Inspection on 31/07/06 for Glastonbury Court

This inspection was carried out on 31st July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Glastonbury Court 30/07/07

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 31st July 2006 2:15pm 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.V302243.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.V302243.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 Mrs Moira Elizabeth Clare Care Home 48 Category(ies) of Dementia - over 65 years of age (33), Old age, registration, with number not falling within any other category (16) of places Glastonbury Court DS0000037079.V302243.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate one name service user with a diagnosis of dementia on the mainstream unit, as detailed in variation application V30862, received 21/03/06. 1st March 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 and 32 older people with dementia. 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. 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 lowest fee charged was £64.65 per week, the highest £368.00. Glastonbury Court DS0000037079.V302243.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was facilitated by Mary Lambert, Acting manager, who came in for this purpose when advised by staff that an unannounced inspection was taking place. A pre inspection questionnaire was provided by the acting manager prior to the inspection. Five relatives provided pre inspection surveys; two service users completed “Have Your Say” surveys. A number of service users were out on a day trip. One service user, who had chosen not to go out, and a carer on a mainstream unit were spoken with. The majority of the focus of the inspection was on the nursing unit, where service users who had limited communication skills were observed, and care and nursing staff spoken with. There were 3 empty rooms on the nursing unit at the time of the inspection, and one vacancy on the first floor. The inspection took six and a half hours. What the service does well: What has improved since the last inspection? Service users preferences about personal care had been elicited and recorded as part of their care plans. Keypads, which secure the doors from the special needs unit to the ground floor, had the code written on them; this allows for service users who are capable to access the main foyer area independently. Basic information had been provided regarding the needs and diagnosis of service users in the nursing unit. Glastonbury Court DS0000037079.V302243.R01.S.doc Version 5.2 Page 6 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. Glastonbury Court DS0000037079.V302243.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 Glastonbury Court DS0000037079.V302243.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4,6 The quality in this outcome area is poor. This judgment has been made using available evidence including a visit to this service. The presence on the nursing unit of a number of service users whose main need for care does not arise from a dementia diagnosis, means that the home is currently operating outside of its categories of registration. There is a need to demonstrate whether the home can meet the needs of all service users. EVIDENCE: The home has not admitted any service users into the nursing unit with a primary need other than dementia since this was identified as a requirement within the inspection process. Names of any service users resident in the home who fall outside of the current registration had been provided to the inspector, although not by the date required. The nurse on duty at the time of the inspection advised that three service users were subject to 117 sections, and confirmed they did not Glastonbury Court DS0000037079.V302243.R01.S.doc Version 5.2 Page 9 have a dementia diagnosis. They advised that another did have a form of dementia, Alzheimer’s, but also had a long-term mental illness. They confirmed that there was another service users on the nursing unit without a dementia diagnosis, their need was a consequence of a Cero Vascular Accident (CVA.) The service users were observed on the unit. On the whole they appeared to interact well with staff and there was little disturbance on the unit on the day of the inspection. However, the nurse advised that the service users are challenging at times, two were described as having mood swings. Details in a copy of a letter from Social Care Services to the Health Trust management dated 7th April 2006 indicated there had been concerns expressed by another member of the nursing staff about staff’s ability to manage the challenging behaviour on the unit at times. This, however was in the context of a dispute, and the then Registered Manager had answered questions about care staff training in challenging behaviours and about the use of agency staff, that the difficulties had been attributed to. A recent dementia mapping, which is the main form of Quality Assurance (QA) that the home uses, was not available to provide a broader picture of the well being of the service users who were identified as being outside of the home’s Categories of registration. These were three service users who do not have a dementia diagnosis, and a fourth whose need is defined as being a consequence of a CVA. It was concerning that a nurse advised that a service user with dementia on the same unit as one of these service users, ”may have to have their door locked to protect them from (the other service user.)” Also see standards 7 and 18. The acting manager advised that a service user who was the subject of a condition of Registration, permitting them to be cared for on the mainstream unit, had moved onto the special needs unit. A letter requesting that the condition be removed was provided on the day of the inspection. Both service users who completed a “Have Your Say” questionnaire indicated that they received enough information about the home before they moved in so they could decide if it was the right place for them. The file of a service user admitted two weeks prior to the inspection was inspected. This service user did not have a pre admission assessment, they were an emergency admission. The home had carried out a stars assessment on the fifth day after admission. Another file for a recently admitted service user was found to have a full pre admission assessment on it The acting manager confirmed that the home does not provide intermediate treatment. Glastonbury Court DS0000037079.V302243.