Inspection on 05/03/07 for Glendale

This inspection was carried out on 5th March 2007.

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 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 Sandra Holland Unannounced Inspection 10:30 5 March 2007 th 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.V331888.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.V331888.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 sharon.blackwell@anchor.org 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.V331888.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. 13th April 2006 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 twelve 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 to £720.00. Glendale DS0000039536.V331888.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and took place over eight hours, commencing at 10.30 and ending at 19.00. Mrs Sandra Holland, link regulation inspector, carried out the inspection and Ms Mary Hunt, registered manager, was present representing the service. As part of the “Inspecting for Better Lives” process, an assessment of all the information held about the home was carried out prior to the visit to the premises. A pre-inspection questionnaire was supplied to the home and this was completed and returned. Some of the information from the questionnaire will be referred to in this report. A tour of the premises was carried out and a number of records and documents were sampled, including care plans, medication administration record (MAR) charts and staff files. Twelve residents, 14 members of staff, a healthcare professional and a visitor were spoken with during the course of the inspection. CSCI feedback cards were supplied to the home for distribution to residents, relatives and visitors and health care professionals, in order to gather the independent views of those involved in the support of residents. Eighteen were completed and returned by residents, five by relatives or visitors, and five by healthcare professionals. The people living at the home prefer to be known as residents and that is the term that will be used throughout this report. The inspector would like to thank the residents, staff and management for their time, assistance and hospitality. What the service does well: The home was attractively decorated and furnished to meet the needs of residents. It was clean, bright and airy and appeared hygienic. Residents’ rooms were made individual with their own belongings, including photos, ornaments, pictures and small items of furniture. Visitors to the home were complimentary about the standard of the service provided. Staff are responsive to changes in residents’ health and seek prompt and appropriate advice. Glendale DS0000039536.V331888.R01.S.doc Version 5.2 Page 6 Residents said they enjoy their meals and a choice of main course is offered. Dining rooms were attractively presented with well laid tables and cool drinks constantly available. What has improved since the last inspection? What they could do better: Contracts which are supplied to residents must contain all the required information including the amount of the fees to be paid and by whom. Assessments of the needs of prospective residents must be carried out and a copy of the assessment must be kept in the home. Care plans specifying residents’ needs must be completed, updated and must accurately reflect the current needs of residents. Assessments of any risks to residents must be carried out, must be updated and must reflect residents’ current needs. The amounts of medication held must accurately match the record held and residents must not be left without a supply of prescribed medication. It is recommended that the amount of any stock of medication is carried forward to new medication administration record charts, to make it easier to carry out checks. The hours worked by activity co-ordinator staff must be reviewed to ensure that they are sufficient to meet residents’ needs and activity staff must receive training in this role. It is recommended that the activity programme is made available to residents in pictorial form. The number of staff on duty at night must be reviewed to ensure that enough staff are available to meet residents’ needs. Recruitment practices must be improved to ensure the protection of residents. Staff must receive appropriate supervision. The accident book in the home should be used as designed, in line with data protection principles, to maintain confidentiality. Glendale DS0000039536.V331888.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.V331888.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.V331888.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): 2, 3 and 6. