Inspection on 05/05/05 for Glenarie Manor

This inspection was carried out on 5th May 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 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

Glenarie Manor 22/06/07

Glenarie Manor 30/05/06

Glenarie Manor 26/10/05

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 L17 4JG Lead Inspector John McCabe Unannounced 05 May 2005 09.00 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 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 Stationary 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 F52_F02_S25105_Glenarie Manor_V225513_050505_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Glenarie Manor Address 15 Aigburth Drive Sefton Park Liverpool L17 4JG 0151 726 0814 Telephone number Fax number Email 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 with Nursing 26 Category(ies) of MD - Mental Disorder 26 registration, with number of places Glenarie Manor F52_F02_S25105_Glenarie Manor_V225513_050505_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Residents between ages 16 and 64 years Date of last inspection 9th November 2004 Brief Description of the Service: The home is a large well mainted three storeyVictorian House situated in Sefton Park in a suburb of Liverpool called Aigburth The care home can accomodate 26 residents, most refered from various Primary Care Mental Health Trusts. All residents have their own single bedrooms which have been personalised by the residents according to their cultrual preferences and choices of the The home has easy access to buses trains, local bistros and pubs. All of the Residents have access to GPs and Social Workers, but very few have access to a CPN. Glenarie Manor F52_F02_S25105_Glenarie Manor_V225513_050505_Stage 4.doc Version 1.30 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 deputy manager, and the homes administrator were on duty, together with supports workers, cook and domestics, 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 What the service does well: What has improved since the last inspection? What they could do better: Record keeping, in some instances the Daily Health Records for the residents had not been signed, a night report for one resident had not been recorded. or the transaction accompanied by twenty-four hour clock timing. On the day of the inspection it was difficult to evidence what Specialist Care Training the staff has received. Staff had signed a record whch stated that they had a “Clinical Update” both senior managers present at the inspection did not know what this meant. The homes manager was informed by the inspector on more than one occasion to deliver Specialist care Training and document evidence of the training in the individual staff member personal file. This is still being facilitated in a satisfactory manner Glenarie Manor F52_F02_S25105_Glenarie Manor_V225513_050505_Stage 4.doc Version 1.30 Page 6 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 F52_F02_S25105_Glenarie Manor_V225513_050505_Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Glenarie Manor F52_F02_S25105_Glenarie Manor_V225513_050505_Stage 4.doc Version 1.30 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 standard(s) 1,2,3,4, 5. The documentation relating to residents admission procedures, is valid up to date and relevant for the service, so ensuring residents are admitted to a safe and therapeutic environment. However, the information, documentation, relating to staffs Specialist Training is meaningless, and does not indicate the collective and individual skills of the staff, which are essential to ensure the assessed and changing care needs of the residents are being met. EVIDENCE: 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. A pre admission care assessment is undertaken on residents before they move into the home on a permanent basis. Other healthcare professionals known to the resident contribute to the assessment. The evidence (records) for special training for care staff is limited and meaningless. Records evidenced on the day of the unannounced inspection stated, that staff has received a Clinical Up Date, both the deputy manager Glenarie Manor F52_F02_S25105_Glenarie Manor_V225513_050505_Stage 4.doc Version 1.30 Page 9 and the registered person could not inform the inspector what Clinical up Date meant. Specialist care training for staff is vital in the care home so as to ensure the assessed and changing needs of the resident are met, the documentation relating to the training should be complete and informative. Glenarie Manor F52_F02_S25105_Glenarie Manor_V225513_050505_Stage 4.doc Version 1.30 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 standard(s) 6,7,8,9,10. The residents’ documentation, risk assessments and care plans are updated and reviewed on a regular basis by the senior nurses in the home. This helps to ensure that residents are nursed and supported in a safe therapeutic environment. Daily health records of some residents was inadequately completed and/or omitted by the nursing staff, record keeping of residents health and welfare is essential to ensure care both mentally and physically, treatments, medications etc, has been undertaken and residents not compromised, EVIDENCE: All residents in the home have an individual care plan formulated by the senior nurses, residents and family, where possible the resident signs the care plan. During Case Tracking, a night report for a resident had been omitted, and in other file no signature of the nurse, accompanied the written report. It is good practice to include twenty-four hour clock timing and a signature when reports are written about resident’s health and welfare. Glenarie Manor F52_F02_S25105_Glenarie