Inspection on 10/05/05 for Glendale

This inspection was carried out on 10th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Glendale 20/06/07

Glendale 05/03/07

Glendale 13/04/06

Glendale 04/10/05

Glendale 11/01/05

Glendale 06/08/04

Glendale 13/05/04

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

CARE HOMES FOR OLDER PEOPLE Glendale Ambleside Avenue Walton On Thames Surrey KT12 3LW Lead Inspector Janet Daulton UnAnnounced 10 May 2005 11:00 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 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. Glendale H58 H09 s39536 Glendale v226880 100505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Glendale Address Ambleside Avenue Walton On Thames Surrey KT12 3LW 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) 01932 251980 01932 232593 Anchor Trust To be confirmed CRH Care Home 60 Category(ies) of DE(E) Dementia - over 65 (26) registration, with number Learning Disability - over 65 (1) of places MD(E) Mental Disorder - over 65 (3) OP Old age (51) PD(E) Physical disability - over 65 (8) Glendale H58 H09 s39536 Glendale v226880 100505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Of the residents accommodated in the home, up to 26 may fall within the category DE(E) and up to 8 may fall within the category PD(E).. The age/age range of the persons to be accommodated will be: OVER 65 YEARS OF AGE. Date of last inspection 11 January 2005 Brief Description of the Service: Glendale is a purpose built care home for older people,situated in a quiet residential area, about one mile from the town centre of Walton -on- Thames. The home provides accomodation and care for elderly service users, and includes care for service users with dementia and physical disability.The accomodation is provided on three floors, and is divided into five units, named Diamond, Sapphire, Pearl, Emerald, and Ruby. Each unit has its own kitchen area, dining area and lounge. There are twelve bedrooms on each unit, all for single occupancy, and each with ensuite wash hand basins and WCs.There is a courtyard and enclosed landscape garden. There are parking facilities on site and there is also road parking. Glendale H58 H09 s39536 Glendale v226880 100505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and the first in the inspection programme for the year 2005/2006. The inspection took place over five hours. Ms. Lorraine Hills Avery, the Manager of the service was present during the inspection. At least twenty service users were spoken with, and three visitors were asked for their views on the care that their relative receives. Staff were also spoken with during the inspection. A tour of the premises took place and the majority of the service users bedrooms were visited. The inspector examined service users records and staff and training records. The inspector found that there was a happy and relaxed atmosphere in the home. Service users looked well cared for, and the home was generally well maintained throughout, and many of the bedrooms were personalised by the service users, reflecting their individual tastes. Staff appeared well motivated and were knowledgeable about the needs of the service users that they were looking after. Service users were satisfied with the standard and variety of food offered to them at mealtimes, and the meal served on the day of the inspection looked appetising. All the service users appeared to enjoy that meal, and they were given a choice whether they wished to eat in the dining area or in their own rooms. Several chose to eat in their rooms, and over chair tables were provided so that service uses could eat comfortably. The method of obtaining service users views about the care and facilities offered by Glendale needs further development to fully meet the National Minimum Standard. One area of the home had an identified problem with odour and this must be addressed. The inspector wishes to thank the manager staff, and service users for their cooperation during the inspection. What the service does well: The home provides a good standard of accomodation, which is offered in single rooms. Care was provided to the service users in a kind and sensitive manner, and the care staff respected the individual preferences and wishes. Service users and relatives told the inspector that staff were kind, and that they could discuss any concerns with the staff. Some service users were unable to express their opinions due to their mental frailty, but these service users appeared comfortable and settled in their surroundings. Glendale H58 H09 s39536 Glendale v226880 100505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: There was an area of the home with an odour problem. The Manager was aware of this problem. The carpets on the ground floor corridor area were marked. Some kitchen equipment needs repair or replacing, as several of the lids of the waste bins in the kitchen units were missing, and one of the heated trolleys was broken. The method of obtaining feedback from service users and relatives needs further development, and a report should be compiled and made available to the service users. Service users were unaware of a questionnaire that had been developed to obtain their views. Several service users would be unable to give an opinion about the care and services because of their mental frailty. Staff training should include more training for staff in care of service users with dementia Glendale H58 H09 s39536 Glendale v226880 100505 Stage 4.doc Version 1.30 Page 7 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. Glendale H58 H09 s39536 Glendale v226880 100505 Stage 4.doc Version 1.30 Page 8 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 Standards Statutory Requirements Identified During the Inspection Glendale H58 H09 s39536 Glendale v226880 100505 Stage 4.doc