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Contracts have been supplied to some, but not all, residents. These did not contain all the required information. The needs of prospective residents must be assessed and a copy of the assessment must be kept in the home. EVIDENCE: The files of a number of residents were sampled. It was noted that, for a recently admitted resident, no contract was held on file to show the terms and conditions of residence, the fees payable and who would pay the fees. For another resident, a contract was held on file, but this had no details as to the fees payable or who would pay these. The contract for another resident had been signed by the resident, but had not been signed by a representative of the home and again did not specify the amount to be paid or who would pay the fees. Glendale DS0000039536.V331888.R01.S.doc Version 5.2 Page 10 Two of the residents are supported financially by a local authority, but the contracts held on file did not specify which local authority was involved or what financial contribution they would make. The manager stated that the needs of prospective residents are assessed by a senior, experienced member of the staff team, prior to their admission to the home. Where possible, prospective residents are invited to spend a day at the home as this enables them to see the home and meet other residents and staff. This also enables staff to more fully assess the needs of the prospective resident. The file of a recently admitted resident was sampled, but their pre-admission assessment was not included and was not available, so it was not possible to know how or when the assessment was carried out. Staff appeared to be confused as to which form should be used for pre-admission assessments. A form entitled “Review of Assessed Needs” had been used to record the pre-admission assessment of a recently admitted resident, although this type of form had also been used to record a review of the needs for another resident. A number of residents are supported financially by a local authority, the manager advised. For these residents, an assessment has been carried out under the care management process and a copy of the assessment has been obtained. The manager stated that intermediate care is not provided at the home. Requirements have been made regarding Standards 2 and 3. Glendale DS0000039536.V331888.R01.S.doc Version 5.2 Page 11 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 and 10. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents’ care plans do not accurately reflect their current needs, have not been updated to record changing needs and some contain minimal information. The healthcare needs of residents are well met. The amounts of medication held did not accurately match the record held and a resident had been left without a supply of a prescribed medication. EVIDENCE: As previously mentioned, the files of a number of residents were sampled. It was noted that the care plans which are used to guide staff to the care and support needs of residents were confusing and some of the information was contradictory. Glendale DS0000039536.V331888.R01.S.doc Version 5.2 Page 12 Information stated in one area of the care plans was different to that stated elsewhere. For one resident it was recorded in the care plan that a walking frame is used, but another area of the care plan stated that a walking stick is used. Other care plans had not been updated to record changes in residents’ needs, and the care plan of a recently admitted resident contained very little information. It would therefore be difficult for staff to know the care and support the resident required. A requirement was made at the last inspection carried out on 13th April 2006 that, following a pre-admission assessment, information must be transferred in sufficient detail to the care plan, to enable staff to meet residents’ needs. A timescale of 30th May 2006 was given, but this has not been met. A requirement was also made at the last inspection that the care plan must record, in sufficient detail, the dementia, spiritual and cultural needs of residents. A timescale of 13th July 2006 was given, but this has not been met. For a number of residents, the areas of their care plans relating to spiritual and cultural needs had not been completed and no reference was made to needs relating to dementia. The manager stated that it is planned to introduce a new style of care plan into the home and that the management and senior staff team are to receive training in the use of the plans next month. This training will then be passed by the senior staff to other staff in the home. From the records seen and speaking to staff it was clear that a number of healthcare professionals are involved in the support of residents, including general practitioners (GPs), community psychiatric nurses (CPNs), dentists, community nurses and optician. A visiting healthcare professional stated that if changes in residents’ healthcare needs are noted, prompt referrals are made to the appropriate specialists. These referrals are usually made through the GP service. The healthcare professional was complimentary about the support staff provide, always escorting the professional directly to the resident, for example. It was noted from the care plans that assessments had been carried out of some, but not all, risks to residents. The risk assessments which had been carried out provided staff with little information about measures which could be taken to minimise risks to residents. Other assessments had not been updated to reflect changes in residents’ needs. Glendale DS0000039536.V331888.R01.S.doc Version 5.2 Page 13 For one resident a risk assessment had been carried out regarding mobility and this referred to the resident using a walking stick to assist their mobility. The diary notes for this resident recorded three falls, which occurred after the risk assessment, but the risk assessment had not been updated to reflect this. Another risk assessment referred to a resident being supervised at all times