Care Home: Glebe, The Care Home

What the care home does well There is a dedicated management and staff team that work in the best interests of people living at the home. Food is of a good standard with choices at every mealtime. People were regularly asked if they would like changes to the menu. Catering staff work hard to provide food for special occasions for example Valentine`s Day, Easter, bonfire night and Christmas. The atmosphere of the home was warm, friendly and inviting. A visitor to the home said that, "I am always made to feel welcome". Recruitment procedures were of a good standard, ensuring that people living at the home were protected. Staff training is up to date and staff are experienced, knowledgeable and welltrained.There is an effective quality assurance system ensuring that people living at the home as well as visitors, have the opportunity to suggest changes to any aspect of the service. People living at the home were full of praise for staff as well as the comfort of the home. One person said that, "staff will do anything for you, I cannot fault anything". Another person said, "we all have everything that we need". What has improved since the last inspection? There have been improvements to the environment. This includes a new patio area and garden furniture, redecoration of communal areas and bedrooms and some improvements to old windows, with more planned. A newsletter has been started to inform people living at the home and visitors of the forthcoming plans. Staff were working hard to find new ideas for outings and activities. What the care home could do better: Delays in the recruitment process can cause unnecessary pressure on existing staff. The dual electronic and paper recording system is causing duplication for staff. Information on the computer system is not fully accessible to all staff and has not always been transferred onto the paper system. New residents do not always have a personal service plan in place as quickly as was needed. Safety issues for example locking chemicals away securely and locking doors to storage areas for safety need further attention. CARE HOMES FOR OLDER PEOPLE Glebe, The Care Home Church Street Alfreton Derbyshire DE55 7AH Lead Inspector Jill Wells Unannounced Inspection 15th April 2008 09:15 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 Glebe, The Care Home DS0000035739.V362380.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. Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glebe, The Care Home Address Church Street Alfreton Derbyshire DE55 7AH 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) 01773 728347 www.derbyshire.gov.uk Derbyshire County Council Ms Gladys Maureen Cope Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Derbyshire County Council is registered to provide personal care and accommodation at Glebe Care Home for service users whose primary care needs fall within the following category: Old age, not falling within any other category (OP) 32 The maximum number of persons to be accommodated at Glebe Care Home is 32 17th April 2007 2. Date of last inspection Brief Description of the Service: The Glebe is situated in the centre of the busy market town of Alfreton, close to local shops, facilities and public transport. The Glebe is owned by Derbyshire County Council and provides 24 hour personal care and accommodation for 32 older people. All accommodation for residents is in ground floor, single rooms. There are no en-suite facilities. There is a large garden accessible to residents. Fees are £392.18 per week for permanent residents, and the fees for people staying for respite are individually assessed. There are additional charges for services such as hairdressing and chiropody. Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced and took place over 7 hours. There were 25 people accommodated in the home on the day of the inspection, three were staying for short term care. 7 residents, 4 staff, 2 visitors, the manager and deputy manager were spoken with during the visit. Some residents were unable to contribute directly to the inspection process because of communication difficulties, but they were observed during the visit to see how well their needs were met by staff. We also looked at all the information that we have received, or asked for, since the last key inspection on the 17th April 2007. This included: • The annual quality assurance assessment (AQAA) that was sent to us by the service. The AQAA is a self-assessment that focuses on how well outcomes are being met for people using the service. It also gave us some numerical information about the service. • What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. • The previous key inspection report. Records were examined, including care records, staff records, maintenance, and health and safety records. A tour of the building was carried out. The quality rating for the service is two star. This means the people who use the service experience good quality outcomes. What the service does well: There is a dedicated management and staff team that work in the best interests of people living at the home. Food is of a good standard with choices at every mealtime. People were regularly asked if they would like changes to the menu. Catering staff work hard to provide food for special occasions for example Valentines Day, Easter, bonfire night and Christmas. The atmosphere of the home was warm, friendly and inviting. A visitor to the home said that, I am always made to feel welcome. Recruitment procedures were of a good standard, ensuring that people living at the home were protected. Staff training is up to date and staff are experienced, knowledgeable and welltrained. Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 6 There is an effective quality assurance system ensuring that people living at the home as well as visitors, have the opportunity to suggest changes to any aspect of the service. People living at the home were full of praise for staff as well as the comfort of the home. One person said that, staff will do anything for you, I cannot fault anything. Another person said, we all have everything that we need. What has improved since the last inspection? 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. Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 7 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 Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 8 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): 1,2,3 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs are fully assessed prior to admission so the individual and the home can be sure the placement is appropriate. EVIDENCE: The statement of purpose and service user guide were available for prospective people wishing to live at the home. Minor amendments were needed to these documents for example the change of the manager, the new contact details of the Commission for Social Care Inspection (CSCI) and information concerning fees. We were told that the manager visits prospective residents at their home or in hospital as part of the assessment process. Prospective residents or their Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 9 family and friends were encouraged to visit prior to making a decision about whether the home will meet their needs. The Glebe has two places for respite care, and will sometimes accept more if vacancies allow. They also provide day-care. This means that most people making a decision to move permanently into the home have already stayed at the home for a short while. This makes their decision easier and also means that staff already know them. A person recently admitted to the home had previously attended for day-care and respite care. They were spoken with and said that, “I am very settled and happy here. Copies of assessments carried out by social services staff were seen on peoples records. Placement agreements were provided for all new people. This document stated that they would be advised separately of charges via the contracting department based in Matlock. The home does not provide formal intermediate care and therefore standard 6 was not assessed. Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples health and personal care needs are met and the principles of respect, dignity and privacy are put into practice. EVIDENCE: The care records of three people living at the home were seen. The care plans were written in a person centred way for example likes to hear staff though response is limited. Records included individuals life history, preferences, as well as information about their health. They were written in plain language, and were easy to understand. Individual records also included personal risk assessments, personal handling plans, prevention of falls assessment, dependency assessments and tissue viability risk trigger tools. At the time of the inspection staff were using a dual system. One was a computer system, accessible only to the management team, and a paper system accessible to all staff. This meant considerable duplication. Some records were up to date on the computer system for example chiropody visits, but had not been recorded on the paper system. A personal service plan for a Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 11 new resident was not fully completed for example under ‘action plan and what needs to be done’ it had been left blank. The person had been admitted two months previously, but the plan was still only available on the computer system therefore not accessible for care staff to read. The manager was aware of this problem and was in the process of attempting to rectify this. Two care staff were spoken with and both said that they were involved with peoples’ care plans and could give details of individual care required. Care staff were expected to write monthly reviews of the individuals that they were a key worker for. This was being done but not always on a monthly basis. Records, staff and people living at the home were all able to confirm that GPs and other health professionals were contacted and visited when required. One person said that, I just need to ask and staff will get me a doctor. A detailed moving and handling plan was in place for someone that needed assistance with moving. All three records had a last wishes plan that was blank. The manager said that people did not want to talk about their last wishes. Medication in the home was stored securely. Either the manager or one of the deputy managers administered medication. All had received medication training. The homes’ self-assessment document said that the home was audited every 3 months by the pharmacist to check stock levels and given advice. The last pharmacy visit was 27th March 08. The pharmacy report showed that everything was in order. The medication administration records were seen and were correctly completed. Controlled drugs were securely stored and the controlled drugs register was checked and found to be accurate. Care records showed that individuals had been assessed or asked if they were able to self medicate. People spoken with said that were treated with respect by staff. Care staff spoken with were very aware of the importance of respecting peoples privacy and could give examples of how they did this. One person’s records stated that the person, does not answer when staff knock on door but continue to knock as a mark of respect One person said that, staff are there if you want them, but will give you some privacy if you dont. Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 12 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): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The range of activities and standard of meals offered was good, which met the needs and wishes of people living at the home. EVIDENCE: There was a wide range of activities that people could be involved with. This included movement to music, reminiscence, quizzes, bingo, crosswords and ‘touch and feel’ bags. On the day of the inspection visit a clothes sale was taking place. Eight residents had recently been to see a production of ‘My Fair Lady’. A singer was planned for St. Georges Day. Records were kept of activities offered, although these were not always fully completed and did not include the names of people that had been involved. A visitor spoken with said that they had seen various activities including a choir and a visit to the pantomime but the person thought that more could be done to stimulate residents. A member of staff wrote in our survey, We could do with an activities coordinator. All jobs get done but sometimes there isnt enough staff to conduct activities in order to keep minds active. Staff spoken with said that staff helped out with trips in their