Inspection on 20/06/07 for Glendale

This inspection was carried out on 20th June 2007.

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

Glendale 05/03/07

Glendale 13/04/06

Glendale 04/10/05

Glendale 10/05/05

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 Lesley Garrett Unannounced Inspection 20th 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 Glendale DS0000039536.V337310.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. Glendale DS0000039536.V337310.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glendale Address Ambleside Avenue Walton-on-Thames Surrey KT12 3LW 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) 01932 251980 01932 232593 mary.hunt@anchor.org.uk keri.sherwood@anchor.org.uk Anchor Trust Miss Mary Hunt Care Home 60 Category(ies) of Dementia - over 65 years of age (26), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (3), Old age, not falling within any other category (51), Physical disability over 65 years of age (8) Glendale DS0000039536.V337310.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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. 5th March 2007 Date of last inspection Brief Description of the Service: Glendale is a purpose built care home for older people situated in a quiet residential area of Walton-on-Thames. The home is approximately one mile from the town centre. The majority of the accommodation is for permanent residence with a small number of respite (short stay) rooms available. Up to 26 service users may have dementia, up to eight service users may have a physical disability and up to three service users may have a mental disorder. Personal and communal accommodation is provided on three floors. There are five self-contained units, each with 12 bedrooms, assisted bathrooms, lounges, dining rooms and kitchen facilities. All bedrooms are for single occupancy, with en-suite wash hand basins and WCs. There is a courtyard and enclosed landscape gardens and parking facilities are available to the front of the home. The fees at this service range from £446.50 per week to £720.00 per week. Glendale DS0000039536.V337310.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. This inspection of the service was an unannounced ‘Key Inspection’. The inspector arrived at the service at 09.30 and was in the service for six hours. The inspection was a thorough look at how well the service is doing. It took into account detailed information provided by the service’s manager, and any information that the CSCI has received about the service since the last inspection. The inspector asked the views of the people who use the service and other people seen during the inspection or who responded to questionnaires that the Commission had sent out. The inspector looked at the home’s records and completed a tour of the building. The inspector also looked at how well the service was meeting the standards set by the government and has, in this report, made judgements about the standard of the service. What the service does well: What has improved since the last inspection? Eleven requirements were made following the site visit in March of this year and they have now all been completed. We observed that contracts are now in place for the folders that we sampled and the manager stated that all service users now had a current contract. Glendale DS0000039536.V337310.R01.S.doc Version 5.2 Page 6 We also observed that pre-admission assessments are now carried out but the manager stated that service users usually have a day’s trial visit to see if they like the home and for the home to do their assessments. Assessed needs of service users are also in place in their individual plans with risk assessments carried out and recorded. The home is in the middle of changing their current documentation with a completion date of the end of August. Medication charts were observed and all medication was available on the day of the visit. The hours worked by the night staff and the activity organiser had been reviewed but there is a requirement for all staff hours to be reviewed as the needs of the service users increase. Recruitment practices at the home have improved and the manager had just completed a complete review of all of the recruitment folders and we observed that induction and supervision sessions had taken place. What they could do better: One requirement and seven recommendations were made following this site visit and can be read at the end of the report. The requirement made was for the manager to assess the needs of the service users to ensure that adequate numbers of staff are on duty at all times to provide the care necessary. Two recommendations were made concerning medication and they were that reasons for non-administration of medication be recorded and any handwritten changes contain the signatures of two people to ensure that medication is administered safely. It was recommended that the supper menu be discussed with service users and the chef to ensure that choice and variety is offered for all meals. Another recommendation was for any offensive odour in the home to be eliminated. During the site visit we discussed the need for the service to seek the views of stakeholders in the home and not just the service users and visitors and, as part of the quality audit system, to make sure that the home’s policies and procedures are reviewed regularly. Glendale DS0000039536.V337310.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Glendale DS0000039536.V337310.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Glendale DS0000039536.V337310.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All service users benefit from an assessment prior to moving into the service to ensure that their needs can be met. Intermediate care is not provided at the home. EVIDENCE: The manager stated that either herself, the deputy or a senior team member do all pre-admission assessments. It was stated by the manager that usually service users will come to the home for a day and their assessment takes place then. We were told that care plans are then generated from this assessment and the home also uses assessments from social services for those service users admitted from their referral. We sampled four individual plans of care and found the assessments in place and also copies of the contract. Glendale DS0000039536.V337310.