Inspection on 21/06/07 for Glenavon House

This inspection was carried out on 21st June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 12/09/06

Glenavon House 18/11/05

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 Savio Toson Key Unannounced Inspection 21st June 2007 09:30 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.V339860.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. Glenavon House DS0000020349.V339860.R01.S.doc Version 5.2 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 9064087 glenavonhouse@tiscali.co.uk GemleighLimited Mrs Denise Worgan Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Glenavon House DS0000020349.V339860.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. May accommodate up to 29 Persons aged 65 years and over receiving nursing care Of these 29 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 12th September 2006 Brief Description of the Service: Glenavon is registered as a care home to give people who use the service, nursing and personal care. Glenavon can accommodate 34 people and five can be between the ages of 50-65years. The home is privately owned by Mr and Mrs Cater and is registered as a company called Gemleigh Ltd. The residents care needs are meet by the care team, managed by Mrs Denise Worgan, has registered nurses, care assistants and catering , domestic and maintenance staff. Several residents have more spacious bedrooms and more communal space since the management’s decision to reduce the beds in some of the double bedrooms down to one person. The residents live in a home situated in the Clifton area of Bristol and is close to local shops and amenities. 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. Residents with wheelchairs can access the garden by going round the side of the house. The cost of living in the home is between £471.00 to 650.00 a week. Additional costs are made for a range of services and these are listed in the homes brochure. Glenavon House DS0000020349.V339860.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over 5.5 hours and was completed in one day. I worked with evidence from a whole range of different sources, including: • Information provided by the manager in the pre-inspection questionnaire • Information taken from resident survey forms • Information from professionals who visit the home • Speaking with residents • Speaking to a visitor • Case tracking a number of residents • Speaking with care staff • Walking round the home • Examination of some of the homes records • Observation of staff practices and interaction with the residents. The overall analysis is that the home is a good place in which to live and to work. What the service does well: What has improved since the last inspection? What they could do better: Resident’s bedrooms would look more homely if some of the items and products used in providing care were properly stored away. The residents may Glenavon House DS0000020349.V339860.R01.S.doc Version 5.2 Page 6 find their days more stimulating if recreational activities were organised on a daily basis. The home needs to improve the decorative state of some of the rooms where walls are marked or stained. The service needs to reconsider how it is selecting meals for the menu and show consideration has been given to residents from diverse and ethnic minority backgrounds. Records used to write the individualised care needed by residents need to be more informative and written on easier to read forms. 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. The summary of this inspection report can be made available in other formats on request. Glenavon House DS0000020349.V339860.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 Glenavon House DS0000020349.V339860.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1-2-3-4-5-6 were considered. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ benefit from moving into a home that had planned for their move into the home. Residents have their needs assessed before they move into the home. EVIDENCE: Residents use information provided by the home to help them see whether the home is right for them before deciding to move in. This information is provided in the service user’s guide. Residents are able to visit the home at any time without appointment so they can see what the home is like on a normal day. This is good practice. The home’s Statement of Purpose, which gives further information on how the home is run, was seen at the last inspection. The Statement of Purpose was reported to be meeting the national minimum standards and the home manager confirmed that the document was upto date. Glenavon House DS0000020349.V339860.R01.S.doc Version 5.2 Page 9 Before residents move into the home the manager arranges for the potential resident’s care needs to be assessed. So if the resident moves in, the home has assured the resident that it can meet their care needs. The manager gave examples of how staff had to learn new skills as the resident’s needs changed. Residents know their contractual rights of living in the home because they were issued with terms and conditions of residency which was signed by them and the home’s representative. Glenavon House DS0000020349.V339860.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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7-8-9-10-11 were considered. Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. Residents are involved in planning their care. Residents live in a home where they are given respect by the staff. The residents get the individualised care that’s been agreed and receive their medicines from staff that know how to safely give them out. Residents are involved in planning their end of life arrangements. EVIDENCE: The residents were getting the care they expected and needed although the care plans were not easy to read because of the handwriting and the layout of the care records. The residents received the right care because of the instructions contained in the care plans. Residents could receive more individualised care from new staff if the instructions were more descriptive. Glenavon House DS0000020349.V339860.R01.S.doc Version 5.2 Page 11 Residents receive individualised care because when their care is reviewed they and their representative are involved in looking at how future care needs to be given to them. The care plans viewed, showed that residents and their representative had been involved in planning the care needed. Residents are given their medicines safely by the home staff who have received training and use the homes medicine policies and procedures. The manager continues to work on developing the medicine administration procedure. On the day of inspection the manager was meeting with the local pharmacist looking at improving the administration of medicines. The medicine administration