Care Home: Gledhow Christian Care Home

What the care home does well What has improved since the last inspection? CARE HOMES FOR OLDER PEOPLE Gledhow Christian Care Home 145 & 147 Brackenwood Drive Leeds Yorkshire LS8 1SF Lead Inspector Paul Newman Key Unannounced Inspection 20th June 2008 09:30 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 Gledhow Christian Care Home DS0000001341.V366629.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. Gledhow Christian Care Home DS0000001341.V366629.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gledhow Christian Care Home Address 145 & 147 Brackenwood Drive Leeds Yorkshire LS8 1SF 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) 0113 2888805 0113 2888816 gledhow@trinitycare.co.uk Trinity Care Ltd Ms Frances White Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Gledhow Christian Care Home DS0000001341.V366629.R01.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 category: Old age, not falling within any other category - Code OP, maximum number of places: 50 The maximum number of service users who can be accommodated is: 50 27th June 2007 2. Date of last inspection Brief Description of the Service: Gledhow Christian Care Home is a purpose built property. The home is located in a residential area close to local amenities and public transport routes. There are car parking facilities. There are gardens surrounding the home that are accessible to the people who live there. The accommodation is on two floors with a passenger lift connecting the two. There are fifty single en suite bedrooms. There are several lounge and dining rooms located throughout the home. There are sufficient communal bathrooms and toilets. From information provided in June 2008 the weekly cost of the placement for each person ranged between £433- £690. Information is available about the service in the form of a statement of purpose and service user guide and this is available at the home. The Company intends to upgrade facilities to provide some ‘premier accommodation’ and work was part way through to achieve this at the inspection visit in June 2008. Gledhow Christian Care Home DS0000001341.V366629.R01.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 2 star. This means the people who use this service experience good quality outcomes. The accumulated evidence in this report has included: • • • • • • The previous key inspection. Information we have about how the service has managed any complaints. What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. Relevant information from other organisations. What other people have told us about the service. Information obtained from people living at the home, relatives, staff and other health care professionals. One inspector made an unannounced visit to the home that lasted seven hours on 20 June 2008. Before the inspection visit, the manager was sent an Annual Quality Assurance Assessment (AQAA) to complete. This is a self-assessment that if completed properly, should give us a lot of information about how the home is operating, what improvements it has made and what is planned for the future. It tells us where we can find evidence that the home is meeting National Minimum Standards. The AQAA that was returned was clear and gave us good information that helped plan the inspection. During the visit, a number of documents were looked at and all areas of the home used by the people living there were inspected. Apart from spending time with the manager and operations manager who was also present at the home that day, a good proportion of time was spent speaking to the nurses, other staff, people who live at the home and visitors. Time was also spent in communal areas and the dining rooms, watching what was going on and checking whether people appeared comfortable and cared for. Surveys were sent out before the inspection visit for people living at the home, relatives and friends, healthcare professionals and staff to express their views on how things operate, the services and care provided. At the time of writing this report, surveys from twelve people using the service, six relatives, two healthcare professionals and twelve staff have been returned and the general feeling expressed was a high degree of satisfaction. Gledhow Christian Care Home DS0000001341.V366629.R01.S.doc Version 5.2 Page 6 Feedback was provided at the end of the inspection to the manager. Feedback included an analysis of the results of the surveys that we had received. What the service does well: What has improved since the last inspection? At the time of the last inspection visit the manager had only been recently appointed and recognised that improvements needed to be made. The AQAA outlined that the eight issues raised in the inspection report had been addressed. There was sufficient evidence found that this was the case. • • • Care plans are now more detailed. Healthcare professionals now have ready access to information. There is better evidence to suggest that people are more likely get the care they need when they ask for it because the staffing situation has DS0000001341.V366629.R01.S.doc Version 5.2 Page 7 Gledhow Christian Care Home • • • stabilised. Requirements are however made in this respect to make sure this continues. Recruitment documentation shows that people are checked and vetted, as they should be. The staff training programme and records show that staff are trained in the skills they need. Receipts are held for all purchases made on behalf of people. Other improvements made have been: • • • • • • • • • More detailed information packs given to prospective service users and their relatives. The involvement of staff members with the pre-admission assessment visits to help there be a familiar face on admission. Enabled a greater number of people more involvement in outings and events, including family events. Introduced the ‘Nutmeg System’ of nutrition and menu planning and implemented improved menus. Developed a better dining experience. Given staff training a high priority and staff