Inspection on 18/11/05 for Glenavon House

This inspection was carried out on 18th November 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

Glenavon House 21/06/07

Glenavon House 12/09/06

Glenavon House 23/05/05

Glenavon House 05/10/04

Glenavon House 29/04/04

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

CARE HOMES FOR OLDER PEOPLE Glenavon House 22 St John`s Road Clifton Bristol BS8 2EZ Lead Inspector Vanessa Carter Unannounced Inspection 18th November 2005 10:00 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 Glenavon House DS0000020349.V263951.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 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. Glenavon House DS0000020349.V263951.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Glenavon House Address 22 St John`s Road Clifton Bristol BS8 2EZ 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) 0117 9734232 0117 9734232 rogermcater@compuserve.com GemleighLimited Mrs Denise Worgan Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Glenavon House DS0000020349.V263951.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. May accommodate up to 34 Persons aged 65 years and over receiving nursing care Of these 34 persons, 5 may be aged between 50 - 65 years with Physical Disabilities Manager must be RN1 or RNA on the NMC Register Staffing notice dated 03/11/1998 applies. Date of last inspection 23rd May 2005 Brief Description of the Service: Glenavon is registered as a care home for service users who require nursing and personal care. It is registered to accommodate 34 people, male or female, of which up to five may be between the ages of 50-65years. Since the last inspection some of the double rooms are only being used for single occupancy, therefore the home does not cater for the full 34 service users. The home is situated in the Clifton area of Bristol. It is sited in close proximity to local shops and amenities and also near to Clifton Railway Station. The home is a detached period property, and accommodation is provided over three floors with lift access to all rooms. The communal space includes a lounge, dining room and conservatory. The gardens to the rear are secluded and well-tended. The area is accessible to those in a wheelchair. The home is privately owned and operated by Gemleigh Ltd, and Mr and Mrs Cater are the proprietors. The current manager, Mrs Denise Worgan, has been in post for approximately 2 years - she is supported by a team of registered nurses, care assistants and ancillary staff. Glenavon House DS0000020349.V263951.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report follows a brief, unannounced inspection visit to the home. Readers who require a full picture of the home, and the services it provides, should refer to the report completed in May 2005. A tour of the home as made, some of the homes records were examined and observations were made of staff interactions with the residents. What the service does well: 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. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Glenavon House DS0000020349.V263951.R01.S.doc Version 5.0 Page 6 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 Glenavon House DS0000020349.V263951.R01.S.doc Version 5.0 Page 7 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): 1 an 3 The admission process is well managed and new residents and their families are given clear information regarding the service. EVIDENCE: No further changes have been made to the Statement of Purpose and homes brochure; the information it contains remains current. The homes pre-admission assessment document is comprehensive and detailed. The form for the most recently admitted persons were seen, and these contained details of their specific needs. The homes process ensures that all new residents are only offered placement if the home is able to meet their needs. There was evidence that the assessment had taken place prior to being admitted to the home. Glenavon House DS0000020349.V263951.R01.S.doc Version 5.0 Page 8 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, 10 and 11 Residents are well looked after in respects of their welfare, health and personal care needs. EVIDENCE: The care planning documentation was looked at for three people. The home manager generally completes the plans. They are detailed and contain specific details regarding that persons needs and how they are to be met. For one person there were specific details regarding a person’s behaviour pattern. The plans were supported with risk assessments around manual handling, pressure sore development and nutrition needs. The plans were person centred and evidence that the home view each person as an individual. The wound care plans for one resident were detailed and highlighted all areas that needed attention. There was evidence that ongoing reviews are made by the residents GP and an “advanced primary nurse”. Glenavon House DS0000020349.V263951.R01.S.doc Version 5.0 Page 9 There was evidence of good evaluation of the plans, with amendments being made where necessary. The home ensures that the residents receive health care services from other professionals. Examples include opticians, podiatrists, speech and language therapists, dieticians and GP. Since the last inspection the home have had a visit from the CSCI pharmacy inspector. A number of requirements and recommendations were made and the home has complied with these. During the course of the visit the care staff were observed interacting well with the residents, being friendly and attentive. One resident said that the staff needed to be more thoughtful about his poor vision. This person’s quality of life would be enhanced if the staff gave greater explanation of what is happening. The person referred to a mug of tea placed in front of him – they couldn’t work out whether the cup was full or empty. It would be good practice for the home to provide drinks in non/tea/coffee coloured cups for this resident. The manager explained that the home continues to look after residents when they reach the end stages of their lives. Representatives from the home will attend funerals in order to pay their respects to the family. The home has good links with local hospice and the manager would arrange appropriate “refresher” training with the hospice home care nurses, if there was specific needs that the resident had, for example syringe drivers to administer pain control. Glenavon House DS0000020349.V263951.R01.S.doc Version 5.0 Page 10 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): 12 and 13 Residents have the opportunity to participate in a varied and stimulating range of activities, and are encouraged to choose how they spend their time. EVIDENCE: Activities are arranged on two afternoons a week and residents have the opportunity to observe or participate in, bingo games, arts and crafts sessions and music. Some residents choose to remain in their own rooms. The local authority fund two younger residents to have a 1:1 support worker, and this enables them to pursue activities independently from the home. The manager explained that subject to staff availability, trips will be made out to the shops or the garden centre, in small groups of two or three. The home has an open visiting policy but the manager explained that the residents do not receive many visitors. Glenavon House DS0000020349.V263951.R01.S.doc Version 5.0 Page 11 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): 18 Residents are cared for by staff who will safeguard and protect them. EVIDENCE: The home has provided “Contributing to the protection of individuals from abuse” training for the staff team and records