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 The quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Care plans are generally good, however there is a need to ensure that the daily living part of the plan is completed as a priority, to enable staff to meet immediate needs. Service users on the nursing unit may not be appropriately protected from disturbance of service users with mental health problems. EVIDENCE: The sheet for the 24-hour care routine within a recently admitted service user’s care plan had not been completed. Other plans seen were complete, comprehensive and clear. They contained service users’ preferences about personal care. There were two entries per day on service users daily care notes. Reviews on the nursing unit are carried out by nurse working in the unit who are also their Care Planning Approach (CPA) coordinators. Three files inspected all had been reviewed, but the notes of one were not available. One file was Glastonbury Court DS0000037079.V302243.R01.S.doc Version 5.2 Page 11 seen to have been reviewed in June 2006, and was next due in December 2006. Another service user, who was subject to a 117 order, had been reviewed in February 2006 Information regarding the diagnoses and needs of service users on the nursing unit was provided in the form of a document which, the acting manager advised, is given to agency nurses coming on shift. The acting manager advised that this was, to the best of their knowledge, an accurate account. When the nurse on duty when asked about the document stated that it was out of date. The document was discussed, and the nurse confirmed the diagnoses written on it. One entry on this document next to one service user on Elm unit stated, “may need locking in (their) room to protect (them) from service user in room (next door) Door alarm on. The nurse on duty advised that this was the service user’s choice, to prevent another service users on the unit wandering into their room at night. They advised that the whilst the door to the service user’s room is alarmed, if you are in the bathroom with the fan on you do not hear the alarm. The nurse advised that no record was kept of when this was done, but it was only done occasionally at the service users request. They advised that the service user was able to operate the lock from the inside of their room. The home had referred a matter of staff leaving door alarm buzzers off to Customer First as a protection of vulnerable adults matter in December 2005. One of the doors where the “buzzers” had been left off was the service user referred to above. The referral did not lead to the inclusion of any staff member on the PoVA list, as there was no indication that this had been done intentionally or any harm sustained by a service user. However, the buzzers were detailed as the accepted method of protecting the service user from the interventions of another, and it was most concerning that on the day of the inspection a method that was indicated as acceptable was locking the room door. The nurse on duty was asked to provide a copy of a recent reviews for this service user; they advised that this could not be provided as it was in a pile of filing, and that the health authority had to accept that they could not do them all in time. The risk assessment on the service user’s file in respect of this was over two years old. One part of this service user’s care plan related to them getting a good night’s sleep, but this did not refer to this practice. The service user was in hospital at the time of the inspection. The service users’ files inspected contained records of doctors’ appointments, appointments with other health care professionals and weight charts. Glastonbury Court DS0000037079.V302243.R01.S.doc Version 5.2 Page 12 Medicine administration records, (MAR) sheets were inspected for six service users, two on each of the three individual units within the nurse led unit, Cherry and Elm and Willow. One service user did not have a photograph on their medical administration records. There were gaps in the medical administration records of two service users, one on Cherry and one on Elm. In each case there were several omissions on one day. Interactions seen between carers and service users were respectful and polite. Glastonbury Court DS0000037079.V302243.R01.S.doc Version 5.2 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,14,15,16 The quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The home provides a good standard of food, and a varied programme of activities, many of which are available to all service users. EVIDENCE: Relative’s comments cards received were mainly positive, the only exception in relation to the number of agency staff is detailed under the section on staffing. One noted “ I consider this home to be extremely well run, especially with the awful heat wave at the moment.” Another commented, “ This is a lovely home with caring staff and everyone who has visited here has been of the same opinion.” All stated that they were made welcome to visit the home at any time, and that they could see their relatives in private. A day trip to the coast had been arranged on the day of the inspection, and a number of service users were out on this during the afternoon. A boat trip had been arranged for 22nd August. The