sheets viewed and assessed, were in good order. The medicine sheets contained evidence of stock control, reasons for omissions and most of the time the box with the signature showing that the medicine had been given, was filled in. Residents and visitors said that the staff respected them and gave them the privacy they needed. Staff were observed getting along with residents and to me it seemed like mutual respect. Staff were also observed knocking before they entered resident’s bedrooms. Residents said “I choose how things are done to me”. Another said “I can do what I want here”. And a third resident said ”I have the freedom to choose things as I like them”. Respecting residents could improve even further if the staff stopped using the term “cot sides” which appeared in some of the risk assessments viewed. The term “cot sides” can be seen as infantilising the resident using them and the word bed rails needs to be used. Residents have been involved in discussing their end of life arrangements and this is recorded into their care plans. The needs of an unwell resident’s end of life arrangements had been discussed, the resident was able to follow out their wishes. The residents wishes were recorded, were clearly understood by staff and the resident’s requests were being supported by the staff. Glenavon House DS0000020349.V339860.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 11-12-14-15 were considered. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can feel supported in remaining involved in their community. Not all the less able residents were receiving individualised activities to ensure they were included and stimulated to help them through the day. Residents are offered a choice of meals. EVIDENCE: Residents benefit from structured recreational activities provided by the home. Residents enjoyed the opportunity to go to the shops, garden centre, zoo or use the garden. Some of the less able residents could not give a clear view of what they wanted. This experience was expressed in a returned resident’s survey and the lack of written evidence in the home. The manager was unable to produce recorded information on how the less abled residents had been meaningfully occupied on a daily basis. Whilst going round the home one resident said they would like to do more and another said “ Oh no I do enough and don’t need Glenavon House DS0000020349.V339860.R01.S.doc Version 5.2 Page 13 more to do” Residents could benefit from more individualised activities and more regular group activities which could add more interest to their lives. Residents were supported in maintaining contacts with their community and families. The manager gave examples as to the service they provided to help residents remain in their community. The resident’s survey, a visitor, a resident and the manager confirmed that residents went outside the home to use the local facilities. Resident have their religious needs meet. The manager demonstrated that she understood the need to support residents in meeting their spiritual needs. One of the residents explained how she received visits from the local clergy. All residents I spoke with said they had control of their lives. They decide how to arrange their bedrooms , when to get up and when to go to bed. These comments from residents reflects well on the home. For instance bedtimes are recorded in the care plans and one resident said” I stayed in bed for as long as I wanted, I’m not told when to get up”. The residents are offered a choice of two meals for lunch and two choices for their evening meal. Several residents explained they selected their meals on a daily basis. Overall the residents view was that the food was “alright”. One resident spoke of his like for the type of meals served in his country of origin. The manager explained some meals were provided to meet this need. But through discussion with the manager the changes to the menu did not provide a range of meals planned to meet the resident’s individual ethnic needs. In order to respect diversity I requested that the meals offered to a person from an ethnic minority background should be radically changed to suit their request for the type of food they liked. The manger confirmed that a new range of recipes were going to be planned. Glenavon House DS0000020349.V339860.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16-17-18 were considered. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by a team that has received training in recognising abuse and protecting residents. Residents live in a home where the manager takes any incident of abuse seriously and keeps checking for any potential abuse. EVIDENCE: Residents live in a home where complaints are taken seriously and followed through. A review of a recent complaint showed it had been dealt with properly. A recent complaint was investigated by the home and the finding were explained Residents are safeguarded from abuse by a manager who is committed to staff receiving training in preventing abuse, selecting staff carefully, allowing staff to leave if unsuitable for the job and acting promptly if she becomes aware of incident of abuse. The records showed that over half the staff had attended training on recognising and preventing abuse. The manager was also aware of the need to monitor all staff currently employed in the home and had effectively managed a recent incident. This incident was taken seriously. Residents are protected from abuse by the manager who knows how to follow the local authority’s “ No secrets” policy and take the right action. Glenavon House DS0000020349.V339860.R01.S.doc Version 5.2 Page 15 The home has a clear complaints procedure but it would benefit from being rewritten in plain English. The four sudden deaths which occurred in the home were discussed and all could be explained with either the coroner or general practitioner confirming the deaths were understandable. Glenavon House DS0000020349.V339860.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19-20-21-22-23-24-25-26 were considered. