Inspection on 30/07/07 for Glastonbury Court

This inspection was carried out on 30th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Glastonbury Court 31/07/06

Glastonbury Court 01/03/06

Glastonbury Court 08/11/05

Glastonbury Court 29/03/05

Glastonbury Court 01/12/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Glastonbury Court Glastonbury Court Glastonbury Road Bury St Edmunds Suffolk IP33 2EX Lead Inspector Mary Jeffries Unannounced Inspection 30th July 2007 09:00 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 Glastonbury Court DS0000037079.V347720.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. Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glastonbury Court Address Glastonbury Court Glastonbury Road Bury St Edmunds Suffolk IP33 2EX 01284352650 01284352645 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) Suffolk County Council Mr Jonathan Newson Ellis Care Home 48 Category(ies) of Dementia - over 65 years of age (29), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (3), Old age, not falling within any other category (16) Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three Service Users in the category of MD (E), as named in the application received 5th February 2007, may be accommodated in the home. 31st July 2006 Date of last inspection Brief Description of the Service: Glastonbury Court is situated in a pleasant residential area of Bury St Edmunds. It is registered for the care of 16 older people, 29 older people with dementia, and 3 older people with a mental disorder. It is a modern two-storey building that was designed for its current use. All rooms are for single occupation and all have en-suite facilities. The rooms are grouped into units of 8, each with its own lounge, kitchen and dining area. Willow, Cherry and Elm, on the ground floor, are the individual units which make up the nurse led unit at Glastonbury Court. Two nurses work on the ground floor between 10 am and 6pm, one nurse at other times. The nurses manage the care on the units, supported by a team leader. These units provide care for older people with dementia, and also the three older people with mental disorder. Beech, Cedar, and Maple do not provide nursing care, and are on the first floor of the home. Beech unit has recently been converted to provide care for older people with dementia. The Home is owned and managed by Suffolk County Council. The current fees range from £66.85 to £368.00 per week. Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection, which focused on the core standards relating to older people. The report has been written using accumulated evidence gathered prior to and during the inspection. An Annual Quality Assurance Assessment (AQAA) was provided by the home prior to the inspection. The inspection occurred on a late afternoon and early evening in July 2007 and took five hours. The process included a tour of the building, and observations of staff and resident interaction. A number of documents were examined including residents care plans, accident records, medication records, the staff rota, recruitment, training records and a recent record of a recent staff meeting. Records relating to health and safety were also inspected. The inspection was facilitated by the manager. Care, nursing and domestic staff participated in the inspection. Ten residents responded to “Have your Say” surveys sent to the home. Four relatives sent in “Have your Say” surveys. Four residents were tracked, two on the nursing units and two on the frail elderly units. Residents were observed on the nursing unit and on the new dementia unit, Beech. Three residents were spoken with in a group; the two of the residents tracked were spoken with in more depth. What the service does well: The home is clean, attractive, and comfortable. The quality of care in the home is experienced by residents to be good. The home is good at listening to residents and acting on what they say. Concerns are responded to well, and there is a proper complaints procedure in place which residents and relatives are aware of. Recruitment procedures are satisfactory, with staff properly inducted. Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 6 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. Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 7 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. Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can expect to have access to the information they need to make an informed choice about the home, and to have the opportunity to visit the home before deciding whether to live there. The home does not offer intermediate care, and therefore NMS 6 is not applicable. EVIDENCE: The Registered Manager advised that someone goes out from the home to assess prospective residents if they are in hospital, but other usually come to the home for pre admission assessments. 70 of residents stated on their survey response that they had received enough information before they moved in to make a decision about whether the home would be the right place for them. 30 noted that this was Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 10 something that their relative had dealt with for them and, or, they couldn’t remember. A resident wrote on their survey, “I had a brochure in the hospital.” Another wrote; “I came up once a week to visit and ask questions about the home and to see if I liked it before moving here.” One resident couldn’t remember, noting “It was a long time ago, my family sorted most things.” One resident stated that they came up for a day assessment and asked various things.” The most recently admitted resident had an assessment on file. Since the last inspection has been established that three of the older people living on the nurse led unit have a primary need arising from mental disorder rather than dementia. These individuals have all lived at the home for some time. The home has demonstrated that it can meet the needs of these people and varied its registration accordingly. A decision had been made by that the nursing unit would be closing at the end of October 2007 as it did not meet the strategic direction of the Primary Care Trust, Suffolk Mental Health Partnership trust and Social Care services. Staff had been advised of this at a staff meeting and relatives had also been informed at a meeting held earlier in July. Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People can be assured that they will have a care plan and that it is regularly reviewed. They can expect carers to have a good understanding of their needs and to treat them with dignity and respect. Residents may have to wait for assistance a short while at busy times. EVIDENCE: Of the four relatives who sent in survey answers, three indicated that the home always gives their relative the support and care that they expected or agreed. One relative advised that the home usually gave this. The two care plans seen were very good; they were clear and contained goals for each area of the plan. At the last inspection it was found that all care plans were not regularly reviewed in a timely way. A new review form had been introduced to ensure greater clarity of planning at the reviews that are held between Key workers and team leaders with nurses involved where appropriate. The files for two residents were inspected and these were found to be up to date and regularly reviewed, including a review of risk assessments. Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 12 One of the residents tracked had, for example, skin assessments on a monthly basis. Reviews of care plans were inspected for two residents on the nursing unit. The home had reviewed the care plan of the service user on the nursing unit who was found at the last inspection to have disturbed sleep and established that their needs could be met on the unit without undue disturbance to other service users. It had also been established that a resident who sometimes had their room locked, to stop another going in at night, was able to unlock their room from the inside. The home had evidence that they had consulted with the fire service about these arrangements and they were considered to be satisfactory. A risk assessment was provided to the CSCI. CPA reviews were on file for these residents. One of them was exactly six months ago; there was no date for the next review. These are usually held at six monthly intervals. A nurse advised that this may be because an exercise was planned to review all of the residents on the nursing unit, in connection with the forthcoming closure of the unit, and the need to establish whether they require d nursing care or continuing care. Care plans included questionnaires about personal care, residents’ preferences in terms of the whether they preferred a male or female carer, and whether if their preference could not be met occasionally, they objected to a member of the other sex providing their personal care. Records contained details of visits from GP’s, chiropodists, opticians and district nurses. 90 of residents responding to the survey commented that they always receive the medical support that they need, 10 stated that they usually did. A resident who had been visited by the district nurse to attend to their legs on a daily basis explained how, as they had improved, this went down to every other day, and that the district nurse now attends just once a week to do bandaging. The teatime medications were observed on Maple and Cedar. Medical records contained photographs of each resident. there was one photograph missing for the most recently admitted resident. The carer doing the medication round advised that they had received Boots training and in-house medication training, including 2 yearly updates. The round was conducted in a relaxed but professional manner. Tablets were correctly popped form blisters and residents were checked to establish if they had a drink to take them with. Records were signed each time a medicine was given, and where the dose prescribed was for one or two tablets, it was recorded what was given. Fourteen records were inspected and were found to be all correct. The controlled rug book was checked against stock and found to be in order. Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 13 The home is good at listening to residents and acting on what they say. All ten residents who sent in surveys indicated that this was always the case. Of the four relatives who sent in survey answers, three indicated that the home always gives their relative the support and care that they expected or agreed. One advised that the home usually gave this. One relative wrote, “They (staff) are very attentive.” Interactions seen between carers and service users on both the nursing init and the other unit were respectful and polite. There was a particularly homely warm and caring atmosphere on the non-nursing units and good interaction between carers and residents on an ongoing basis, for example the staff were heard telling residents what they were doing, even when not directly involved in their care, so that the relationship between them was actively maintained. Glastonbury Court DS0000037079.V347720.