showed that approximately 80 of staff have already received instruction. The remaining staff will be have a session arranged on this subject. The home has a copy of the Bristol City Council “No Secrets” guidelines and the manager has previously demonstrated her knowledge of the procedures to undertake, should an allegation of abuse be made. Observations made of interactions between staff and residents, demonstrated that the residents are well cared for and safe. Glenavon House DS0000020349.V263951.R01.S.doc Version 5.0 Page 12 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, 20, 21, 22, 23, 24, 25 and 26 Residents live in a comfortable and homely environment that has an ongoing programme of redecoration and refurbishment with additional equipment being provided to benefit both residents and the staff. EVIDENCE: The home is an elegant Victorian property, located in the heart of Clifton, Bristol, close to both shops and local amenities. It is a detached property, and although there are a number of steep steps up to the main front door, there are ramped accesses to both sides of the home. An internal lift ensures that the home is accessible to residents with impaired mobility. The living accommodation is arranged over three floors. In addition the basement area accommodates the laundry, kitchens and staff rooms. Since the last inspection the home have installed glass viewing windows in the door leading up from the basement, to ensure that the door does not open out onto passer-by’s. Glenavon House DS0000020349.V263951.R01.S.doc Version 5.0 Page 13 The home is registered for 34 residents however currently offers placement to only 29 – a number of the shared rooms are being used by just one resident. This change gives the home a better feeling of space. Communal space consists of a lounge area, dining room and large conservatory. A number of the residents choose to remain in their own rooms throughout the day, and have TV’s, telephones and radio’s they are able to use. All of the bedrooms were seen during a tour of the home. They were appropriately furnished, and reflected the residents’ personality, by the possessions they have in their rooms. The home has an ongoing programme of decoration and all areas of the home looked fresh and tidy. Minor works are required to some of the paintwork, however this job is already scheduled. The residents are living in a much more pleasant environment. The home is clean and tidy throughout, and was free from any offensive odours. The manager explained that one person’s own upholstered chair is being replaced, as it is not easily cleanable. There are a number of toilets located throughout the home, five bathrooms and a shower room. This is sufficient to meet the needs of the residents. Additional commodes have already been provided and the manager plans to purchase one more each month until there is one available for each resident. This is good practice and will ensure that residents are protected from the risk of cross-infection, and staff avoid having to lift equipment around the home. The home has purchased an additional standard following advice from the Health and Safety Executive. This will ensure that the staff are able to move the residents safely. In addition the home has five hoists, a range of slings, one turntable and a number of sliding sheets. The homes programme of installing radiators with low temperature surfaces has been completed, bar one room where they are waiting for specific spare parts. All fire doors are fitted with magnetic devices that will release the doors in the event of the fire alarm system being activated. The maintenance person was making alterations to the device in the lounge during the course of the inspection. This evidences that the residents live in a home that is safe. Glenavon House DS0000020349.V263951.R01.S.doc Version 5.0 Page 14 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): Residents are cared for by staff who are skilled and competent to do their jobs, and can be assured that their needs will be met. EVIDENCE: The home currently has only 26 residents and the staffing numbers on duty at the time of the inspection were appropriate to this. The manager explained that five care staff are allocated for a morning shift and four for an afternoon/evening shift. In addition there is a registered nurse on duty at all times. Examination of the duty rota’s confirmed this. The managers hours are supernumerary to the staffing notice, however she explained she does like to remain “hands on” and participate in caring duties. The home is fully staffed, having just employed three new workers. In addition to the care staff, the home has a handyman, a laundry assistant and a domestic. The home is to be commended on their commitment to NVQ Level 2 training for the care staff. Of fifteen care assistants, ten have already achieved a level 2 and four are working towards achievement. This equates to 93 of care staff being qualified and will ensure that residents are looked after by staff who are skilled and competent. In addition two staff have NVQ level 3 as well. Three new recruits will be considered for training once they been in employment for six months. The staff training plan includes sessions on mandatory training courses and specific clinical topics. Records evidence who has attended each session. Glenavon House DS0000020349.V263951.R01.S.doc Version 5.0 Page 15 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, 37 and 38 The home is well managed and residents benefit from living in a home that is run in their best interests and is safely maintained. EVIDENCE: The home has a competent manager who has been in post for a number of years. The home has made significant improvements in a number of areas since she has been in post. The overall appearance of the home, the amount of moving and handling equipment, and the training opportunities for the staff, will now ensure that the residents live in a home when they will be well cared for. The manager has a very “hands-on” management style and at all times, ensures that the residents remain at the heart of any decision making. Glenavon House DS0000020349.V263951.R01.S.doc Version 5.0 Page 16 The home has established a quality assurance monitoring system and produced an annual plan of development. It has based this upon feedback from residents, CSCI inspections and City Council “contract compliance visits”. This is good practice and will ensure that the service remains appropriate to the residents needs. The homes records that were examined were all well maintained and kept secure. The fire log evidenced that all necessary weekly, monthly and quarterly checks are undertaken. The hot and cold water temperatures are monitored. All fire doors are kept open with magnetic door devices which are disarmed should the fire alarm system be activated. This evidences that the home takes their responsibility for the health and safety of the residents seriously. Glenavon House DS0000020349.V263951.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X X 3 3 Glenavon House DS0000020349.V263951.R01.S.doc Version 5.0 Page 18 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. Standard Regulation Requirement Timescale for action 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 OP10 Good Practice Recommendations The specific resident with poor vision should be provided with appropriate drinking cups to promote independence. Glenavon House DS0000020349.V263951.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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 Glenavon House DS0000020349.V263951.R01.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!