notice board advertised a Pat Dog, which visits the home once a month, and a bi-monthly songs of praise. Day to day activities are provided on individual units, but staff confirmed many of the activities are open to all service users. Glastonbury Court DS0000037079.V302243.R01.S.doc Version 5.2 Page 14 One service user who completed a “Have Your Say” questionnaire indicated that there were sometimes activities arranged by the home that they could take part in, the other commented that there were usually activities. A service user on the frail elderly unit expressed their continued satisfaction with life at the home, and enjoyment of the support of care staff and other residents on the same unit. Service users observed on the nursing unit had freedom of movement within the unit and on the day of the inspection non were obviously distressed. One service user who completed a “Have your say” questionnaire commented, “ a good varied choice (of meal) is always provided.” A service user spoken with on Cedar described the food as “alright.” A bowl of fruit on the unit had tired old skins and needed replacing. The main meal that day was cottage pie, this was written up on a blackboard in the unit. The cook advised of the measures that were taken to provide food for diabetic service users and also for two vegetarian service users. Carers were observed interacting with service users at teatime on one of the nursing units. It was a quiet relaxed time, and interactions were polite and respectful. Service users on Cherry unit were well dressed and clean; one of the service users tracked were watching T.V during the late afternoon, the other was sitting with a group of three other service users but was not relating to any of them. There was a list of day trips undertaken by one of the other service users. Glastonbury Court DS0000037079.V302243.R01.S.doc Version 5.2 Page 15 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 The quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The home does not receive an excessive number of complaints, and those that are received are dealt with properly. EVIDENCE: CSCI “Have your Say” service user comments were available on a desk in the foyer, as were relative’s comments forms. Both service users providing surveys commented that staff listen and act on what they say. All five relatives responding advised that they were aware of the home’s complaints procedure. The home had a complaints log which included outcomes. There was a record of one complaint since the last inspection, this was dealt with a stage 1 of the home’s complaints procedure, and was not upheld. This showed that the home received a limited number of complaints and the one that they had received had been dealt with appropriately. A number of matters had been appropriately referred to Customer First, including an incident of reported missing monies. The police had investigated and found that the incident could not be proved. No evidence has yet been provided to demonstrate whether nurses working on the unit have had Protection of Vulnerable Adult training. Glastonbury Court DS0000037079.V302243.R01.S.doc Version 5.2 Page 16 The acting manager advised that in one case they wanted to involve a social worker for a service user in the nursing unit, but had been unable to as the dual role of the nurse on the unit, as the key worker for CPA (as well as provider of care) meant that this function was considered met. Glastonbury Court DS0000037079.V302243.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,22,25,26 The quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Service users can expect to live in a clean, comfortable, homely environment. EVIDENCE: Both service users providing surveys commented that the home was always fresh and clean and this was the case on the day of the inspection, the home was found to be clean and well maintained. Keypads which secure the doors from the special needs unit to the ground floor had the code written on them. The home is provided with all appropriate equipment, ramps, and a lift. A standard lamp had been provided to ensure that there was adequate lighting for a service user to do their hobby in one of the lounges. Glastonbury Court DS0000037079.V302243.R01.S.doc Version 5.2 Page 18 Service users were seen to have footplates in place when transported by wheelchair. Staff and a service user advised that the unreliable hoist in one bathroom had not yet been replaced. The issue with the hoist, as previously identified, is that unless it is worked very carefully the mechanism can jolt and this is unnerving for service users. Bathrooms seen were clean and tidy and clear of clutter. The laundry was seen to be cleaned and well organised. A carer explained that they all carers do laundry. The carer was aware of the appropriate way to carry soiled laundry through the home. The kitchen was very clean; the cook advised that they had just had a deep, steam clean. Fridge and freezer records were maintained. Glastonbury Court DS0000037079.V302243.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 The quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Staffing numbers have usually been maintained, but there is a need to ensure that shifts are covered by permanent staff. EVIDENCE: One service user who completed a “Have Your Say” questionnaire indicated that there were always staff available when they needed them, the other commented that there were usually staff available when they needed them. Both indicated that they always received the care and support they need. The home had recently rearranged staff shifts on the ground floor to provide 2 carers per unit between 8 am and 9 pm; this was due to commence on August 5th, 2006. A number of carers from the first floor were out with service users on the day trip at the time of the inspection. All but one relative who responded to the pre inspection survey stated that they considered the home to always have sufficient staff on duty. One relative commented that they were concerned about the staff problems, stating that there were many agency carers, and that familiar faces were very important for the service users. 