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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to enjoy a good quality of daily life and for their wishes and preferences to be accommodated as far as possible. They can expect for their relatives to be kept well informed about their care. EVIDENCE: 70 of residents responding to our survey thought that there were usually activities planned by the home that they could take part in, 30 thought that there sometimes were. A relative commented, “……… is a different person since she’s been in there, she’s bubbly, she’s come out of herself. When she comes to visit me she’s wanting to get back because she thinks all her friends there will be missing her.” During the early evening the inspector toured the nursing unit. There was a relaxed and comfortable atmosphere. One resident on the frail elderly unit was vigorously playing the piano, which is sited in one of the corridors. Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 15 One resident wrote on their survey; I went on the sea side outing and take part in crafts and games.” There was a letter of thanks in the home from one relative for a day trip and picnic that had been on. A resident spoken with advised that children used to come in to see them from the local school, but that this had dropped off because it was school holidays. One relative wrote on their survey response; “I find that team leaders and carers also care for people like myself. If there is a problem with (the relative) I am informed in such a way that no matter how serious it the problem I do not overly worry, as I have very confidence that the staff have my (relative’s) best interest at heart.” One resident had recently had a big ninetieth birthday at the home; the family had been able to have use of the large meeting room and obtain the catering services of the home, and friends and family as well as the residents friends from their unit and other units were invited. There were photographs of the event in the home and the resident told the inspector how much they had enjoyed it. This resident’s relative spoke to the inspector and was very impressed by the kindness and knowledge of all of the staff and happy that the event had been such a joyous one. Three of the four relatives providing survey response indicated that the home always keeps them up to date with important issues affecting their relative or friend who lives in the home. One advised that they were usually kept informed. Of the four relatives who sent in survey answers, three indicated that the home always supports their relative to live the life that they choose. One advised that it usually did. One resident spoken with had moved rooms since the inspector had last met them. They advised that they had asked if they could do this when a room came up, as they now had a very good view over the entrance to the home and they enjoyed seeing the comings and goings. Another resident spoken with advised that they had a cup of tea brought to them in bed in the morning as this was their preference. The residents’ survey indicated that 60 usually like the meals at the home, 30 always like them and 10 , (1), sometimes like them. One residents’ survey comment was “Can’t fault the food provided.” Another noted, “Too much mince dishes.” They also commented, “Would like to have supper later than planned.” This resident was spoken with, they advised that they had tea just before 5 o’clock, and although they had a drink and a biscuits about 9.30pm, having had a good cooked meal at 12.30 they were not hungry by 5 o’clock. They said that a long evening lay ahead when a later tea would be something to look forward to. This resident felt that the timing was to suit staffing rather than the residents. Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 16 The cook was spoken with, as it had been noticed that in the foyer there was a certificate that they had earned on reaching the national finals in a care homes catering competition for cook of the year. The cook spoke with enthusiasm about the dishes she prepared for residents. They advised that they had no one who required a diabetic diet in the home at present, and one person who sometimes preferred vegetarian food. They had advised that there had recently been some updating of the menus, as pasta had been tried but the residents didn’t like it on the whole. One recent addition to the menu was beef burger in a bun. A resident spoken with advised that the main meal of the day had been chicken and bacon casserole, but that they had had an alternative, fish and mash. The pudding of the day had been treacle tart. Teatime was observed on one of the units. This was a social and pleasant time. Residents were served with cheese ham and pineapple on toast. There was a bowl of fresh fruit on each unit. Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 17 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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Glastonbury can expect that their concerns will be listened to and acted upon, but that if they should have to make a complaint a proper procedure is available and accessible. EVIDENCE: No formal complaints had been received by the home. One resident responding to our pre inspection survey answered no to the enquiry “Do you know who to speak to if you are not happy.” They added, “I’m never unhappy.” They also indicated that they did not know how to make a complaint, but stated that their family would do this for them if it were needed. These answers were supported by other very positive answers to the rest of the survey about their life in the home. Another resident who stated that they did not know how to make a complaint added, “ I don’t know because I don’t need to make a complaint.” Apart from residents who are always happy, or whose relatives would deal with a complaint, everyone responding to our survey knew how to complain, and 90 always knew who to talk to if they were not happy. Of the four relatives who sent in survey answers, three indicated that the home had always responded appropriately if they or their relative living at the home had raised concerns. One advised that it usually had. Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 18 The Registered Manager had previously worked in another County, and had not received any Safeguarding training since they had been in post in this home. They were aware of local referral routes. One carer spoken with advised that they had not had recent Protection of Vulnerable Adults training, but had received it. Newly recruited staff head records of PoVA training on their files. A safeguarding meeting had been held shortly before the inspection to consider three separate incidents involving different residents which had occurred within a short space of time. These had been correctly reported to CSCI with regulation 37 notices, and also to Customer First. There was no evidence to indicate that abuse had taken place in any of these instances. Another matter concerning some missing monies was also dealt with under safeguarding procedures, and the police looked into this situation. The resident had not kept their money in the safe available, and the police were unable to take this forward, but did attend the home and give advice to residents. Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 19 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): 19,20,21,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to live in an attractive and well-maintained home. EVIDENCE: An attractive welcoming foyer, with comfortable seating and relevant information greets people on entering the home. The statement of Purpose, latest inspection report, a compliments and complaints book are all available for residents and relatives to see. The kitchen was very clean and orderly. Bathrooms through out the home were seen to be clean and orderly with appropriate liquid soap and paper towels. Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 20 The laundry was seen to be clean and well organised. A resident spoken with advised that most of the time they get the right clothes, but that once one item went missing from the laundry. A number of residents spoke of or demonstrated good relationships with other residents in the home, and the living arrangements are conducive to this. The nursing and non-nursing units are both further divided into three smaller units, so that life is organised around small group living. Individual rooms seen were attractively decorated and personalised, and residents were seen to have safes in their rooms. A schedule of maintenance tasks and small repairs was maintained in the home. The home is provided with all appropriate equipment, ramps, and a lift. The hoist in one of the bathrooms, which had previously been noted to jolt on occasions, had not been replaced as recommended. Whist there is no indication that there is any risk attached to the use of this hoist, residents have previously advised that the experience of using it can, at times, be disconcerting. On this occasion the hoist was being serviced during the inspection. It was seen that this hoist had caught the edge of the bath and the surface of the bath had been compromised in two places on the lip of the bath where the hoist swings across, and enamel removed. This is an infection control risk. Although the hoists were seen to be being serviced, there was no evidence available in the home that the lift had been serviced. There was evidenced that it had been repaired following it having been out of use for a short period of time. (The CSCI were notified of this.) 60 of residents responding to our survey considered the home to always be fresh and clean. 40 thought it usually is. Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 21 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): 27,28,28,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to be careered for by a well-qualified staff team who are responsive to their needs. They may find that at times they may have to wait to be attended to, however they can expect the quality of care they receive to be very good. EVIDENCE: In response to the survey enquiry “Are the staff available when you need them?” 60 answered usually, 20 answered always and 20 answered sometimes. 90 however thought that overall they always got the care and support they needed, 10 thought that they usually did. One resident commented about staff that they “cannot always be there at that exact time but they try their best to do what they can.” Another commented, “Depending on if it’s a busy time.” They also commented “Sometimes carers are busy when I want assistance so I wait for them to finish.” One relatives survey response to what they thought the home could do to improve was; “They do need more staff sometimes everybody wants hep at the same time.” A resident spoken with explained that they got up a quarter of an hour earlier so that they could get the slight assistance they needed with dressing without waiting for 10 or 15 minutes. Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 22 The levels of staffing were adequate on the nursing unit on the day of the inspection. There is one nurse on duty at all times on the nursing unit, and two carers on each of the three sub-units. Care on the unit is nurse led. The staffing level was up to compliment on the three non nursing units, and was adequate. The AQAA indicated there had been some reduction in the use of agency staff and carers spoken to thought that this was the case. Over 50 of staff are qualified to NVQ2 or above. Two files of recently recruited staff were inspected. These showed that proper processes had been conducted. All required information was on file including proof of identity and references and PoVA first checks and CRBs. Relatives were asked in the survey whether they thought that the care staff have the right skills and experience to look after people properly; half of those answering (2) thought that they always did, one thought that they usually did, and one thought that they only sometimes did. One of these relatives was spoken with. They could not praise these staff highly enough, but advised that there had been a short period when the home had used a lot of agency staff and they had felt that they couldn’t always understand the residents properly and also that their moving and handling skills were not always as good as they should be. “When agency staff are used there is a communication barrier with residents not being able to understand what the agency people are saying. Also there is a lack of agency people understanding the different needs of residents. This can and has caused distress to several of the residents.” Since the last inspection the manager has obtained and provided evidence of up to date mandatory and statutory training for the nursing staff working at the home. The files of three care staff, including two who had been recruited since the last inspection were inspected. There was evidence of appropriate Skills for Care induction training for the new staff. Manual handling and Unisafe updates had been provided for staff in October 2006. Recently recruited staff had received Protection of Vulnerable adults training, but there had been no updates for other staff. Two carers working on the Beech dementia care unit spoke of loving their work. Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 23 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): 31,33,35,37,38.Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst residents can expect the home to be responsive to their needs they cannot be assured that all safety and management checks have been undertaken and recorded. EVIDENCE: There had been a change of manager since the last inspection. A Registered Manager from another home was seconded to Glastonbury for a period until the appointment of Mr. Jonathon Ellis in December 2006. He obtained Registration with the CSCI in May 2007. As requested, the home had provided the CSCI with a copy of the most recent dementia mapping exercise, but this had not been recently undertaken and no further mapping had occurred. Despite this, the feedback on the quality of care Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 24 on the dementia unit was good, and as noted elsewhere in this report the home is responsive to residents’ needs and wishes. The Registered Manager was unable to provide regulation 26 visit reports for every month; these should be available in the home. They advised this was a recognised problem and that Social Care Services had appointed someone to undertake this work. Service users monies are managed through Suffolk County Council client account, and individuals had accounts within them. During the inspection it was noted that a resident’s care plan had been left on a small table in a lobby area outside of Maple unit. This was pointed out and immediately moved. One resident noted an additional comment on the survey they returned; “ Everything is very satisfactory.” A Hazard Analysis Critical Control point (HACPP) risk analysis had been completed in September 2006. This was concerned with the processes involved in the production of the home’s food. The home’s certificate of Registration was displayed, and the Public Liability insurance certificate was displayed. Good information was available in the foyer of the home including the last CSCI report. The Suffolk County Council Fire Officer wrote to the CSCI in July 2006, to advise that a recent inspection of the premises had been satisfactory, however there was no evidence of any fire training recorded since the last inspection, apart from to new staff who had received this. Regular drills were evidenced. Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 25 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 3 X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 2 3 3 3 2 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 2 X 3 X 3 2 Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 26 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. 1 Standard OP22 Regulation 16(2)(c) Requirement Timescale for action 30/09/07 2 OP26 13(4) 3 OP33 26 4 OP38 23(4)(d) The home must ensure that the lift has been fully serviced to ensure it will remain in good working order and residents can have access to all parts of the home. Action must be taken to ensure 15/09/07 that the bath with damage to the enamel surface does not remain an infection control risk. Monitoring visits must be 15/09/07 undertaken in accordance with regulation 26. This is a repeat requirement from July 2006. Regular Fire training must be 30/09/07 undertaken for staff to minimise the risks to residents in the vent of a fire. 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 Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 27 1 2 OP15 OP18 Residents’ views on the timing of the evening meal should be sought. PoVA update training should be provided, for staff and manager Glastonbury Court DS0000037079.V347720.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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. 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