attendance is now much improved. Staff teams have been redeveloped to ensure a greater skill mix on both units of the home. Completed extensive improvements to the environment. Actively promoted an open and positive atmosphere and encouraged people to make suggestions for improvements and to discuss any concerns with the management team. Introduced bi-monthly newsletter containing information for service users and their family and friends. • What they could do better: This has been a positive and productive year and there is clearly a high motivation on the part of the manager and staff to achieve excellent quality standards. They should feel pleased with the progress they have made and can look forward to building on this with further improvements that are planned over the next year and were identified in the AQAA. Two requirements are made, although it is acknowledged that there has been a positive improvement in staffing and service delivery over the last year. The requirements are linked together because we want to be sure that people get the care they need in a timely way. Gledhow Christian Care Home DS0000001341.V366629.R01.S.doc Version 5.2 Page 8 • • People who live at the home must be able to have their personal needs met at appropriate times. This is to ensure their dignity is maintained. There must be sufficient staff working at the home to meet people’s needs at all times. A recommendation is made to encourage the development of more person centred and detailed care plans, but once again the improvements made over the last year are acknowledged. • The AQAA acknowledged that the home wants to continue to develop the care plans in a person centred way, and these improvements should continue. It is this quality and detail that fully evidences that staff are made aware of peoples’ preferences. 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. Gledhow Christian Care Home DS0000001341.V366629.R01.S.doc Version 5.2 Page 9 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 Gledhow Christian Care Home DS0000001341.V366629.R01.S.doc Version 5.2 Page 10 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 and 3. Standard 6 does not apply to this home. People who use the service experience good quality outcomes in this area. People have up to date written information about the home to help them decide if the home is suitable for them to live in. People are properly assessed before admission so all concerned can be sure the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The surveys that were returned and conversations during the day indicated that people were provided with enough written information about the home. The home has brochures that provide information about the home as well as a service user guide and statement of purpose which are displayed in the Gledhow Christian Care Home DS0000001341.V366629.R01.S.doc Version 5.2 Page 11 entrance foyer and also available to anyone on request. These contain up to date information. Four care plans were checked during the day. One of these was for the most recent admission. All had a pre-admission assessment that was supported by additional social work assessments and care plans. On admission each service user or next of kin signs a contract containing the terms and conditions of their stay at Gledhow Christian Care Home. The home has now begun to involve other staff in the pre admission process and tries to make sure that the staff member who attended the assessment with the Home Manager or Deputy Manager are on duty when the person arrives. It helps the person coming to live at the home being greeted by someone they are familiar with and this is good practice. From the information gathered in the pre-admission assessment a plan of care is written. Gledhow Christian Care Home DS0000001341.V366629.R01.S.doc Version 5.2 Page 12 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. People who use the service experience good quality outcomes in this area. People get the care they need and the care plans provide instructions and guidance for staff to follow so they are fully aware of peoples’ needs. There are safe medication practices that make sure people get the drugs that are prescribed for them. People are treated with respect and in a dignified way. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The four case files that were checked showed that information had been accurately used from the pre-admission assessment to draw up the plan of care. People and their relatives spoken with during the visit confirmed that they had been involved. The plans addressed individual health, personal and the home recognises that it needs to continue to develop social care plans. The plans offered sufficient guidance to staff for them to know what each Gledhow Christian Care Home DS0000001341.V366629.R01.S.doc Version 5.2 Page 13 person’s care needs are, and how they should go about addressing these. Additional training and supervision has been given to staff involved with care planning. The home has been trying to develop the care plans to make them more ‘person centred’ so that there is a lot more information about peoples’ personal preferences, preferred lifestyle and their life history. There was evidence of this on the files seen. The AQAA acknowledged that they want to continue to develop the plans in this way, and this is encouraged. It is this detail that fully evidences that staff are made aware of peoples’ preferences, although in speaking to people at the home, watching what was going on and speaking to staff, it is clear that they know the people they care for very well. On admission, a range of risk assessments are made for moving and handling, nutrition, dependency and pressure sore risk. These are reviewed regularly. People have their weight recorded at least monthly and there was evidence to show that any significant changes are referred to the GP. Other healthcare professionals are consulted when required and these include the dietician, tissue viability nurse, and community psychiatric