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents live in a safe clean environment but the home could be in better decorative order. The residents can choose how to arrange their bedrooms. Residents lived in a clean environment and a home where the manager and staff knew their responsibilities to keep a clean, infection free environment. EVIDENCE: Residents live in a home where the effectiveness of the maintenance person, domestics and laundry person are monitored weekly. The home also uses a maintenance log book. A resident said that her room was “kept very clean”. The home was assessed to be in good repair and on the day of inspection the maintenance man was arranging for a carpet to be replaced. Glenavon House DS0000020349.V339860.R01.S.doc Version 5.2 Page 17 The residents live in a home where the fixtures and fittings are being upgraded to improve the look of the building. Residents live in a home where some of the walls and woodwork are scratched, marked or have paint missing. Residents live in bedrooms arranged as they would like to have them; so all bedrooms are different. However I noticed that clinical lotions and products were being left out in resident’s bedrooms which took away the homeliness of the room. I advised for clinical products such as incontinent pads needed to be stored away. The residents can use a range of equipment to help them move around the home. Some of the residents would be living in a better bedroom environment if their bedroom carpet were cleaned more often. This was discussed with the manager who already had a cleaning schedule ready. The Residents lived in a clean environment and a home had an infection control policy, a cleaning schedule, a record of when the cleaning was done. The manager confirmed that there had not been any infectious outbreaks in the home. Glenavon House DS0000020349.V339860.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive care from staff who have been trained to meet their individual needs. And the residents are kept safe because of the manager’s expectation that staff working in the home need to have the right attitude towards the residents. EVIDENCE: Residents receive care from staff who vary in numbers according to the changing needs of the residents. Staff are supported by the maintenance, domestic laundry and kitchen staff. None of the residents mentioned they felt rushed or that they experienced staff shortages. On the day of inspection there were two more care on staff on duty than required by the staffing notice. Out of eight relative surveys, seven said their person who was using the service had their needs met by the staff. Out of 10 residents who completed a survey nine said staff were always or usually available to help them. One relative said its “a very good service”. Residents safety is maintained by a manger who is prepared to let staff go if they have the wrong attitude and is prepared to monitor the performance and attitude of the current staff through observation, supervision and talking to Glenavon House DS0000020349.V339860.R01.S.doc Version 5.2 Page 19 residents for their views. This was supported by a resident who said ”Staff attitude has improved”. Residents receive care from staff who were selected by a competent recruitment process and this was demonstrated by the three personnel records randomly selected on the site inspection visit. The records showed that criminal records checks were carried, references taken up and interview records kept. Residents are receiving care from staff who got relevant training from internal and external sources. The training includes the fire, manual handling but also the care components for caring for residents with dementia. The manger showed me the training staff have already received this year and the training planned for the next several months. Some training sessions had already been arranged and a speaker booked to do the session. Glenavon House DS0000020349.V339860.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31-32-33-35-36-37-38 were considered. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a home that is well managed and run in their best interests. EVIDENCE: Residents live in a home with a competent manager who has been at Glenavon for several years, having previously been a home manager in other local nursing homes. The manager is a trained nurse and has completed the relevant management training. Glenavon House DS0000020349.V339860.R01.S.doc Version 5.2 Page 21 Residents can make their views known to a manager who has a very “handson” management style and visits all the residents daily. Staff said that the manager was approachable, and they felt able to make suggestions and discuss issues with her. Residents are able to make their views known at meetings held monthly with the notes from the meetings displayed in the hallway. Any relatives are welcome to attend the residents meeting. One resident said “its lovely here and I get on well with the nurses”. Another resident said “the staff were very nice”. However another resident said staff were “so and so”. Parts of the services which the residents receive are regularly audited by the manager. The registered provider has not been completing the monthly management audit as required by law. Residents could be assured that the provider knows their service is functioning if the provider did a monthly report on they thought their home was running. Resident’s personal monies handed over to the home for looking after were stored safely. And the two resident’s petty cash balances which were checked at the site inspection were correct. The residents receive care from staff who are regularly supervised to ensure they are satisfied with their work and are keeping up to date. The home’s records that were examined were all well maintained and kept secure. The residents live in a home which is well maintained and no health & safety issues were identified during the course of the inspection. Glenavon House DS0000020349.V339860.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 2 X 3 3 3 3 Glenavon House DS0000020349.V339860.R01.S.doc Version 5.2 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 OP12 Regulation 16(2)(n) Requirement Some of the less able residents would remain more interested in their surroundings, by the home arranging more regular recreational activities The registered owner needs to produce a management quality audit of the home every month. Timescale for action 26/07/07 2 OP33 26(1) 01/07/07 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 OP7 Good Practice Recommendations Residents could get benefits of individualised care from new staff sooner if the care plans contained more instructions on how the residents want their care to be provided. Residents would get better care from care plan which are set out in care record that are easier to use. Residents from ethnic minority backgrounds would benefit from a review of the menus offered to them. A three week menu containing ethnic dishes needs to be prepared. DS0000020349.V339860.R01.S.doc Version 5.2 Page 24 2 3 OP7 OP14 Glenavon House 4 5 OP24 OP18 Service users must live in bedrooms that look homely and not with a clinical feel to them. So all clinical products must be stored away properly. Resident need to be respected as adults so the use of “cotsides” to describe bedrails must cease. Glenavon House DS0000020349.V339860.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Glenavon House DS0000020349.V339860.R01.S.doc Version 5.2 Page 26 - 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. 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