CARE HOMES FOR OLDER PEOPLE
Glencoe Care Home 10-11 Chubb Hill Whitby North Yorkshire YO21 1JU Lead Inspector
Mavis Pickard Unannounced Inspection 06/12/05 10:50 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 Glencoe Care Home DS0000044875.V266292.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. Glencoe Care Home DS0000044875.V266292.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Glencoe Care Home Address 10-11 Chubb Hill Whitby North Yorkshire YO21 1JU 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) 01947 602944 Endeavour Care Ltd Mrs Linda Magill Care Home 19 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (19) of places Glencoe Care Home DS0000044875.V266292.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th October 2004 Brief Description of the Service: Glencoe is a care home providing personal care and accommodation for up to 19 older people with a dementia type illness. The premises are located close to the town centre of Whitby and overlooking the town’s public park. Glenco is a large detached house the front of which has a small gardened area with steep steps leading to the main entrance.There is also a path to the side of the house. A patio/gardened area to the rear is accessible from residents areas of the home by a short flight of steps. On street car parking to the front of the house is limited. Glencoe Care Home DS0000044875.V266292.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken with the assistance of the home’s registered manager over a 4-hour period. The Inspection looked at assessment and care documents, health and safety documentation and practices and involved a tour of the home. Direct observation was made of the way the home is running throughout the visit and in particular during informal meetings with residents. What the service does well: What has improved since the last inspection?
The registered manager is currently developing an assessment tool that will assist her to gather comprehensive information about prospective residents prior to admission. There is evidence that the process of induction of staff has been implemented and that a programme of in house/ video based training is being devised to provide information for staff in respect to dementia and its associated behaviours and other core learning associated with care provision. Fire safety equipment and hot water outlets are checked regularly. Glencoe Care Home DS0000044875.V266292.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. Glencoe Care Home DS0000044875.V266292.R01.S.doc Version 5.0 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 Glencoe Care Home DS0000044875.V266292.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&3 Residents and/or their representative are provided with appropriate preadmission information. Residents have their needs assessed prior to admission albeit the written detail is limited. Residents and/or their representatives a do not receive written assurance that the home can meet their need. EVIDENCE: The home’s statement of purpose and service user guide that are provided to prospective residents and/or their representatives prior to admission gives people the information they need to be able to make a decision about the services provided at Glencoe. 2 of the most recently admitted residents pre-assessment documents were examined where it was found that they lacked detail about the prospective resident’s needs.
Glencoe Care Home DS0000044875.V266292.R01.S.doc Version 5.0 Page 9 The manager said that she is presently formulating a way of collecting sufficient detailed information about prospective residents to enable her to make an informed decision to offer admission. This should be done without delay. The manager said that presently people offered accommodation are not provided with written documentation or a letter that ensures them that their needs can be met by the home. Glencoe Care Home DS0000044875.V266292.R01.S.doc Version 5.0 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9 & 10 Residents have a care plan. Residents are protected by the homes medication policy. Residents are treated with respect. EVIDENCE: Documents examined show that all residents have an individual care plan setting out in detail the care to be provided. The care plans examined were clear and comprehensive, giving staff guidance in the provision of care. The home has a medication policy that is followed by all staff. Presently no residents are responsible for their own medication. From direct observation it is clear that people accommodated are treated with respect and that their right to privacy is upheld. Time spent with staff and residents in an informal way gave evidence that people are treated well and are respected as individuals.
Glencoe Care Home DS0000044875.V266292.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 Residents maintain contact where possible with family and friends. EVIDENCE: From direct observation and from the examination of records it is clear that where possible residents are encouraged and enabled to maintain contact with their friends and family. The manager said that there are people accommodated who have no visitors and who she believes have no family or friends who choose to visit the home. The manager added that the family and friends of people accommodated who visit, include in their interaction with their own relatives, others who may not have visitors. The home presents as a happy place to live. It is clear from observation of interaction between the manager, staff and the people accommodated that the atmosphere in the home is inclusive. The possibility of introducing advocacy or befriending services to the home was discussed. The manager said she would look what is available in the local area. Glencoe Care Home DS0000044875.V266292.R01.S.doc Version 5.0 Page 12 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 &18 Not all complaints are recorded. People are protected from abuse. Training in respect to understanding what constitutes abuse has not been implemented. EVIDENCE: The home’s complaint policy and procedures are appropriate. The record of complaints shows that no complaints have been made. It was discussed that a complaint had been received in 2004 that was as far as possible investigated by the home and is known to the Commission. The home has no record of the complaint. All complaints must be recorded and the record kept in the home. Although it is clear from speaking with the manager and from the observation of practice in the home that people are protected as far as is possible from abuse, to date the manager and staff has not undertaken formal training in respect to understanding and/or dealing with abusive situations. The manager said that she and staff would undertake video and work book inhouse training about this subject. Glencoe Care Home DS0000044875.V266292.R01.S.doc Version 5.0 Page 13 It was discussed that to better enable the registered manager to provide this type of training to staff, external nationally recognised formal training may be advisable for her. Some local authorities provide free training in respect to this issue the provider and/or manager is asked to investigate this possibility. Glencoe Care Home DS0000044875.V266292.R01.S.doc Version 5.0 Page 14 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): 19,20,24,26 Indoor communal facilities are well maintained, comfortable and safe. Not all outdoor communal facilities are well maintained and safe. Private facilities are safe, comfortable and people have their own possessions around them. The home is clean. EVIDENCE: A tour of the home was undertaken which showed that the interior of the communal and private areas of the home are well maintained and comfortable and clean. Residents private rooms are pleasantly furnished and decorated and show that people are encouraged to have their own possessions around them.