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 Glastonbury Court DS0000037079.V302243.R01.S.doc Version 5.2 Page 20 carers. Care on the unit is nurse led. A carer spoken to on the fist floor advised that they were the floating carer that day. They advised that if there is an unexpected absence then it is the floating post that will not be covered. The unit has had to use a high number of bank staff and agency staff. In theory the nursing team is managed by a senior nurse supported by a team of nurses and carers. The nurse on duty and the acting manager advised that there were only two nurses who worked permanently from the home, but that the use of nursing staff from a bank pool of nursing staff employed by the trust provided some continuity. A list provided showed that in a recent period of 55 days, 31 shifts had been covered bank nurses, 92 shifts by agency nurses. The nurse advised that they tended to use the same agency nurses repeatedly. A letter from a social care manager previously referred to in this report, dated 10th April 2006, stated that to have three agency staff on one shift is extremely rare. A record of agency care staff used showed that in the two months up until mid July, two and a half thousand agency hours had been used in addition to the agency/ bank nurses. This is equivalent to approximately 40 hrs, or 5 shifts per twenty-four hour period, and indicates an over reliance on agency care staff. The manager advised that a recruitment day for care staff had been held at the beginning of the month, and interviews held two days prior to the inspection. The homes most recent newsletter provided information on staff training; seven members of staff had recently completed NVQ 2, and the deputy manager had completed NVQ 4. Five members of staff had commenced or were about to commence NVQ2, and another NVQ3. The Pre Inspection Questionnaire stated that 55 of care staff held NVQ 2 or above. A recently employed carer spoke about the elements of their induction course and the training file of another recently appointed carer evidenced that induction had taken place. A requirement was made at the two last inspections that the Registered Persons must ensure that there is a staff training and development programme for nursing staff working in the home which meets the changing needs of service users. The acting manager advised that they had not yet been able to obtain a training analysis in respect of the nursing staff. The nurse on duty on the day of the inspection advised that agency nurses and one trust bank nurse were being used regularly. They advised that the nurses were a mixture on Registered General Nurses (RGN) s, and Registered Mental nurses, (RMN) s. They advised that the bank nurses experience was with the elderly, but not with those with dementia or mental health needs. Also see standard 18. Glastonbury Court DS0000037079.V302243.R01.S.doc Version 5.2 Page 21 Two members of staff had been employed since January 2006. Staff files showed that one of these had been recruited prior to the receipt of a Criminal Records Bureau check, or a PoVA first check had been obtained. All other documentation required was on file. Both of these members of staff had received appropriate induction. Glastonbury Court DS0000037079.V302243.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,37,38 The quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. Service users cannot expect the acting manager to have full information to ensure that their care needs are met. EVIDENCE: The Registered Manager had resigned since the last inspection. An interim management arrangement was in place. Mary Lambert, an experienced manager from another of Suffolk County Council’s homes, had been seconded to be acting manager at Glastonbury Court. In addition to being a Registered Manager at a home of a similar size with a similar service user group, Mary Lambert has a nursing background. At the time of the inspection the County Council was in the process of recruiting a new prospective Registered Manager. Glastonbury Court DS0000037079.V302243.R01.S.doc Version 5.2 Page 23 Although there is a joint working operational policy in place between Social Care Services and the Health Trust, there had been some tensions in working relationships within the home. At the last inspection the Registered Manager advised that the current structure was being reviewed by senior management, and notes of a meeting concerning this were seen. The CSCI has not yet been informed of any changes that have been agreed. A senior manager within Social Care Services had informed the CSCI that they had been asked to investigate two matters relating to communication of concerns about care practices within the home. Separate discussions with the acting manager, and with the nurse on duty indicated that one of these had not been fully resolved. However, a relative of a service user on Willow provided a written comment on the management of the home; “ I consider this home is extremely well run, especially with the awful heat wave at the moment.” There was no evidence to suggest that the three first floor units were suffering from these issues. Newsletters were available in the foyer of the home. These included information on the processes whereby the County Council were reviewing their provision of care services. Regulation 26 reports had not been received by the CSCI since November 2005. The acting manager advised that these had been done, as they are done on a peer basis across social care services homes, but copies were not available. A recommendation was made at the last inspection that the next