because of the risk of falling, but this impacts of the resident’s freedom of movement and does not enable the resident to be independent. The stock of medications held in the home were checked with the records held. It was noted that a supply of a prescribed medication for one resident had run out and the resident had missed three doses of the medication. It was clear from speaking to the resident that the medication was required. The senior on duty advised that the medication had been requested from the GP but had not yet arrived. After checking that it had been prescribed, a member of staff went out immediately to collect the medication from the pharmacy. The records relating to other medications were not clear. For one resident the receipt of three tablets had been recorded, although the MAR chart had been signed to record that this had been administered on ten occasions. For another resident, the amount of a medication present did not accurately match the record held. It is recommended that any stock held in the home when a new MAR chart is used, is carried forward to the new chart. This will ensure that an accurate record is maintained, a clear audit trail can be followed and checks can more easily be made. The senior on duty advised that this had been recommended at a recent medication training session. Staff were observed to treat residents with respect, speaking in a relaxed and friendly but appropriate manner. Residents’ privacy was promoted, with staff taking care to knock on residents’ bedroom doors before entering and providing personal care in a tactful and discreet way. Requirements have been made regarding Standards 7 and 9 and a recommendation has been made regarding Standard 9. Glendale DS0000039536.V331888.R01.S.doc Version 5.2 Page 14 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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are offered a range of activities, although the hours worked by activities staff need to be reviewed. Residents are supported to maintain contact with their families and friends. A well-balanced diet is provided. EVIDENCE: It was observed that the majority of the residents in the home were not engaged in any meaningful activity, and a number were wandering restlessly around their units. Others were seen chatting in the lounges or watching television. Some residents chose to spend their time in their room and this choice was respected. A small number of residents said they would like to go out more, even just for a walk locally, but they felt this was not possible because of a shortage of staff. Glendale DS0000039536.V331888.R01.S.doc Version 5.2 Page 15 The manager stated that the activity of the day is carried out on a different unit each day. Residents from other units are welcome to go to the unit where the activity is taking place, but it was not clear how residents would know what was happening or where. The manager stated that staff would advise residents, but this does not enable residents to make an independent choice. From information supplied in the pre-inspection questionnaire, it was seen that activities staff are currently employed for up to 40 hours each week, which equates to less than one hour per week for each resident. To ensure that the social and cultural needs of all residents are met, including those with dementia or physical disabilities, the hours worked by activities staff must be reviewed and should include staff to provide activities across the whole week. A range of activities is offered including bingo, a quiz, art, games, manicure sessions, sherry mornings and horseracing sessions. A weekly activities programme was seen in a written form on the unit noticeboards. It is recommended that this is displayed in pictures and words to make it more accessible for some residents. The manager stated that the activities co-ordinator has not yet undertaken training specifically for the role, although this is planned. This must include training in activities for people with dementia, to ensure that the needs of residents are fully met. Visitors are made welcome in the home and a visitor who visited at suppertime was spoken with. From the visitors record book, it was clear that a number of visitors come to the home on a regular basis. One resident spoke of going out with their family each week and another spoke of recently going out to attend a family celebration. The meals which were served on the day of inspection appeared appetising and wholesome. At lunchtime two main courses are offered to residents to enable them to make a choice and residents said that they enjoy their meals. Staff advised that further alternatives, including an omelette, salad or filled jacket potato, were available to residents if preferred. Resident responses on CSCI feedback forms indicated that residents always, or usually, enjoyed their meals. Staff advised that specialist diets including those for differing ethnicities can be accommodated, and currently diabetic diets are provided in addition to the main menu. Requirements and a recommendation have been made regarding Standard 12. Glendale DS0000039536.V331888.R01.S.doc Version 5.2 Page 16 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 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaints have been appropriately managed and staff are aware of their role in the protection of residents. EVIDENCE: A complaints