nurse. Medication procedures and practices were discussed and seen, and the storage and the recording of drugs that are administered (including controlled drugs) were checked. No problems were found and practices that were seen were safe. Audits are made of care plans and medication held at the home. All personal care and visits from healthcare professionals and Doctors are carried out in the privacy of people’s own bedrooms. During the inspection, staff were seen knocking on bedroom doors and making sure that doors were closed at times when personal care was being delivered. People spoken to said that that staff are attentive to their needs and wishes, although some of the surveys suggested that staff did not always attend to people in a timely way. One said that her aunt would like a weekly bath but was not always offered this. Whilst maintaining peoples’ anonymity, all of the written comments made in surveys were included in the analysis and a copy was given to the manager so that all the views expressed could be raised and discussed at the next staff meeting. Some positive comments made reflected good standards of care and was more representative of what was seen and said on the day of the visit: • Very supportive’. • ‘They provide good all round care both physically and mentally’. • ‘My mother is encouraged and helped to attend Holy Communion, prayer meetings and bible study so that she can draw comfort from those elements that are always an important part of her life. She has been introduced to other residents and thoughtfully placed in company of those likely to be friends’. • ‘Staff seem very aware of Mother’s personality as well as physical needs and they tell me of changes in moods habits etc’. • Staff are very approachable and willing to talk and listen’ Gledhow Christian Care Home DS0000001341.V366629.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): 12, 13, 14 and 15. People who use the service experience excellent quality outcomes in this area. Peoples’ social expectations and personal preferences are met and there is a lot on offer for them including excellent links with the local community. They are able to exercise choice in their lifestyles so they can be as independent as they can. People living at the home are provided with an excellent varied and nutritious diet so they can eat healthily. We have made this judgment using available evidence including a visit to this service. EVIDENCE: There are two enthusiastic activity co-ordinators who hold informal meetings with service users to encourage suggestions so that the social calendar can be developed. During the afternoon of the visit there was an entertainer in who people and relatives were enjoying and he was followed by strawberries and cream refreshments. Before this, staff were actively encouraging people and Gledhow Christian Care Home DS0000001341.V366629.R01.S.doc Version 5.2 Page 15 visitors to attend. Staff spoken with talked about trying to make sure that people developed social relationships and this was also said in one comment in a survey returned by a relative. Information about planned activities and events are displayed within the home and in the bi-monthly newsletter that is now produced. One to one time is allocated for those residents who are not able to participate in group activities or outings or who prefer one to one time. The home has many different church representatives visiting on a weekly basis offering different services, for example, ‘pray and praise’ or church services. People are encouraged to maintain contact with their local community and there are no restrictions on friends and visitors visiting the home. All of those spoken with said that they felt welcome. Some people had personal telephones in their bedrooms so that they could keep contact when they liked. Links with the local Gledhow Primary School have been developed and encouraged and the children visit the home on a regular basis interacting positively with our service users. Teenagers from Allerton Grange High School attend the home on a weekly basis on work experience and fellowship sessions. These teenagers spend time talking to people and develop good relationships. The home has sponsored a Donkey that regularly visits the home. ‘Simon’ is also able to visit residents in their own rooms. The home has a minibus with several insured and competent drivers enabling regular outings and this has included enabling several service users to attend family weddings and events that otherwise they would have missed. There are themed days to add to the experience of living at the home. The day before the inspection there had been an Italian day with the home decorated up, staff wearing costume and special menus for those who wanted the ‘Italian experience’. The current cycle of menus seen was excellent, providing choice, variety and nutrition. The home now uses a system called ‘Nutmeg’ adopted by Southern Cross so that the nutritional value of each meal can be calculated. Homebaking is provided every afternoon. Peoples’ special dietary needs are catered for including diabetic, soft and puree. The dining rooms were well set but one has been developed to reach a very high standard giving an excellent dining experience for people. The other dining areas are also to be upgraded. People clearly enjoy a lot of choice in their daily routines, and those spoken with said they are able to get up and go to bed when they wish, spend time on their own or join in activities or chat with friends or simply watch what was going on. They looked well cared for, were happy and the relationships with each other and the staff were relaxed. It was good to see some relatives joining in the activity during the afternoon. Gledhow Christian Care Home DS0000001341.V366629.