. Residents were aware of the information held about them and had signed relevant forms such as care plans. The weekly keyworker sessions enabled staff to communicate on a regular basis with residents and cover matters of confidentially. Glasson House DS0000010444.V372091.R03.S.doc Version 5.2 Page 12 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 14 15 & 17 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are flexible arrangements so that staff can assist residents to take up opportunities in the community, maintain family links, lead social lives and enjoy varied activities. Food arrangements are good with residents encouraged to prepare meals and to eat healthily. EVIDENCE: Over the two days of the inspection all the residents were spoken with and observation was made of the activities they took part in. There was a range of activities including residents going to day centres, visiting relatives and going out for exercise and shopping. The staff said that the majority of residents went out each week for a meal. Residents confirmed this. Residents also spoke about holidays and day trips. A holiday to Blackpool had been arranged for later in the autumn and residents spoke about day trips to places such as Folkestone. The amount of activity depended on individual residents with some going out more than others. Health and mobility also played a part. Glasson House DS0000010444.V372091.R03.S.doc Version 5.2 Page 13 Staff have been able to arrange activities and encourage residents to go out and take up community facilities. Relations with families and relatives were encouraged and some of the relatives were enjoying regular contact with their families. The kitchen is a central meeting place in the home. An area where residents and staff can spend time together. During the inspection staff were observed to be chatting with residents there. There is a round table at which residents can sit and have drinks. The food served is varied. The menu was set out to include a range of food including traditional meals and which had been chosen as part of the healthy eating initiative. Residents are asked about meals provided during meetings and informally throughout the day. There was lots of fruit at the home and staff were observed to be encouraged to eat fruit and drink fruit juice. Residents take it in turns to cook meals and are encouraged to take simple precautions such as checking the temperature of food before it is served. Residents were observed assisting with the cooking of the mid-day meal. The manager said that this had been successful with residents having developed new skills since coming to the home. Food safety is carefully managed. The storage facilities were clean and tidy and there were records kept of the fridge and freezer temperatures as well as the temperature of the food served and of the maintenance of equipment. There was a hazard analysis displayed on the kitchen wall. There has been no recent inspection by the local authority environmental health team. Glasson House DS0000010444.V372091.R03.S.doc Version 5.2 Page 14 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 20 & 21 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents’ care and health needs are carefully managed with good links with health care and other professionals. Residents can be sure that staff are knowledgeable and experienced and have a good understanding of how to care for people with mental health concerns. EVIDENCE: There was a friendly and relaxed atmosphere at the service with residents and staff happy to talk about life at the home. The registered manager has a clear vision of how the service is to be run and was able to speak in detail about actions taken by staff to make sure that residents’ needs were met. An example was recent care that had been provided to a resident with a terminal illness. There had been close work with the local palliative care team and staff at the home had successfully been able to care for the resident rather than an alternative placement having been required. There is a caring atmosphere at the home with staff able and willing to adapt to meet resident’s needs. For example, much care and attention was being provided to residents who had physical care needs in addition to mental health needs. There was a great deal of understanding shown towards residents’ Glasson House DS0000010444.V372091.R03.S.doc Version 5.2 Page 15 mental health needs and how these needs impacted upon their lives and actions. There was evidence of CPA reviews as well as input from a range of health care professionals. There are positive links with health care professionals involved in the care of residents. Evidence of this was provided through letters, medication reviews and overall reviews on residents case files. As has already been discussed, the registered manager has introduced a new electronic form of care planning and record keeping. This format will be useful in recording matters such as residents’ preventative health care checks. There were some gaps in the records. However, the registered manager was able to look into this and she provided evidence that the checks had taken place as well as some background information. The registered manager advised that she will now keep these type of records on the electronic forms. The medication policy and procedure was reviewed in August 2008. The registered manager reviews each policy and procedure on a regular basis and thorough records are kept as well as notes of any changes made. This recent review of the medication policy is a good example of how this policy review system operates. The medication storage arrangements and administration records were inspected. The Boots system is used which involves the use of blister packs. The Boots system is a relatively straightforward system where medication is in date order in the packs. A daily log is kept of the storage temperature. The medication recordings were being made competently and staff were knowledgeable about the medicines resident’s had been prescribed. One minor item of medication needed to be returned to the pharmacy. The manager took responsibility for this. Glasson House DS0000010444.V372091.R03.S.doc Version 5.2 Page 16 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 & 23 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Careful arrangements have been made to safeguard residents and to enable residents to complain if desired. Residents can be sure that staff are knowledgeable about safeguarding matters and that their money is being properly looked after and accounted for. EVIDENCE: The complaints procedure is clearly set out and involves a 28 day period for complaints to be responded to. The complaints policy is made available to residents as well as others such as relatives and professionals. The complaints records were viewed but there has been no recent complaint recorded. Residents, responded through the returned surveys, said that they knew how to complain if needed. The safeguarding arrangements are managed well. There is a safeguarding policy and procedure, which is reviewed on a regular basis. The policy is detailed and provides a great deal of information about safeguarding matters and how incidents or allegations of abuse must be responded to. There is reference to the local authority as well as details of the “Whistleblowing” policy. Staff said that they had received Safeguarding training and this was confirmed when the training records were viewed. Glasson House DS0000010444.V372091.R03.S.doc Version 5.2 Page 17 The money handling arrangements for residents were inspected. The overall arrangements are good with resident’s money well looked after and accounted for. A sample of records were inspected. These were clearly set out with records kept of cash held in individual safe boxes, the central safe and in residents’ bank accounts. Most