Inspection on 04/10/05 for Glendale

This inspection was carried out on 4th October 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 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 Janet Daulton Announced Inspection 4th October 2005 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Glendale DS0000039536.V256742.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. Glendale DS0000039536.V256742.R01.S.doc Version 5.0 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 Anchor Trust Lorraine Susan Hills-Avery Care Home 60 Category(ies) of Dementia - over 65 years of age (26), Learning registration, with number disability over 65 years of age (1), Mental of places Disorder, excluding learning disability or 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.V256742.R01.S.doc Version 5.0 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. 10th May 2005 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 in Walton-on- Thames. The home is approximately one mile from the town centre. Service provision affords permanent and respite care and includes care for service users with dementia and physical disability. Personal and communal accommodation is provided on three floors. There are five units, each with twelve beds, each self-contained, with assisted bathrooms, lounges, dining rooms, and kitchen facilities. All bedrooms are for single occupancy, with ensuite wash hand basins and WCs. There is a courtyard and enclosed landscape gardens. Glendale has off road parking facilities. Glendale DS0000039536.V256742.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 4.5 hours and was the second inspection carried out by the Commission for Social Care Inspection for the year 2005-2006. To obtain a full view of the extent to which the home meets the National Minimum Standards it will be necessary to read both reports. The inspection was carried out by Mrs. J Daulton, Lead inspector for the service. The Manager Ms. Lorraine Hills-Avery was present for all of the inspection. A tour of the premises took place. Eight care plans, the complaints log, and a sample of safety certificates were inspected. The inspector spoke to the majority of the service users during the day. The inspector also spoke with some of the staff on duty at the time of the inspection. The inspector had received written feedback from ten service users, three relatives/visitors, and from one GP. This was generally a positive inspection, and the feedback from service users and relatives was overall satisfactory and positive. The inspector would like to thank the staff and service users for their time, assistance, and hospitality during the inspection. What the service does well: The home provides a homely and attractive environment for the service users. The service users appeared relaxed and well cared for. The staff were seen to be caring for the service users in a friendly and respectful way. All service users contacted stated that they felt safe and well cared for in the home, and liked living there. Service users were encouraged to maintain control over their daily life as much as possible. Glendale DS0000039536.V256742.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Glendale DS0000039536.V256742.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 Glendale DS0000039536.V256742.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): 1,2,5,6 A range of information was available for prospective service users, providing details about the home. Service users had their needs assessed before they moved into the home to ensure that the home could provide for those needs. EVIDENCE: An information pack was given to prospective service users. To fully comply with the Regulations all service users should have information about the last inspection report, or details of how to access it. All service users had terms and conditions of residency, and two were sampled and examined. The terms and conditions included a period of notice. The information pack stated that prospective service users were invited to visit the home prior to making a decision, and all service users were admitted for a sixweek trial period. Intermediate care was not provided by the home. The manager stated that emergency admissions were a rare occurrence. Glendale DS0000039536.V256742.R01.S.doc Version 5.0 Page 9 Glendale DS0000039536.V256742.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): 7,8,9, Most of the care needs identified in service users plans were being met, however there was a shortfall in some of the care plans in detailing the action taken to meet health care needs. Care was provided in privacy in a respectful manner. Overall medication administration was satisfactory, however there was a shortfall in signing for medications administered. EVIDENCE: Care plans formed part of the Individual Lifestyle agreements. These were sampled and examined on all units. Overall the standard of care planning was satisfactory, however some of the care plans were more comprehensive than others, and gave more personal details and life history. A care plan was in place for all those records sampled setting out the actions to be taken to meet the needs. A summary of the care plan was also available in the communication book on each unit. Two of the care plans sampled were not completed to a satisfactory standard, as assessments and activities of daily living had not been completed fully. One care plan detailed that the service user was to be weighed weekly, however there was no evidence that this was being done on a weekly basis. Glendale DS0000039536.V256742.R01.S.doc Version 5.0 Page 11 Medication records were examined. Overall Medication was being stored and administered in accordance with the homes policies and procedures. Medication administration records were sampled and checked on each unit. There were two omissions in the medication administration chart. There were risk assessments in place for service users self medicating. Glendale DS0000039536.V256742.R01.S.doc Version 5.0 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 the following standard(s): 12,14 The social and recreational activities were being developed. Service users were able to maintain contact with families and friends. EVIDENCE: There has been good progress since the last report with activity provision. A member of staff was employed to provide activities on a daily basis. Further development was planned, and the activities organiser adapts on a daily basis to provide