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): 16 and 18. People who use the service experience good quality outcomes in this area. The people who live at the home and their relatives know how to complain and feel confident that they will be listened to and that action will be taken when necessary. There are adult protection procedures that staff are aware of through training, so people can be assured that they can feel safe because staff know what to do. EVIDENCE: The home aims to deal with situations as they occur, and encourages families to discuss any area of concern with the nurse or manager at the outset. In the conversations with people during the day and in the written comments made in surveys that were returned, this was clearly the normal way of doing things. People felt comfortable about raising things and said that they were listened to and actions were taken. One comment made was, ‘minor complaints have been dealt with efficiently’. Where formal complaints have been made, these have been investigated under the appropriate procedures and properly documented. By chance, one family who had made a complaint about their father’s care were visiting, and in conversation mentioned this. One of the daughters concerned spoke about the issues and felt the home had listened and acted. Some of this was about Gledhow Christian Care Home DS0000001341.V366629.R01.S.doc Version 5.2 Page 17 aspects of her father’s care that should have been noted in the care plan. The care plan was checked and had been modified showing that the home had taken the issues seriously and noted things so that staff were clear on what to do in certain situations. The complaints procedure is displayed in reception and also in service user guides that are provided. Protection of Vulnerable Adults training is ongoing for staff and is mandatory training. This is also discussed with staff at supervision sessions held six times a year. Other checks made on recruitment, safekeeping all met required standards. medication and money held for Gledhow Christian Care Home DS0000001341.V366629.R01.S.doc Version 5.2 Page 18 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 and 26. People who use the service experience good quality outcomes in this area. People living at the home live in a clean, comfortable and safe environment that is properly maintained and regularly improved with recent improvemnts achieving excellent standards. We have made this judgment using available evidence including a visit to this service. EVIDENCE: The tour of the premises found things clean, well maintained, and odour free with the gardens tidy and providing easy access for residents to enjoy the outdoors. Bedrooms were comfortable and personalised and there is an ongoing programme of redecoration and refurbishment. The company began work earlier this year to re-brand some areas into luxury/premier Gledhow Christian Care Home DS0000001341.V366629.R01.S.doc Version 5.2 Page 19 accommodation. standards. The work that has been completed so far is to very high To highlight the work that has been going on these are some of the improvements made: • A large number of bedrooms have been redecorated and new carpets have been laid. • Several bathrooms and communal areas have been redecorated and refurbished. • The hairdressing salon has been redecorated. • All corridors have been redecorated to a high standard. • New brighter lighting has been installed along all of the homes corridors and some communal areas. • Both kitchenettes have been redecorated. • New dining tables have been purchased. • New lounge chairs have been purchased. • Garden furniture has been purchased for the decking area. • The cleaning programmes have been redeveloped and are monitored more closely. At the time of the inspection visit, final work was being completed to carpet on a staircase. The call system was checked during the tour and this was working satisfactorily. People were asked if staff respond quickly and said they did. A lot of different equipment was available throughout the home to aid moving and handling and help people maintain independence. Surveys suggest that the home is always clean and tidy and this was certainly the case on the day of inspection. People and relatives said that this was part of the reason that they had chosen to live at the home plus the fact that there were no unpleasant smells. Some said they had visited other homes that did not come up to these standards. The AQAA confirmed that all regulatory health and safety monitoring checks were up to date at the time of the inspection. Staff were seen to be wearing protective clothing to avoid the risk of cross infection. The laundry is well equipped. Gledhow Christian Care Home DS0000001341.V366629.R01.S.doc Version 5.2 Page 20 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. People who use the service experience good quality outcomes in this area. People living in the home are cared for by committed staff who are properly recruited, trained and qualified for the job. We have made this judgement using available evidence including a visit to this service. EVIDENCE: It is evident that there is a much improved staffing situation than this time last year. The manager has been able to recruit some experienced carers and sickness rates have reduced. Staff spoken with said that morale had improved a great deal. They felt that changes made to teams to provide a good skill mix had been beneficial and they were very much pulling together. There was no longer any divisions because someone was allocated to care in a particular part of the building and there were several examples during the day of good staff practice and team work. The manager will however, need to monitor staffing levels in relation to dependency levels of the people they care for so that there is better evidence in surveys returned from people living in the home to reflect that staff are available when people need them. Out of the twelve returned, only one said always available, six said usually and the other five said sometimes. The balance in the surveys returned by staff indicated that there were usually Gledhow Christian Care Home DS0000001341.V366629.R01.S.doc Version 5.2 Page 21 enough staff on duty. This is always a fine balance for management