own time. Another staff member in our Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 13 survey said that, we have fun on days like Valentines Day and Mothers Day to make them special. The manager told us that on the Easter morning staff dressed up as Easter bunnies to serve meals, which was much appreciated by everyone. Residents meetings were held on a 2-3 monthly basis. Minutes of these meetings showed that people were well consulted concerning trips out, entertainment and use of residents fund money. The manager told us that peoples religious needs were met with group and private communion by both Catholic and Church of England. There was also a monthly service from the Gospel Church. Staff told us that residents could go to bed and get up when they wish to do so. One resident said that, I could go to bed at 1 a.m. if I wanted to. Staff said that if any person did not want their meal at the regular time they would be offered soup or sandwiches later in the day. People were encouraged to bring their own personal possessions with them and bedrooms that were seen were comfortable and had been personalised. There was a choice of food at mealtimes. On the day of the inspection the options were belly pork and stuffing or cornish pasty with fresh vegetables followed by a milk pudding, bread-and-butter pudding or ice cream. There was the option of a cooked breakfast every morning. All the people that were spoken with said that the food was of a very good standard. One person wrote on our survey that they especially liked the Sunday dinners. One person spoken with said that, the food is marvellous. Information provided was that all care and catering staff had received training in safe food handling. Staff spoken with confirmed this. Both the cook and kitchen assistant were spoken with. It was evident that they enjoyed their job and did everything they could to please people living at the home, talking with them to find out their wishes and preferences. A monthly newsletter had been started to inform people of news and events during the following month. The manager told us that an annual meeting had been arranged with a representative from the library service to discuss peoples’ preferred choices. People had requested more large print books. Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 14 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): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and are protected from abuse. EVIDENCE: There were no complaints recorded at the home since the last inspection visit. The manager was advised that concerns and informal complaints should also be recorded to show that the service was responsive to individuals concerns. The Derbyshire County Council corporate complaints procedure was displayed but did not include the new contact details of the Commission for Social Care Inspection (CSCI). People spoken with said that they would talk to staff or the manager if they had a complaint. Care staff confirmed that they had attended training in safeguarding vulnerable adults, and training for kitchen and domestic staff on this subject was planned. Staff spoken with were aware what to do if they suspected abuse of a vulnerable adult. Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The home is a large Victorian house that has been adapted to provide all ground floor facilities. There are 32 single rooms, all with a wash hand basin. No bedrooms had en-suite facilities. A tour of the building showed that the home was clean and well maintained. People spoken with said that they were happy with the level of cleanliness at the home. Information from the service was that two lounge areas had been decorated and refurbished and 11 bedrooms had been decorated since the last inspection visit. The dining room was newly decorated and waiting the new cutrains. A Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 16 new patio area had been laid and patio furniture had been purchased. Some work had been done to the wooden windows, although painting the outside of these windows was still required. There were sufficient numbers of bathrooms and toilets to meet peoples needs. One toilet that was seen had a piece missing in the flooring underneath the sink, which was unsightly. There were grab rails and other aids around the home to assist people and maximise their independence. One lounge area had been changed to an activities room, although this was still available at other times for people to use if they wished to do so. Several doors with signs in place, ‘fire doors keep locked shut’ were unlocked. These were immediately locked when pointed out to the person in charge. There was a small hairdressing room, and the hairdresser visited weekly. Laundry facilities were sited away from the main areas where food was stored and prepared. This was a large area and had relevant equipment. People spoken with were satisfied with the laundry service. Bedrooms that were seen were comfortable and homely. People had personalised their own room. One person said that, my bedroom is lovely but I like to spend time with other people. A new telephone system had been put in place. This only rang in the office, which may mean that the phone cannot always be heard by staff. Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 17 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): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The recruitment practices and staff training programme were good and ensured that people were protected by competent, well-trained staff. There were sufficient numbers of staff to support the people who use the service. EVIDENCE: On the day of the inspection visit there was the deputy manager and 3 care assistants on duty, as well as the cook and kitchen assistant. The duty rota showed that this was usually the case. The manager usually worked 9 a.m.