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): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users’ health and personal care is based on their individual needs and is set out in their individual plans of care. There was clear demonstration that medication was administered to all individuals in a safe and appropriate way. Privacy and dignity is promoted. EVIDENCE: The manager told us that the home is changing the individual plans of care from an old system to a new one that will be used throughout Anchor Homes. The completion date for this process has been stated as the end of August. We sampled four individual plans of care and found that they contained good documentation on care plans and risk assessments. There was evidence that these had been reviewed and consultation with the service user or their representative had taken place. Glendale DS0000039536.V337310.R01.S.doc Version 5.2 Page 11 The home benefits from the support of a local general practitioner (GP) who will visit whenever called. On the day of the site visit both the GP and district nurse visited the home to see a service user and discussed outcomes with the manager. The district nurse told us that, ‘They work closely with the home but that some units run more smoothly than others and that sometimes the staffing levels are very low’. The manager stated that they have support from the speech and language therapist and dietician and other support for service users is received from the chiropodist, dentist and opticians. The home receives its medication every month and this is delivered to the home. Blister packs are used and all staff who administer the medicines are trained to do so and we observed evidence of this training. The pharmacy carries out advisory visits every year and the manager said that other home managers within the group do audits on their procedures. We looked at some of the medication administration charts and found that no explanation is given for non-administration and some changes to medication that have been made by hand do not contain two signatures, and this will be a recommendation at the end of the report. The privacy and dignity procedures for the home were discussed with the manager who stated that this subject is included on induction for all new staff. We observed staff knocking on the bedroom doors before entering and speaking to service users in a respectful manner. A survey form returned to us said ‘on most of the units they are very good about individual’s privacy and dignity’. Glendale DS0000039536.V337310.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): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social and recreational activities meet the service users’ expectations and they receive a varied diet according to their assessed requirements and choice. EVIDENCE: The home has a full time activities organiser who provides activities in the different lounges around the home. A programme is displayed and on the day of the site visit service users were in the downstairs lounge having a sherry and discussing newspaper articles. We were told that outings to the shops and local pub are popular. A survey retuned to us said, ‘I like going for a walk to the shops and coffee mornings in the garden’. The manager said that they were in the middle of organising their summer fete and were hoping for good weather. The home has organised four days of training in activities that is taking place shortly and this is for all members of staff. There are church services held every month and the manager said that any religion could be catered for. Glendale DS0000039536.V337310.R01.S.doc Version 5.2 Page 13 The manager told us that some service users had recently attended the opening of a new school and some neighbours of the home visit regularly and also help with the garden party. Local schools visit on special occasions, for example Christmas and Easter. We were told that there are no restrictions on visiting and, if necessary, relatives can stay overnight as there are rooms available, particularly if their relative is unwell. The manager stated that choices are given to all service users, which include when to get up and go to bed. One survey returned to us said, ‘My mother is asked if she would like a rest during the day’. Service users are routinely asked what they would like to wear that day and what the activity is and if they would like to join in. The environmental health officer visited the home in March 2007 and no requirements were made during that visit. Most of the survey forms returned to us were complimentary about the food, ‘The meals are very good and cups of tea and coffee are served regularly’. Another comment was, ‘Mother has a good appetite and is well catered for’. One comment received in a survey form stated that, ‘It is nearly always sandwiches on the menu for supper and something different would be nice, for example something on toast’. The manager stated that it is often soup and sandwiches for supper and therefore there will be a recommendation that the supper menu is discussed with the chef and service users, and changes made if appropriate. On the day of the site visit the manager told us that service users were always consulted about the summer and winter menus and the home was about to implement a snack with the evening drink at about 20:00. Glendale DS0000039536.V337310.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): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are protected by the home’s complaints policies and safeguarding adults procedures. EVIDENCE: The manager stated that she keeps a complaints log and has received one concern since the last site visit, which had been investigated within the home’s timescales. Available at the home is also a compliments, concerns and complaints form, which can be filled in by any service user or visitor to the home. No complainant has contacted the Commission with information concerning a complaint made to the service since the last inspection. We observed that the home has the local authority’s procedures for safeguarding adults and the manager stated that the home follows these procedures. The manager stated that the home has had no referrals under these procedures since the last inspection. Documentation observed demonstrated that staff have had training in safeguarding adults and this takes place regularly. On the day of the site visit the home could not locate the home’s internal safeguarding policy but again repeated that the staff all use the local authority’s procedures. Glendale DS0000039536.V337310.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service live in a well-maintained environment, which was clean and hygienic. EVIDENCE: During a tour of the building we noticed that service users’ bedrooms have been personalised and that generally the home was decorated to a good standard. The manager explained that there is a planned maintenance and refurbishment programme. Included in this year’s refurbishment are all communal areas that will be decorated and carpeted. The outside of the building will be painted and the reception area is to be refurbished. We were also told that when a room is vacated it is also decorated. Glendale DS0000039536.V337310.R01.S.doc Version 5.2 Page 16 The home has a large garden, which is safe, and the grass is mown frequently. To the sides of the home are smaller gardens with patio areas and garden furniture for service users to sit out in the better weather. The side gardens would benefit from additional maintenance to bring this to the same standard as the large garden. The home employs full and part time housekeepers. We spoke to one housekeeper who stated they are kept very busy but benefit from regular training. One comment received stated, ‘One thing that needs improvement is the unsavoury smell that is often in the corridors’. On the day of the site visit there was an offensive odour in one particular room, which the manager was aware of, and staff have been given the necessary equipment to tackle this malodour. This needs to be monitored by the staff to ensure appropriate odour controls are in place. Glendale DS0000039536.V337310.