activities that the service users want. A record was maintained of all the activities provided. The service users stated that they particularly enjoyed the bingo and horse racing activities that were organised. On the day of the inspection several of the service users were having a manicure. An advocacy service was available if required, and service users were encouraged to handle their own financial affairs. Many of the service users had families who had responsibility for the financial arrangements of their relative. Meal provision was not examined at this inspection, please see the previous report. Glendale DS0000039536.V256742.R01.S.doc Version 5.0 Page 13 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 The home had a simple, clear and accessible complaints procedure, which included timescales for the process. The homes policy for dealing with allegations of abuse was in line with Surreys Multi - agency procedures. EVIDENCE: The service had a complaints policy in place, fully accessible to service users and relatives. The policy complied with the National Minimum Standards. It was apparent from records seen at inspection that written complaints were dealt with in an appropriate manner. Service users stated on their feedback forms that if they were unhappy with their care they knew who to speak to. All staff had received vulnerable adults training. Glendale DS0000039536.V256742.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): 19,24, 25, 26 The location and layout of the home was suitable for its stated purpose. It was accessible, safe, and well maintained with a pleasant and homely atmosphere. EVIDENCE: During a tour of the home the premises were seen to be well maintained with service users able to access all areas of the home and gardens. On the day of the inspection the home was found to be warm and bright with a homely atmosphere and a satisfactory standard of housekeeping and cleanliness. A maintenance man and gardener were employed. Records were kept of routine maintenance. Doors to service users bedrooms could be locked, and some service users had their own keys. All the service users rooms that were seen during the Glendale DS0000039536.V256742.R01.S.doc Version 5.0 Page 15 inspection were decorated with personal effects, and the standard of furnishings was satisfactory. All service users had a lockable drawer in their room. Water temperatures were randomly checked, and water was delivered at a safe temperature. Staff had received training in infection control, and staff were seen to carry out good basic infection control measures when caring for the service users. There were adequate facilities for laundry. Glendale DS0000039536.V256742.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): 27,28,29,30 The numbers and skill mix of the staff met the service users needs. Service users were protected by the homes procedures for recruitment. EVIDENCE: The staff rota inspected demonstrated that the staffing numbers and skill mix were appropriate to meet the assessed needs of the service users living in the home. Domestic and laundry staff were employed. The Manager informed the inspector that 75 of the staff team had attained level 2 NVQ. All interactions observed between staff and service users during the inspection were seen to be caring and respectful. At the time of the inspection, the home had a stable staff team. Recruitment checks were carried out on new members of staff, and staff received Statements of Terms and Conditions. Records of training evidenced that staff received induction training after employment. Glendale DS0000039536.V256742.R01.S.doc Version 5.0 Page 17 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 The Management of the home provided strong leadership. Health and safety updates and training for staff must be carried out to promote the health, safety, and welfare of service users. EVIDENCE: The manager had completed the fit person process and was registered with The CSCI. Service users and staff reported that the manager was approachable and had an open door policy. The home had obtained feedback from service users on the care and facilities that were offered, and the results of the survey were displayed in the entrance. Overall the feedback was very positive. Glendale DS0000039536.V256742.R01.S.doc Version 5.0 Page 18 Where the money for service users was handled by the home, this was appropriately recorded. The moving and handling and fire safety training records showed that not all staff working in the home had received this training, and requirements have been made. The monthly visit completed under Regulation 26 was not being regularly done and reported. Glendale DS0000039536.V256742.R01.S.doc Version 5.0 Page 19 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 2 3 x x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x 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 3 3 3 x 3 x x 1 Glendale DS0000039536.V256742.R01.S.doc Version 5.0 Page 20 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. No. 1 Standard OP1 Regulation 5 Requirement Information given to service users must include the last inspection report, or details of how to access it from the home. The assessment in the care plan must give sufficient detail about the service user to enable correct action to be taken to meet the needs. The health care needs of service users must be met, i.e. weights must be recorded regularly if the care plan details this. All medication must be signed for when administered All staff working in the home must have regular updates and training in safe moving and handling procedures All staff must receive updates in fire safety training The care home must be visited monthly on an unannounced basis by a representative of the provider, and a report of that visit produced. This is an outstanding requirement. Requirement date at last inspection of 10/05/05 not met. DS0000039536.V256742.R01.S.doc Timescale for action 30/11/05 2 OP7 15 30/11/05 3 OP8 14(2) 04/10/05 4 5 OP9 OP38 13(2) 13(5) 04/10/05 31/10/05 6 7 OP38 OP37 23(4) 26 31/10/05 31/10/05 Glendale Version 5.0 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Glendale DS0000039536.V256742.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Surrey Area Office 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 DS0000039536.V256742.R01.S.doc Version 5.0 Page 23 - 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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