policy and procedure is available in the home and is supplied to residents in their service users’ guide, the manager stated. From the pre-inspection questionnaire it was noted that a small number of complaints had been made since the last inspection. The manager was able to advise of the issues involved and of actions taken to address these. A visitor to the home was aware of the complaints procedure and stated that they felt able to address any complaint or dissatisfaction to the manager or person in charge. Ten of the 18 residents who completed and returned a CSCI feedback card indicated that they knew how to make a complaint, although eight other residents did not know how to complain. As two of the relatives or visitors who completed and returned CSCI feedback cards also indicated that they were not aware of the complaints procedure, it is recommended that greater emphasis is placed on raising awareness of the complaints procedure. Glendale DS0000039536.V331888.R01.S.doc Version 5.2 Page 17 It was clear that a number of residents at the home would not be able to say if they had a complaint and these residents would be dependent on staff, and others involved in their support, recognising changes in their behaviour to indicate this. Staff spoken to stated that they would report any concerns they had about the abuse, or potential abuse of residents, to the manager or the senior in charge, and would not hesitate to do so. Staff were aware that they could contact others outside the home if they felt it was needed if concerns were not addressed. A number of staff advised that they had received training in the safeguarding of adults and in the rights and responsibilities of residents. The manager stated that in the event of an incident or suspicion of abuse, the home would follow the Surrey multi-agency procedure for safeguarding adults and this procedure has been implemented in the past. A recommendation has been made regarding Standard 16. Glendale DS0000039536.V331888.R01.S.doc Version 5.2 Page 18 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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home presents as a comfortable place in which to live and was colourful, clean and appeared hygienic. EVIDENCE: The home is arranged as five individual, family-style units over three floors and a lift provides access to each floor. Each unit has a lounge, dining room and small kitchen and residents have single bedrooms which are fitted with en-suite toilets and wash-hand basins. Bathrooms with easy access baths are available close to resident bedrooms on each unit. The manager advised that plans are being developed to create a separate dementia wing consisting of two units each accommodating twelve residents. Letters of consultation have been sent out to the relatives of residents to advise of this, to explain the benefits and to gather the relatives’ views. Glendale DS0000039536.V331888.R01.S.doc Version 5.2 Page 19 All areas of the home were very clean and tidy and appeared hygienic. Hand washing facilities with liquid soap and paper towels are provided in all appropriate places and staff were seen to use these. Staff were also observed to use personal protective equipment, including aprons and gloves, to prevent the spread of infection. The home has a contractual arrangement for the collection and disposal of clinical waste from the home. Resident responses on the CSCI feedback forms indicated that they always found the home to be fresh and clean. The home has two laundry rooms, one situated on the ground floor and another on the first floor. These are equipped with the appropriate facilities and a full-time allocated member of laundry staff is employed. Glendale DS0000039536.V331888.R01.S.doc Version 5.2 Page 20 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 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. A team of staff are employed to meet residents’ needs, although night-time staffing and the hours worked by activities staff need to be reviewed. Recruitment practices in the home need to be improved to fully safeguard residents. Staff receive training appropriate to their role, but induction records were not available. EVIDENCE: From the information provided it was clear that a full team of staff are employed to meet the needs of the residents. These include care staff, kitchen staff, housekeeping staff, laundry staff, a handyperson/gardener, an activities co-ordinator, a receptionist and an administrator. The manager stated that ten care staff and one senior are on duty for each of the morning and afternoon shifts, and three care staff are on duty with a senior each night. During discussions with residents and staff, it was stated that at times there were not enough staff on duty to adequately meet residents’ needs. At times only one member of staff is allocated to work on a unit instead of the stated two. Glendale DS0000039536.V331888.R01.S.doc Version 5.2 Page 21 As the home consists of five units spread over three floors, at night there are not enough staff on duty to provide one member of staff for each unit. This staffing ratio does not take into account staff break times and staff having to assist each other in the event of an incident or accident. A requirement was made at the last inspection that sufficient and adequately skilled staff must be available to meet residents’ needs at all