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained and skilled but may not always be in sufficient numbers to fill the aims of the home and meet the changing needs of people who use the service. EVIDENCE: The skill mix of staff for each unit and the rota can be adjusted accordingly. The manager stated that she assesses the service users to establish their care needs and staff can then be adjusted accordingly. One survey form returned to us and a conversation with a health care professional suggested that there might not always be sufficient staff on duty. Another survey form returned stated, ‘Often the units seem very understaffed and the front desk is often not staffed’. It will be a requirement at the end of the report for the manager to assess each unit to ensure that the needs of service users can be met at all times. The manager stated that over 50 of their staff have the national vocational qualification certificate and all new staff are enrolled on the course when possible. We were also told that all the team leaders have the Level 3 qualifications. Glendale DS0000039536.V337310.R01.S.doc Version 5.2 Page 18 We sampled three staff recruitment folders and found that all the necessary documentation to enable the home to employ staff was in place. It was observed that the manager had ensured that all employees had two references but it is recommended that friends are not used for reference purposes and this is stated on the home’s application forms. The manager stated that she has just completed a review of all employment folders for the staff to ensure that all the documentation is in place. We observed the training plan for this year for the home. The manager stated that the following mandatory training has taken place or is planned: safeguarding adults, manual handling, health and safety, fire, food hygiene and activities. On the day of the site visit a member of staff was doing the manual handling training with housekeeping and reception staff. Glendale DS0000039536.V337310.R01.S.doc Version 5.2 Page 19 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): 31, 33, 35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness, and has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: The manager has been in post since October 2005 and is registered with the Commission and has completed her Registered Managers Award. A deputy manager and team leaders support her in the home. A survey form returned to us stated that her mother had to move to another unit and ‘the manager and deputy have both been extremely helpful and supportive. She was able to choose her room and the maintenance person moved everything quickly’. Glendale DS0000039536.V337310.R01.S.doc Version 5.2 Page 20 The home has a quality assurance programme and the manager stated that a questionnaire had been sent to the service users and relatives in May and the results had just been analysed. The manager stated that the results of the survey will be fed back at the service user and relatives’ meeting and also by letter, but this had not been completed yet. Meetings are held twice a year and the last one was in April. As part of the inspection process a number of survey forms were sent to the home to be distributed by the manager and these included service users, relatives and healthcare professionals. Some of the comments from these survey forms have been used in this report. It is a recommendation at the end of the report for the managers to seek the views of other stakeholders in the home. As part of the inspection process the manager had completed a self-assessment quality document (AQAA) and returned this prior to the site visit. It showed that the policies and procedures had not been recently updated and this will be a recommendation at the end of the report. The manager stated that the home has an administrator who deals with service users’ personnel allowances. All money is banked and all receipts are kept, providing an audit trail. On the day of the site visit the administrator was not in the home and therefore this process was not tested but had been checked at the last visit in March 2007 and found to be satisfactory. The home has a full time maintenance person and, from information seen during the site visit and the information supplied to us in the AQAA, it is clear that regular health and safety checks take place. During the tour of the building no health and safety issues were identified. Glendale DS0000039536.V337310.R01.S.doc Version 5.2 Page 21 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Glendale DS0000039536.V337310.R01.S.doc Version 5.2 Page 22 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 OP27 Regulation 18 Requirement The manager is to complete a care needs assessment in all of the units on all service users to make sure that at all times there are sufficient staff on duty to care for the needs of the service users. Timescale for action 20/07/07 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 2 Refer to Standard OP9 OP9 Good Practice Recommendations It is recommended that any non-administration of medications should be recorded. It is recommended that any handwritten entries on to the medication administration chart to either add a new medication or to alter an existing item should contain the signatures of two people. It is recommended that the supper menu be discussed with service users and the chef. 3 OP15 Glendale DS0000039536.V337310.R01.S.doc Version 5.2 Page 23 4. 5 OP26 OP29 It is recommended that the home monitors and controls any offensive odours within the home. It is recommended that the home follow its own recruitment policy and does not accept references from the friends of prospective employees. It is recommended that the home seek the views of all stakeholders to the home to include visiting professionals. It is recommended that the home reviews its policies and procedures. 6 7 OP33 OP33 Glendale DS0000039536.V337310.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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 Glendale DS0000039536.V337310.R01.S.doc Version 5.2 Page 25 - 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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