but there was also evidence that the staffing situation was steadily improving as sickness rates fall and the staff team stabilises. The home exceeds targets for the number of care staff who should have a National Vocational Qualification (NVQ). The training matrix seen that shows what training individual staff have received confirmed what the AQAA had said about training being given a high priority since the last inspection. New and existing staff talked about their induction and ongoing training and it was good that one member of staff with a great deal of experience had undergone the same induction as someone without experience. In fact relatives and people living at the home nominated the same member of staff for the Company’s ‘Carer of the Year Award’ for which she was selected as a finalist and won awards. The recruitment files for the three most recently appointed staff were checked. These showed that recruitment was thorough with the required referencing and vetting being done. All staff had application forms, interview check lists a contract, two references, one being from the last employer, and checks had been made with the Criminal Records Bureau. This makes sure that people are protected from staff who may not be suitable to work in the care industry. From what was seen during the day, there are good relationships, people looked well cared for, were happy and there was a good atmosphere in the home. Relationships were warm and there was some friendly banter from time to time. Visitors also appeared to be enjoying their time in the home and had good relaxed relationships with staff. Gledhow Christian Care Home DS0000001341.V366629.R01.S.doc Version 5.2 Page 22 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, 33, 35 and 38. People who use the service experience good quality outcomes in this area. The home is well managed and the opinions and interests of the people are central to the way the home is run. Safety checks and systems of communication make sure that the home is a safe place to live. We have made this judgment using available evidence including a visit to this service. EVIDENCE: The registered manager is experienced and qualified as a nurse and is currently working towards a management qualification. From the Gledhow Christian Care Home DS0000001341.V366629.R01.S.doc Version 5.2 Page 23 conversations with people, visitors and staff she is considered approachable, encourages new ideas and has high standards of care. Staff feel that they have a clear understanding of what the manager expects from them. There are regular staff meetings, individual supervision sessions and staff feel supported. The company has systems of surveying people and their relatives and the results of the surveys were made available during the visit. On a daily basis it was also clear that staff regularly check on the wellbeing of people making sure they are comfortable or if they need anything. There are regular ‘Residents and Family’ meetings and positive comments made by relatives indicate they feel these are useful and productive. The Manager holds a surgery on a monthly basis so that relatives can see her in private. The company makes its own quality checks that make sure that the home is compliant with legislation and National Minimum Standards and if not, what actions need to be taken. Part of this is for the operations manager to visit monthly. She writes a report on the conduct of the home reporting on people she has spoken with including relatives and staff, records and audits that have been made, complaints, staffing and a tour of the premises. A copy of the report is sent to us each month and this helps us monitor what is going on. The home’s administrator holds some people’s personal money for safekeeping. She described and demonstrated the systems, procedures and practices for making sure this is properly accounted for and is safe. One person’s records were checked and receipts for all purchases supported the record. People can be assured their money is well looked after and accounted for. Staff were seen to be wearing appropriate protective clothing to prevent cross infection and safety checks are made of the facilities and equipment to make sure the home is a safe place to live. The housekeeper and team do well to make sure the home is clean and free from unpleasant odours. Staff are trained in safe working practices and are up dated regularly. Some records of safety checks were seen and found to be up to date. Accident records were also checked and were properly recorded and are audited by the manager to check if risks can be reduced. The AQAA confirmed that equipment and facilities are checked regularly to make sure it is in good and safe working order. Gledhow Christian Care Home DS0000001341.V366629.R01.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 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 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 Gledhow Christian Care Home DS0000001341.V366629.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 OP10 Regulation 12 (4) Timescale for action People who live at the home 30/09/08 must be able to have their personal needs met at appropriate times. This is to ensure their dignity is maintained. Outstanding from 31/07/07 2. OP27 18 (1) There must be sufficient staff working at the home to meet people’s needs at all times. Outstanding from 31/07/07 30/09/08 Requirement Gledhow Christian Care Home DS0000001341.V366629.R01.S.doc Version 5.2 Page 26 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 OP7 Good Practice Recommendations The AQAA acknowledged that the home wants to continue to develop the care plans in a person centred way, and these improvements should continue. It is this quality and detail that fully evidences that staff are made aware of peoples’ preferences. Gledhow Christian Care Home DS0000001341.V366629.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Gledhow Christian Care Home DS0000001341.V366629.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!