Dementia mapping on the ground floor should include the service user on a 117 order. This service user had passed away since the last inspection, and the acting manager was not able to locate the last dementia mapping exercise. The acting manager advised that they understood a dementia mapping exercise was done two times a year, but they were unsure where these were or when the last one was carried out. No other form of quality assurance was carried out with service users as far as they were aware, however, they advised that the cook had been asked to do one around food. Service users monies are managed through Suffolk County Council client account, and individual files had accounts within them. The system in place was discussed with the acting manager. They advised that two staff signatures were always required for transactions on behalf of service users with dementia. Balances were not checked on this occasion. In the two cases where monies had reported as going missing, these were monies held by the service users themselves, and evidence of the loss could not be established. The acting manager advised that both service users had been encouraged to use the facilities provided by the home. Glastonbury Court DS0000037079.V302243.R01.S.doc Version 5.2 Page 24 The cook who was spoken to advised that the home does not yet a have a critical control point hazard analysis (HaCCP) for food production. 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. The fire log book was up to date. The fire alarm went off on the evening of the inspection and the fire service attended promptly. The acting manager subsequently informed the inspector that this false alarm had resulted from a thunder fly setting off a detector. Glastonbury Court DS0000037079.V302243.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 X X 3 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 2 18 2 3 X 3 3 X X 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 3 X 2 2 Glastonbury Court DS0000037079.V302243.R01.S.doc Version 5.2 Page 26 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 OP4 Regulation CSA regs 2001 Requirement The home is operating outside of the category and must apply for a variation in the home’s registration in respect of any service users who are outside of the current categories and numbers of registration. Care plans must be completed in a timely way. The home must review the care plan of the service user on the nursing unit who has disturbed the sleep of a service user with dementia, and establish whether their needs can be met on the unit without undue disturbance to other service users. Where the planned use of any form of restriction is practiced, it must be in line with a current risk assessment agreed & signed by appropriate representatives, and the minimum restraint required must be used. A copy of the most recent review and a current risk assessment must be forwarded for a service user who has, at times, been locked in their bedroom. DS0000037079.V302243.R01.S.doc Timescale for action 04/09/06 2. 3. OP7 OP7 15(1) 15(2) 12(1) 31/08/06 11/09/06 4. OP7 13(7), 15(2)(c) 31/07/06 5. OP7 15(2) 04/09/06 Glastonbury Court Version 5.2 Page 27 6. 7. OP9 OP18 13(2) 18(1) 8. OP29 19(1)(B) Schedule 2 18(1) 8. OP30 9. OP33 26 10. OP33 24 (2) 11. OP37 17(3) 12. OP38 13(4) (a)(c) 13. OP38 23(4) Medical Administration Records must be complete. The Registered Persons must ensure that there is a staff training and development programme for nursing staff working in the home which meets the changing needs of service users. This is a repeat requirement from the last inspection. Members of staff must not commence work prior to the receipt of a Criminal Records Bureau check or PoVA first check. The Registered Persons must ensure that there is a staff training and development programme for nursing staff working in the home which meets the changing needs of service users. This is a repeat requirement from the last inspection. Regulation 26 reports must be available or inspection and reports for the period December 2005 up until July 2006 must be forwarded to the CSCI. The most recent dementia mapping exercise carried out with service users from the nursing unit must be forwarded. Reviews must be on file and care plans completed in a timely way, and risk assessments must be up to date. A Hazard Analysis Critical Control point (HACPP) risk analysis must be completed for processes involved with the production of the home’s food. The home must consult with the fire service regarding any proposal to lock a service user in their room. DS0000037079.V302243.R01.S.doc 31/07/06 15/09/06 31/07/06 30/09/06 15/09/06 15/09/06 15/10/06 30/11/06 29/08/06 Glastonbury Court Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP7 OP17 Good Practice Recommendations Care plans, including risk assessments and daily living plans for service users on the nursing unit should be reviewed by the acting manager. Consideration should be given to the appropriateness of the person responsible for care management of a service user within the home also being the service users care programme approach coordinator. Medical administration records should have a photograph of the service user, particularly where there is a high use of agency staff and service users have dementia. Fruit available for service users should be fresh and appealing. A hoist which staff can reliably use without it stalling should be provided in the bathroom on Cedar unit. The high level of use of agency nursing staff on the nurse led unit should be reviewed. 2. 3. 4. 5. OP9 OP15 OP21 OP27 Glastonbury Court DS0000037079.V302243.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 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 Glastonbury Court DS0000037079.V302243.R01.S.doc Version 5.2 Page 30 - 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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