times, particularly at night. A timescale of 30th May 2006 was given but this has not been met. Over half of the care staff have achieved a National Vocational Qualification (NVQ) in Care at Level 2, the manager stated. The home has four staff trained as NVQ assessors to support staff undertaking this. A number of staff files were sampled and it was noted that most, but not all recruitment records and documents had been obtained before people were employed to work in the home. For a number of staff a full employment history had not been obtained, and for one member of staff only one employer was listed, but no dates of employment were recorded. The age range of this member of staff would indicate a longer employment history was likely. The application form for this member of staff contained minimal information and had not been signed or dated. The application forms in use in the home ask applicants to supply a ten year employment history, although The Care Homes Regulations 2001 (As Amended), state that a full employment history must be obtained. The manager stated that she would raise this with the Anchor organisation. The health of another member of staff had not been assessed during their application for employment, as no health questionnaire was present in that person’s file. For one member of staff who had transferred from another Anchor home, no record was held to confirm that references or a Criminal Record Bureau (CRB) disclosure had been obtained. Staff stated that they had undertaken a variety of training courses during the past year, which they said they had enjoyed and benefitted from. Staff training records were seen and it was clear that staff had received training required by law, including fire safety, first aid and food hygiene, and other training to develop their knowledge and skills, including NVQs, dementia care and challenging behaviour. From the staff files seen, it was noted that a record of the induction carried out was not present. Records of staff induction must be maintained and retained in the home. Glendale DS0000039536.V331888.R01.S.doc Version 5.2 Page 22 The staff group is predominantly female with a small number of male staff, which reflects the gender balance of residents. There is cultural and racial diversity amongst the staff team, which is not reflected in the resident group. The majority of residents who completed and returned CSCI feedback forms indicated that they were of British origin and of a Christian faith. Requirements have been made regarding Standards 27, 29 and 30. Glendale DS0000039536.V331888.R01.S.doc Version 5.2 Page 23 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, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home must be more robust to fully safeguard the health, safety and welfare of residents. Residents’ monies are appropriately managed. Staff must be appropriately supervised and the results of the quality survey carried out should be analysed. EVIDENCE: The manager stated that she has many years experience in care and has been a deputy and acting manager in a number of Anchor homes, has achieved the NVQ Registered Manager’s Award and is now registered to undertake NVQ Level 4 in Care. The manager has undergone the process to be registered with CSCI and this was completed in September 2006. Glendale DS0000039536.V331888.R01.S.doc Version 5.2 Page 24 An action plan and an update to the action plan were supplied to CSCI by the manager stating that requirements made at the last inspection had been met. A number of these requirements were found not to have been met at this inspection. A requirement was made at the last inspection that a survey (quality assurance) must be carried out to assess the quality of the service provided by the home. A timescale of 30th July 2006 was given and this has been partially met. The manager stated that two surveys had been carried out in July 2006, with one survey being provided to residents and a different survey provided to relatives. A number of the surveys were completed and returned, but the results of the surveys had not been analysed, the manager stated. It is recommended that the analysis of the surveys is carried out so that any issues can be addressed and feedback can be provided to residents and relatives. A supply of CSCI feedback cards had been supplied to the home for distribution to residents, relatives and visitors and healthcare professionals. Eighteen of these were completed and returned by residents, five by relatives or visitors and five by healthcare professionals. The majority of the relatives and healthcare professionals indicated that they were satisfied with the overall care and support provided. The majority of residents had been assisted by staff or their relatives to complete their CSCI feedback forms. The responses indicated that residents felt that staff listened to them and acted on what they said, staff were available when needed and medical support was obtained when needed. The majority of residents indicated that they knew who to speak to if they were unhappy and knew how to make a complaint. At the last inspection, residents had expressed their dissatisfaction regarding residents’ meetings held in the home and expressed a wish to be more involved and to be assisted to present their concerns and ideas. It was noted at this inspection that a residents’ meeting has not been held since