Inspection on 26/10/05 for Glenarie Manor

This inspection was carried out on 26th October 2005.

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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glenarie Manor 22/06/07

Glenarie Manor 30/05/06

Glenarie Manor 05/05/05

Glenarie Manor 09/11/04

Glenarie Manor 17/05/04

Glenarie Manor 02/02/04

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

CARE HOME ADULTS 18-65 Glenarie Manor 15 Aigburth Drive Sefton Park Liverpool Merseyside L17 4JG Lead Inspector John McCabe Unannounced Inspection 26th October 2005 09:30 Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 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 Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Glenarie Manor Address 15 Aigburth Drive Sefton Park Liverpool Merseyside L17 4JG 0151 726 0814 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) Colin McCabe Ian Boycott-Samuels Care Home 26 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (26) of places Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents between ages 16 and 64 years Within the overall total of 26 residents two named male residents may be accommodated who are over 65 years of age until such time as either persons assessed needs change and they cannot be safely cared for at home 5th May 2005 Date of last inspection Brief Description of the Service: The home is a large well maintained three storey Victorian House situated in Sefton Park in a suburb of Liverpool called Aigburth. The care home can accommodate 26 residents, most referred from various Primary Care Mental Health Trusts. All residents have their own single bedrooms, which have been personalised by the residents according to their cultural preferences and choices. The home has easy access to buses trains, local bistros and pubs. All of the residents have access to GPs and Social Workers, and access to a Community Psychiatric Nurse (CPN.) Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and commenced at 0930 hrs. The registered person and a bank nurse were present together with support workers, the cook, the domestic staff, and the full time handyman. Currently there are 26 residents in the care home, many of whom have been there many years. A full tour of premises took place, and I spoke with care staff and residents during the inspection. At the time of the inspection the home was clean and tidy. What the service does well: What has improved since the last inspection? The daily health records of residents have shown some improvement. but further work is needed. Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 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. Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5. The home management must ensure that there is a more consistent approach to undertaking pre admission assessments for all residents. The assessment should include a full and informed consultation with the resident and family and other health care professionals known to the resident. The resident’s guide to the home is user friendly and informative. This allows any potential resident to gain an insight into what can be expected should they choose to take up a placement there. EVIDENCE: Before residents are admitted to the home on a permanent basis, the resident’s psychiatrist, community psychiatric nurse and social worker undertake a pre admission assessment. The initial assessments before a resident is admitted must also include a nursing assessment undertaken by senior psychiatric nurses in the home. However, during a review of a resident’s personal file it was observed that the senior nurses from the care home had not undertaken a pre admission nursing assessment for this resident. (The resident was admitted to the home in May 2005). There was evidence that the residents Blood Pressure, pulse, height, weight etc had been recorded but, no other clinical details that would compliment a personalised Care Plan for the resident. Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 Page 9 The pre admission nursing assessment compiled by the home senior nurses is essential to ensure that the residents care needs are identified and the homes workforce has the skill mix to care for the resident. The home assessment is the basis of the residents initial care plan, and also ensures that the home is admitting the correct category of resident as stated on the homes CSCI registration certificate. The resident can visit the home, or have an overnight stay before moving in on a permanent basis. The residents guide sets out clear and accessible information, about the care home, facilities, accommodation, fees, terms and conditions, contract and the qualifications of the staffs. Staffs in the home undertake specialist care training to ensure that the residents assessed and changing care needs are met. Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,0,10. The residents’ care planning and risk management documentation must be consistently completed in every case. Failure to document relevant clinical information potentially leaves residents who use the service at risk. EVIDENCE: Each resident in the home usually has an individual care plan, which is formulated by the senior nurses and the resident. The care plan includes risk assessments, choices and preferences of activities, nutrition, medications etc, and the naming of a support worker who will support the resident. However, during case tracking, it became apparent that one resident had no care plan or risk assessments documented. All the paperwork relating to the care plan was blank. Risk assessments, lifestyle, choices and preferences of the resident were not recorded; the resident has complicated care needs relating to his psychiatric illness yet care staff are not made aware of this via a care plan and risk assessment. Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 Page 11 The senior nurses in the home must provide all care staff with relevant information about each resident so as to ensure the care needs are met, and the resident is cared for in therapeutic environment which encompasses the choices and preferences of the resident. Staff in the care home encourage residents to live a normal independent life as possible, which includes taking responsible risks. In turn this promotes independence and encourages informed decision making by the resident. Meetings for residents are held in the home and relevant documentation concerning each resident is maintained and kept secure in accordance with Data Protection Act 1998. Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17. The care home staff have a good understanding of the residents support needs. This is evident from the positive relationships, which have been formed between staff and the residents. EVIDENCE: Residents in the care home are encouraged to take paid jobs, attend day centres, and participate in community activities. Many of the residents in the home are on Section 117 of The Mental Act (1983). These residents receive financial welfare allowances on a weekly basis in excess of the basic weekly allowance. This in turn provides for increased flexibility and choice over how the resident exercises their right to use their money. Some residents do attend a day centre for activities of their choice. Resident’s enjoy leisure activities according to their choices and preferences and in the summer months day trips are organised and staff accompany the residents when necessary. Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 Page 13 One resident told the inspector that he was going on holiday with his brother, and spending Xmas with his family. Residents help plan menus and in one case one of the resident will occasionally cook a Chinese meal for his family and other residents. Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. The systems for the administration of medications are good with clear and comprehensive arrangements being in place to ensure residents’ medication needs are being met. EVIDENCE: All residents in the home can access their NHS entitlements; which includes access to a GP, dentistry, opticians and chiropody services. Community Psychiatric Nurses (CPNS), Psychiatrists and Social Workers known to the resident help ensure that both the mental health needs and physical needs of the residents are met. Four (4) of the residents self medicate, and have been risk assessed to do so. All of these residents have a locked drawer facility in their own bedroom for the safe keeping of their medications. The inspector reviewed the homes medication policies and procedures and inspected the Medicine Administration Records Sheets (MARS) of all the residents. All documents and policies where in accordance with the National Minimum Standards (NMS). Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. The arrangements and policies in the care home for protecting residents are robust, (including Whistle blowing) and staff have a sound knowledge and understanding of Adult Protection issues, which helps to protect residents from any potential abuse. EVIDENCE: The home has a complaints procedure and policy, which is documented in the resident’s guide/handbook. All information relating to complaints contains the address and telephone number of the CSCI. Since the last inspection, there have been no internal complaints, or complaints to the commission. The care home has up to date information on the Protection of Vulnerable Adults (POVA), which all staff in the home are familiar with. Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27,28,29,30. The standard of décor within this home is excellent, with evidence of continuing improvements, through maintenance and planning. The home does present as a homely, safe and comfortable environment for the residents. EVIDENCE: The care home environment is excellent. All areas of the home are clean, light, well decorated and maintained including the rear garden area. On the day of the inspection the handyman’s office was being redecorated. The home has a second kitchen with laundry and cooking facilities. Those residents who are interested can do some of their own cooking with help from care staff. Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 Page 17 Resident’s bedrooms have been personalised, and contain pictures and artefacts that refer to their own choices and preferences. The home has a gym; snooker room and television room with Sky broadcast. All bathrooms and toilets in the home provide privacy, and meet individual needs. The homes infection control policy is in date and valid. Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36. The registered person operates a robust and comprehensive recruitment policy to ensure that staff have the required skills to facilitate care for all residents. All staff in the care home receive documented supervision six times per year to ensure that their performance/work with the residents is safe and promotes a sense of well being for each resident. EVIDENCE: All staff in the home have job descriptions, which are linked to achieving resident’s personal goals and ambitions in a therapeutic environment The recruitments policy of the home is robust and all staff has updated CRB/ POVA enhanced clearance certificates. Recently the registered person has appointed a carer to be the weekend cook for the home. Though she has no formal qualification i.e., food handling, food hygiene, and cooking for twenty people. the registered person is confident she can do the job. All staff in the home have documented supervision six times per year, which ensures that all staffs have the opportunity to discuss with the manager, and other senior staff any issues, which can effect or improve the care for the Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 Page 19 residents. Documented supervision of all staff also gives the staff and managers opportunities to discuss their own /or identified training needs. Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,38,40,41,42,43. The registered manager is supported well by senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. The documentation relating to the safety of the home is complete, up to date and valid, so ensuring a safe, comfortable, hygienic home for the residents. EVIDENCE: The registered manager is very experienced psychiatric nurse, who has had many years care home management experience. Currently the manager is not undertaking any formal care home management qualifications such as NVQ Level 4, Care Management. Nor have they enquired with the academic institutions as to whether his previous management experience, equates with an NVQ Level 4 programme. Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 Page 21 Other home managers have used the Accredititation of Previous Experiential Learning (APEL), and have been informed that they have no need for further management qualifications to run the home. It is therefore recommended that the registered manager should explore this further. The management approach of the home is open, positive and transparent for both residents and staff. Meetings for both residents and staff are held throughout the year. The records in the home demonstrate that the views of residents and staff are taken into consideration when the home policies and procedures are formulated. The certificates of worthiness and insurances for homes appliances, including the Employees liability Certificate are in date and valid. The home has qualified has First Aid staff on duty at all times of the day. Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 2 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 4 3 3 3 3 3 4 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Glenarie Manor Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 DS0000025105.V260887.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14 Requirement The registered person must ensure that a pre admission nursing assessment is undertaken on all residents before they are admitted to the care home. The registered person must ensure that each resident has an individual care plan, which is regularly up dated by the senior nurses in the home. This is to ensure that the assessed and changing care needs of the resident can be met. Timescale for action 30/11/05 2 YA6 15 30/11/05 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 YA19 Good Practice Recommendations It is recommended that a signature is obtained from the pharmacy representative when residents medications are removed from the care home to the pharmacy. Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Glenarie Manor DS0000025105.V260887.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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