-5 p.m. It was evident from observations that there were sufficient staff on duty to meet peoples needs. One person wrote on our survey in response to the question concerning staff availability when needed, sometimes I have to wait but I know they will come when they can. A staff member wrote on our survey, all staff are very friendly and approachable and will do everything they can to help. A visitor spoken with said that staff are very welcoming, I usually get a cup of tea. Another visitor said that, it is a very warm, friendly place. A member of staff said that, “ I Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 18 have never been happier than in this job”. It was evident from discussions and observation that all staff put residents first and worked very well as a team. Staff records that were examined showed a safe recruitment procedure, although criminal record bureau(CRB) disclosure numbers and dates were not being recorded when the disclosures had been destroyed. There was an induction programme in place that met the Skills for Care standards and included first aid, food hygiene, moving and handling, hoist training, dementia care, safeguarding adults and bereavement. Information received was that staff turnover was generally very low, and recent changes had been due to staff retirement. The manager described a well-developed training programme, however training records were not available as they were computerised and only accessible to one deputy manager. The manager was aware that this needed to be rectified. Staff had achieved well above the minimum requirement of 50 care staff with National Vocational Qualification, (NVQ), at level 2 or 3. Almost all staff had undertaken NVQ level 2 and two night care staff had achieved NVQ level 3. Kitchen and domestic staff were also offered relevant NVQ courses. All new staff received training in equality and diversity, and staff spoken with had an understanding of this subject. The deputy managers were experienced and well-trained. One had completed NVQ level 4 and a second deputy was due to start this. Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 19 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): 31, 32, 33, 35, 36, and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is very well managed, with effective quality assurance systems, ensuring that people are listened to and the home continues to develop and improve. EVIDENCE: The manager had completed the Registered Managers Award (RMA). It was evident from discussions and observation that the manager is very dedicated and committed to ensuring that residents and staff were happy. A staff member said that, the manager is excellent, and all deputies are very supportive and will help out Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 20 The service manager visits the home to support the manager. There were also regular managers meetings where they receive support and share good practice. There were a number of ways that the manager ensures that people were given an opportunity to comment on the service. This includes an annual quality assurance survey undertaken by an independent agency. The results were compiled together and action taken to address any issues or suggestions. The service also had internal surveys for people living at the home. People had twice-yearly reviews of their care. One of the two involves a care manager from Social Services. This gives people living at the home and their families another opportunity to address any issues. Residents meetings were held to discuss how the home should be run, menus, outings, activities and entertainment. People are asked if they would like any changes made. People living at the home were recently consulted regarding some money available for new windows. They were asked whether bedroom or communal areas were to be replaced and they chose to replace the communal areas The manager and deputy manager undertook regular supervision for all staff, which was clearly recorded. One staff member said that supervision was very useful and gave them time to talk about training and any issues concerning their job. Regular health and safety checks were being done. This included testing water temperatures, call systems and fire equipment. A sample of test certificates were seen and found to be up to date. Chemicals were being stored in a room with no lock on the door. The person in charge said that this was because staff were using these cleaning fluids regularly. Staff were observed using gloves and aprons where appropriate. Information received from the service was that all policies and procedures were in place and had been reviewed, although some had not been reviewed for several years. The policies were Derbyshire County Council corporate policies. Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 21 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 3 3 3 x 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 x 2 Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 22 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 OP38 Standard Regulation 13(4) Requirement Chemicals must be stored securely at all times for the protection of people living at the home. Timescale for action 01/05/08 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 OP1 Good Practice Recommendations The Statement of purpose and service user guide should be revised and include the correct name of the manager, the up to date address and telephone number of CSCI and information concerning fees to ensure that prospective and existing residents have the correct information that they may need. All service user plans and other records on the computer system should be available for care staff to help them to care for people. The activities recording system should be in more detail to allow staff to review individuals’ social stimulation. 2. OP7 3. OP12 Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 23 4. OP16 The homes complaints procedure should include the address and telephone number of the Commission for Social Care Inspection (CSCI) to give people the opportunity to contact us if they need to. The flooring that had a piece missing underneath the sink of toilet 1A should be repaired or replaced to improve the environment for people living at the home. Changes should be made to ensure that the new telephone system can be heard throughout the building to ensure a timely response to incoming calls. When crminal records bureau(CRB) checks have been destroyed the disclosure numbers and the date of the disclosure should be recorded to provide evidence that they have been received. 5. OP21 6. 7. OP19 OP29 Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Glebe, The Care Home DS0000035739.V362380.R01.S.doc Version 5.2 Page 25 - 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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