October. The manager stated that the deputy manager takes the lead in organising residents’ meetings, but the deputy is currently off sick. A planned schedule of resident meetings has been drawn up, but it is not clear when this will start taking place. The administrator advised that monies are held for safekeeping for a number of residents. To safeguard residents’ finances, only administrative or senior staff have access to these and two signatures are recorded for each transaction. The computer and handwritten records corresponded and the amount of money held accurately matched the record held. Glendale DS0000039536.V331888.R01.S.doc Version 5.2 Page 25 From speaking to staff it was apparent that they are not receiving supervision as often as required. A number of staff advised that they do not feel supported as they have not had the opportunity to meet with a supervisor to discuss any concerns or employment or training issues. During the tour of areas of the home, no hazards to the health or safety of residents were observed. From information supplied, it is clear that the required maintenance and checks on systems and equipment in the home are carried out to the required frequency, to promote the safety and welfare of those who live and work at the home. The home was assessed by the Anchor organisation health and safety department in February 2007 and has been awarded a “Safe Site” award. A requirement has been made regarding Standard 36 and a recommendation has been made regarding Standard 33. Glendale DS0000039536.V331888.R01.S.doc Version 5.2 Page 26 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 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 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 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 X 3 Glendale DS0000039536.V331888.R01.S.doc Version 5.2 Page 27 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 OP2 Regulation 5 and 5A Requirement Contracts or a statement of the terms and conditions of residence must be supplied to residents, on or before the day they move into the home. The contract or statement of terms and conditions must include the required information regarding the fees to be paid, the method of payment and the person or persons by whom the fees are payable. Timescale for action 08/06/07 2 OP3 14 A pre-admission assessment of 05/03/07 the needs of a prospective resident must be carried out by a suitably qualified or suitably trained person and a copy of the assessment must be retained in the home. The assessed needs of a resident must be recorded in their individual plan (care plan) and the plan must reflect the resident’s current needs. The plan must be reviewed and updated to reflect changing needs. DS0000039536.V331888.R01.S.doc 3 OP7 15 15/04/07 Glendale Version 5.2 Page 28 4 OP7 4 Unnecessary risks to health or safety of residents must be identified and, so far as possible, eliminated. Risk assessments must be carried out for any identified risks to residents and these must be reviewed and revised if there are changes to the risk. Residents must not be left without access to their prescribed medication. Residents must be consulted about their social interests and arrangements must be made for them to engage in local, social and community activities. Suitably qualified and experienced persons must work at the care home in such numbers as are appropriate for the health and welfare of residents. The numbers of staff available at night and the hours worked by activity co-ordinator staff must be reviewed. 05/03/07 5 OP9 13 05/03/07 6 OP13 16 (m) 08/06/07 7 OP27 18 08/06/07 8 OP29 19 Robust recruitment practices 05/03/07 must be in place and the information and documents specified in The Care Homes Regulations and Schedule 2 must be obtained before a person is permitted to work in the care home, to ensure the safety and protection of residents. 08/06/07 Staff working at the care home must receive training appropriate to the work they are to perform. The activities co-ordinator must receive training for that role and training in activities for people with dementia. DS0000039536.V331888.R01.S.doc Version 5.2 Page 29 9 OP30 18 Glendale 10 OP30 18 A record must be maintained and 05/03/07 retained in the home of the induction of staff. Staff employed to work at the care home must receive appropriate supervision. 08/06/07 11 OP36 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations It is recommended as good practice to carry forward the amount of medication held to new MAR charts, to enable ease of checking and a clear audit trail to be followed. It is recommended that the activities programme is made available in a picture and word format to ensure it is accessible to all residents. It is recommended that all who use the service are made more aware of the complaints procedure. It is recommended that the results of the quality survey are analysed and action taken to address any issues arising. It is good practice to use the accident record book as designed, to ensure compliance with data protection law. 2 OP12 3 4 OP16 OP33 5 OP38 Glendale DS0000039536.V331888.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Oxford Office 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.V331888.R01.S.doc Version 5.2 Page 31 - 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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