residents have their own bank accounts. The system was clear and there was an audit trail from receipt of money to residents through expenditure and deposit in bank accounts. Glasson House DS0000010444.V372091.R03.S.doc Version 5.2 Page 18 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 - 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are good facilities for residents. The home is clean and attractive. Residents needs have been catered for with adaptations made to the home where needed. There is continual improvement with regular decoration and upkeep. EVIDENCE: The care home is comfortable, well cared for and provides residents with a pleasant, homely environment. Residents were keen to give a tour of the building and to show off their bedrooms. During the inspection the lounge was being decorated and new flooring was being laid in one resident’s bedroom. The home has an extension and allows access for people who may have physical disabilities. There are two communal rooms: a lounge and a dining room. There is a pleasant garden to the rear of the home. Each resident has their own bedroom. A sample of the bedrooms were seen. All were comfortably furnished and arranged with personal possessions of each resident. Glasson House DS0000010444.V372091.R03.S.doc Version 5.2 Page 19 The interior of the home has been regularly decorated and looks clean and neat. The stair carpet now looks worn and marked and needs replacement. The registered manager said that this was soon to be replaced. There is a cleaner who works part time at the home and part time at the provider organisation’s other care setting. The standard of cleanliness was high with the home clean, fresh and well presented. The laundry is contained in a room on the first floor. This is a useful part of the service where residents can take turns to wash their clothes. Glasson House DS0000010444.V372091.R03.S.doc Version 5.2 Page 20 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): 31 32 33 34 35 & 36 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents benefit from being cared for by an experienced, motivated and qualified staff team. There is a range of training opportunities for staff with the manager having a good overview of staff and how to motivate and develop them. EVIDENCE: Staff retention is very good at this home. Many of the staff have worked at the home for a number of years. The most recently appointed staff member was appointed four years ago. In addition, the staff have completed a great deal of training including NVQ qualifications, the Registered Managers Award and qualifications within mental health. The registered manager encourages staff training and development. Residents therefore benefit from skilled and qualified staff who have developed expertise working with people with mental health issues. There is a relaxed confidence about the staff and how they work with residents. One member of staff said that she liked, “getting qualifications and the opportunities given to her to do them”. Glasson House DS0000010444.V372091.R03.S.doc Version 5.2 Page 21 There are two staff on duty throughout the day with the manager working usually from Monday to Friday on an office hours basis. There is one member of staff at night working on a sleep-in basis. Staff said that the staff numbers were adequate. The training records were inspected. Staff have received a great deal of relevant training included NVQ qualifications. It was identified that there was the need for some staff to receive refresher training in, for example, first aid. This was discussed with the registered manager. She was able to say that training had been arranged for the autumn. Evidence of the booking for this training was provided. The staff supervision arrangements are generally good. The registered manager is able to meet with staff regularly, daily if needed, to ensure that practice is good and staff are supported. The records of supervision however, were such that regular supervision sessions had not been provided to all staff this year. The manager said that her aim was to provide six sessions of group supervision and individual supervision before the end of the year. This does not entirely meet the staff supervision standard in the national minimum standards. However, given that the home is small and that staff can meet with the manager each day if needed, the arrangement is acceptable. Each member of staff has a main file with details of recruitment, training and supervision. There had been no recent staff appointed so the recruitment standard was not fully assessed at this inspection. Glasson House DS0000010444.V372091.R03.S.doc Version 5.2 Page 22 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 38 39 40 & 42 People who use this service experience excellent outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is lead by a competent and capable registered manager. Residents have been included in the quality processes and they can be confident that their wishes and needs are being taken into consideration. The home is well maintained with health and safety matters properly responded to. EVIDENCE: The registered manager has worked at the home for a number of years and brings experience and confidence to the role. She was able to express clearly the aims of the service, the needs of the residents and future plans for the service. The quality assurance file was inspected. This file provides evidence of a track record over a number of years of positive feedback. There were survey returns from the last few years from residents, relatives and visiting professionals. Surveys returned to the home, for example, were detailed and Glasson House DS0000010444.V372091.R03.S.doc Version 5.2 Page 23 built up a picture of detailed comments about the service from relevant people. Evidence was also provided about the food survey, which had been completed in October 2007. This involved asking residents for their views on the food provided. The responses lead to the introduction of healthier eating at the home including the availability of a wide range of fresh fruit and juice. Available for all during the inspection, for example, were pineapples and melons as well as other fruit. Other quality assurance initiatives were discussed with the registered manager. A new tool, the “Creating Better Lives”, tool had been introduced. This is based on the government White paper, “Creating Better Lives”, and focused on achieving better outcomes for people using services. Specific “Creating Better Lives” surveys had been completed for each resident and a sample were seen. These surveys involved covering with residents key themes about the service including activities and promoting independence. The surveys had detailed responses and clearly provide staff with a great deal of information to assist with providing care. The records of the servicing and maintenance of the home’s installations and equipment were shown. These included fire safety checks as well as checks of the electrical, gas and water systems. These were all up to date and well ordered and provided evidence of a thorough approach having been taken to record keeping. As already mentioned, there was evidence that the policies and procedures are reviewed regularly and amended if needed. Glasson House DS0000010444.V372091.R03.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 3 2 3 3 3 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 4 3 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 4 3 4 4 x 3 x Glasson House DS0000010444.V372091.R03.S.doc Version 5.2 Page 25 No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Glasson House DS0000010444.V372091.R03.S.doc Version 5.2 Page 26 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Glasson House DS0000010444.V372091.R03.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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