Glencoe Care Home DS0000044875.V266292.R01.S.doc Version 5.0 Page 15 There is no indication that any internal area of the home accessible to residents are unsafe. However the external areas accessible to residents are not wholly safe. The rear of the premises has a pleasant patio area where, the manager says residents can sit out in the warmer weather. There is no level access to this area and some parts of it have uneven paths. At one point there is a deep step where residents may be at risk of falling. The manager is considering fitting a gate so that residents would only be able to use the safer parts of the garden and patio. It is important that all areas of the home including the garden is safely accessible to people who live there, that they may independently use the garden should they wish so to do. If necessary within a risk assessment framework. The front of the premises is difficult to negotiate. It is unlikely that residents or visitors would be able to feel confident in negotiating the steep and slippery steps. There is a side path to the home that is easier to use. . Glencoe Care Home DS0000044875.V266292.R01.S.doc Version 5.0 Page 16 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): 29 &30 The home’s recruitment policy and procedures protect residents. Staff have not received all the training they need. EVIDENCE: The recruitment files of 2 most recently employed staff and 1 more established member of staff were examined where it was found that all aspects of the Care Homes Regulations schedule 3 are met. These regulations set out the checks that need to be taken prior to employing staff in a care home including Criminal Records Bureau [CRB] and Protection of Vulnerable Adults [POVA] disclosures. 2 most recently employed care workers are foreign nationals and therefore the undertaking CRB/POVA disclosures at such an early time in their employment and life in this country, is the manager, advised not realistic. The manager is advised by CRB to undertake these checks after about 6 months; in the meantime both staff have satisfactory police checks from their own country. Glencoe Care Home DS0000044875.V266292.R01.S.doc Version 5.0 Page 17 The staff training matrix was not examined. The manager has recently implemented appropriate induction training for care staff, however the home does not meet current standards that recommends that a minimum of 50 of care staff are trained to NVQ level 2 or above by 2005. The manager confirmed that staff to date has not undertaken Adult protection nor dementia training but that she is about to take staff through this type of training in-house with the use of video and work books. Glencoe Care Home DS0000044875.V266292.R01.S.doc Version 5.0 Page 18 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35 & 38 A person fit to be in charge manages the home. The ethos of the home is open, positive and relaxed. The home is run in the best interests of residents and their financial interests are safeguarded. There are Health and Safety concerns. EVIDENCE: The registered manager presented as being a caring, experienced and competent person to be in charge of the home. Although she has not yet completed the qualifications recommended by current standards, she said that she is presently negotiating so to do.
Glencoe Care Home DS0000044875.V266292.R01.S.doc Version 5.0 Page 19 It is concerning to know that the manager is recorded as the person ‘on-call’ at all times. The registered person should ensure that the manager is supported appropriately in her role. The ethos of presented as and not staff by all. This is the home is relaxed and open, people accommodated and staff having mutual respect. The way the home is run is resident led led. It is clear that the manager is accessible and approachable to be commended. Although resident’s finances were not examined they had been at the previous inspection. The manager went through the process she employs to keep residents personal allowances safe. This is appropriate. Water safety checks were carried out. All hot water outlets are fitted with failsafe valves and ensure hot water delivery at about 43°C. All radiators accessible to residents are covered. Fire records were examined where t was noted that extinguishers are checked regularly and that the fire service has visited and signed the fire record book. However there are some concerns regarding health and safety [please refer to standards 19-26] There was no report available for the purpose of regulation showing that a fire safety inspection had been completed by a Fire Safety Officer and the manager said that the presently home does not have a fire risk assessment in place. Glencoe Care Home DS0000044875.V266292.R01.S.doc Version 5.0 Page 20 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 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 2 3 1 X X X 3 X 3 STAFFING Standard No Score 27 X 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 4 X X 3 X X 1 Glencoe Care Home DS0000044875.V266292.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. Standard 1 OP3 Regulation 14(a-d) & Sch3(1)(a ) Timescale for action The registered person must 06/12/05 ensure that residents are admitted to the home only following a comprehensive and holistic written assessment of their needs undertaken by people trained to do so. The registered person must 06/12/05 ensure that a record is maintained in the home of all complaints including detail of the investigation and any actions taken. The regsitered person must put 24/12/05 forward to the Commission a plan, with dates for its completion, to ensure that external grounds of the home are made suitable and safe for use by residents. The registered person must 06/12/05 ensure that a written Fire Risk Assessment is undertaken in accordance with the Fire Precautions[Workplace] Regulations 1997. Requirement 2 OP16 17(2) Schedule 4 (11) 3 OP20 23 2 (n&o) 4 OP38 23(4)13 (4)(a-c) Glencoe Care Home DS0000044875.V266292.R01.S.doc Version 5.0 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP18 OP30 OP31 OP31 Good Practice Recommendations Consideration should be given that the registered manager undertakes nationally recognised training in respect to the Protection of Vulnerable Adults. The registered person should ensure that a minimum of 50 of care staff are trained to National Vocational Qualification[NVQ] level 2 or equivalent by 2005. The registered person should ensure that the manager undertakes a qualification at least to National Vocational Qualification [NVQ] at level 4 or equivalent. Consideration should be made by the registered person in respect to the manager receiving appropriate support to undertake her role appropriately. Glencoe Care Home DS0000044875.V266292.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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