Manor_V225513_050505_Stage 4.doc Version 1.30 Page 11 Risk assessments are undertaken on each resident to ensure their safety both in the home, and when they go out in public. Meeting for residents are held in the home, all documentation, which refers to each resident, is maintained in accordance with Data Protection Act 1998. Glenarie Manor F52_F02_S25105_Glenarie Manor_V225513_050505_Stage 4.doc Version 1.30 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 standard(s) 11,12,13,14,15,16,17. The care homes staffs 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 service users in the home are on Section 117 of The Mental Act (1983). These residents receive financial welfare allowances on a weekly basis; many of the residents informed the inspector that it was not worth going out for paid work, as they would lose their welfare benefits. Resident’s enjoy leisure activities according to their choices and preferences. The day before the inspection the residents and staff went to the seaside town of Rhyl for a day out, the residents informed the inspector that the beer tasted better when you are at the seaside. Glenarie Manor F52_F02_S25105_Glenarie Manor_V225513_050505_Stage 4.doc Version 1.30 Page 13 The residents informed the inspector they enjoyed the meals in the home, but still enjoyed having “Take a Way” meals and going to the Chippie. Glenarie Manor F52_F02_S25105_Glenarie Manor_V225513_050505_Stage 4.doc Version 1.30 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 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; Community Psychiatric Nurses (CPNS) Psychiatrists Social Workers ensure that both the mental 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. During the inspection 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 NMS. However, it is important that home records a date and signature of the pharmacy representative, who removes resident’s drugs from the home to the pharmacy. Glenarie Manor F52_F02_S25105_Glenarie Manor_V225513_050505_Stage 4.doc Version 1.30 Page 15 Glenarie Manor F52_F02_S25105_Glenarie Manor_V225513_050505_Stage 4.doc Version 1.30 Page 16 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 standard(s) 22,23. The arrangements and policies in the care home for protecting residents are robust, (including Whistle blowing) and staffs have the knowledge and understanding of Adult Protection issues, which 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 has 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 F52_F02_S25105_Glenarie Manor_V225513_050505_Stage 4.doc Version 1.30 Page 17 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 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 main front lounge was being redecorated. Resident’s bedrooms have been personalised, and contain pictures, 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 F52_F02_S25105_Glenarie Manor_V225513_050505_Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36, The registered person operates a robust and comprehensive recruitment policy to ensure that staffs 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 staffs 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. Staff training needs to be improved, especially Specialist Training. Training should be in accordance with the NVQ/TOPPS training programmes. All staff in the home have documented supervision six times per year, this is part of the home quality assurance monitoring protocols. Glenarie Manor F52_F02_S25105_Glenarie Manor_V225513_050505_Stage 4.doc Version 1.30 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,40,41,42,43. 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 are completes 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 and formal care home management qualifications (NVQ Level 4). The management approach of the home is open positive and transparent for both residents and staff Glenarie Manor F52_F02_S25105_Glenarie Manor_V225513_050505_Stage 4.doc Version 1.30 Page 20 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 are in date and valid .The home has qualified has First Aid staff on duty at all times of the day. Glenarie Manor F52_F02_S25105_Glenarie Manor_V225513_050505_Stage 4.doc Version 1.30 Page 21 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 3 2 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 4 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Glenarie Manor Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 2 3 3 3 3 F52_F02_S25105_Glenarie Manor_V225513_050505_Stage 4.doc Version 1.30 Page 22 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 3 Regulation 18 Requirement The registered person shall ensure that specialist training for care staff in the home is facilited and documented in their person file. This is to ensure the saefty and well bieng of a residents and staff The registered person shall ensure that the daily health records of the residents are maintained accuratley. This refers to a reprot not being signed by a nurse, and the ommission of night report for another resident. Timescale for action 30th May 2005. 2. 10 12 Immediate. 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 19 Good Practice Recommendations It is recomeded that a signature is obtained from the pharmacy represantive when residents medications are removed from the care home to the pharmacy. Glenarie Manor F52_F02_S25105_Glenarie Manor_V225513_050505_Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Liverpool Office 3rd Floor, 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 F52_F02_S25105_Glenarie Manor_V225513_050505_Stage 4.doc Version 1.30 Page 24 - 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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