Version 1.30 Page 9 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 standard(s) 3,4 The home ensures by a pre- assessment that it can meet the needs of the service users. EVIDENCE: There was evidence that service users were assessed either through the care management programme by social services, or if service users were selffunding by the manager of the home prior to admission. Each service user had a plan of care based on the assessment. Those examined demonstrated an awareness of the needs, and were written in a manner that put the service users own perceptions of their needs as paramount. The manager informed the inspector that there were three service users whose needs had changed and the home could no longer fully meet those needs. Arrangements were in place for transfer, and more input was being given by the Community health services. Staff training records evidenced that staff were receiving training to meet the needs of the service users. All staff should receive training in dementia care. Glendale H58 H09 s39536 Glendale v226880 100505 Stage 4.doc Version 1.30 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 standard(s) 7,8, 9, 10, The care needs of the service users were being identified and met. The standard of recording was overall satisfactory on all units; however there were some gaps on the recording sheets which detail when other health care professionals have visited. Care was provided in a respectful manner, and the privacy of service users maintained. Some medication was not being appropriately stored. EVIDENCE: Care plans, or Individual lifestyle agreements were sampled and inspected on all units. The standard of written documentation continues to improve. The service user signed the care plan. Risk assessments were completed where necessary. Service users were weighed regularly where necessary, and referrals had been made to a dietician. A communication book on each unit detailed any significant changes or information that must be shared between staff on different shifts. However there were gaps in the care plan in the recording of professional visits. Staff were recording if service users declined the offer of baths or showers. Staff were observed during the inspection to care for the service users with due respect for their privacy and dignity. This was also verified by service users and relatives. It was pleasing to note that the incidents of falls have Glendale H58 H09 s39536 Glendale v226880 100505 Stage 4.doc Version 1.30 Page 11 fallen. This manager stated that this was due to an increased staff awareness and training, and completed risk assessments. A full inspection of the medication procedures was not assessed on this occasion. However eye drop medication was seen to be stored inappropriately in a kitchen fridge in one of the units. Glendale H58 H09 s39536 Glendale v226880 100505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 14,15 Service users received a varied and appetising diet with a choice being offered. Visitors were made to feel welcome at the home. Service users were encouraged to maintain their independence as much as they were able. EVIDENCE: The activity provision will be examined at the next inspection as a new activity coordinator had only been in post one week. Visitors who spoke to the inspector stated that they were able to visit at any reasonable time and were welcomed by the home, and their comments about any aspects of their relatives care were given appropriate consideration. Several service users stated that they went out regularly with their families. Many service users had decorated their rooms with their own personal possessions. The service users care plan was kept in the service users rooms, and accessible to the service user, although several service users stated that they did not wish to read them, but understood that they contained information about their care. Service users or their relatives were encouraged to handle their own financial affairs. The chef manager was interviewed during the inspection The choice of food offered was varied and nutritious, and several service users spoke highly about the food offered. The chef stated that there were no specialised diets required Glendale H58 H09 s39536 Glendale v226880 100505 Stage 4.doc Version 1.30 Page 13 at that time. Implements to facilitate easier eating were available and staff were seen to assist service users who were unable to eat independently. Glendale H58 H09 s39536 Glendale v226880 100505 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 18 Service users and relatives were generally aware of the complaints process, and felt able to comment about their concerns without fear of recrimination. EVIDENCE: A complaints file was available which contained details of any concerns or complaints made by service users or their representative. There had been 4 complaints detailed since the last inspection, and the manager of the home had managed these appropriately. There was one vulnerable adults procedure in progress at the time of the inspection, with Social Services being the lead. There was evidence that staff were due to receive vulnerable adults training on 15 June 2005. The home had a copy of the updated Multi Agency procedure for vulnerable adults investigations. Glendale H58 H09 s39536 Glendale v226880 100505 Stage 4.doc Version 1.30 Page 15 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 standard(s) 19 25 26 Service users accommodation was generally well maintained and comfortable. The offensive odour in one area of the home must be managed to provide a clean and pleasant environment for all service users. Several of the waste bins in the kitchens were missing their lids. One of the heated food trolleys was not working on the day of the inspection, and had not been working for the last two days. EVIDENCE: The manager stated that domestic staff were being recruited to address the shortfall in cleaning staff. One area of the home had a significant odour problem. The manager stated that measures were being put in place to deal with this. The carpets in the corridor area on ground floor were marked. A maintenance man was employed to attend to maintenance and repair matters. Records were kept of his maintenance checks, including hot water temperature checks. In some of the rooms visited service users could not control the temperature of their radiators. Glendale H58 H09 s39536 Glendale v226880 100505 Stage 4.doc Version 1.30 Page 16 Staff were observed to carry out procedures with due consideration to good infection control. Gloves and aprons were being worn where appropriate. The laundry facilities were satisfactory and the laundry areas were tidy. Glendale H58 H09 s39536 Glendale v226880 100505 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29. The number of staff on duty during the inspection was sufficient to meet the needs of the service users. The home has a commitment to NVQ training for staff. EVIDENCE: The home was fully staffed and did not rely heavily on agency staff. The Manager was in the process of interviewing for domestic staff to replace a domestic who was leaving the following day. The rota was examined and seen to be an accurate record of the care staff working. The manager’s hours were not being recorded on this rota. It was pleasing to note that several staff have completed their NVQ training. 6 staff have finished their NVQ level 2, 7 had also finished, and a workshop was being held the week of the inspection for 11 staff who were to register for their NVQ training. Recruitment files were examined on 5 new members of staff. All had two references on file, and four had Criminal records Bureau checks on file, and one had been sent off. The manager stated that that member of staff was not working unsupervised until their clearance had been received. Terms and conditions signed by the employee were held on file. The manager had worked hard to update the training files for staff. Records were available for mandatory training, and other training such as infection control, diabetic awareness, and medication training. The deputy manager carried out the induction training, and this was in line with TOPPS specifications. Induction training records were seen for the new staff, and staff confirmed that they had received induction training. Glendale H58 H09 s39536 Glendale v226880 100505 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,37,38 Information about service users was maintained securely. The methods for ensuring that service users are consulted about how well the home is doing in serving their best interests needs further development. EVIDENCE: Records were seen to be stored securely, and any care information and records about service users held on each unit were locked away when staff had completed them. The manager had drawn up a comprehensive questionnaire to obtain views from service users and relatives. These were left at the front reception. To date there had been 3 replies. A fire risk assessment had been completed in November 2004 and a generic risk assessment for the building had n been completed in February 2005. Records were seen of staff fire training and moving and handling training. Reports under Regulation 26 were not being forwarded to the Commission for Social Care Inspection. Glendale H58 H09 s39536 Glendale v226880 100505 Stage 4.doc Version 1.30 Page 19 Glendale H58 H09 s39536 Glendale v226880 100505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 2 x x x x x 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 2 x x x 2 3 Glendale H58 H09 s39536 Glendale v226880 100505 Stage 4.doc Version 1.30 Page 21 yes 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. 2. Standard 8.11 9.1 Regulation 17(1) 13(2) Requirement Staff must record on the designated sheet any visits by health care professionals. Eye drops must be stored correctly, and records manitained of the temperatures of the fridges were medication is stored. All staff must have vulnerable adults training service users can control the heating in their own rooms. a record must be maintained of the managers hours of work in the home. 50 of care staff have attained NVQ level 2 or equivalent. All staff must have a CRB declaration before employment. Regulation 26 reports must be submitted to the Commission for Social Care Inspection. This is an outstanding requirment from the last inspection A quality assurance system must be implemented, and the report of the findings made available to service users or their representatives. This is an outstanding requirement from Timescale for action Henceforth 100505 Immediate 3. 4. 5. 6. 7. 8. 18 25.4 27.2 28.1 29.3 37.1 13(6) 23(2)(p) 17 Schedule 4 18(1)(a) 19(1)(a) 26(5)(a) July 31st 2005 July 31st 2005 Henceforth 100505 December 31st 2005 Henceforth 100505 Henceforth 100505 9. 33.1 24(1)(2) July 31st 2005 Glendale H58 H09 s39536 Glendale v226880 100505 Stage 4.doc Version 1.30 Page 22 the last inspection 10. 11. 26.1 19 23(2) 23(2) The kitchen bins must have lids The heated food trolley must be repaired or replaced June 30th 2005 June 30th 2005 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. Refer to Standard 4.2 19 Good Practice Recommendations staff should receive specific training in dealing with service users with dementia. consideration should be given to replacing of the marked carpet in the corridor on the ground floor where there is heavy wear. Glendale H58 H09 s39536 Glendale v226880 100505 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Glendale H58 H09 s39536 Glendale v226880 100505 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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