Inspection on 04/04/06 for Glendon House

This inspection was carried out on 4th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Glendon House 13/08/08

Glendon House 05/09/07

Glendon House 01/05/07

Glendon House 10/01/06

Glendon House 17/06/05

Glendon House 01/02/05

Glendon House 30/06/04

Glendon House 17/02/04

Glendon House 09/09/03

Glendon House 26/03/03

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

CARE HOMES FOR OLDER PEOPLE Glendon House 2 Carr Lane Overstrand Cromer Norfolk NR27 0PS Lead Inspector Ann Catterick Unannounced Inspection 4th April 2006 09:00 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 Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 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. Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Glendon House Address 2 Carr Lane Overstrand Cromer Norfolk NR27 0PS 01263 578173 01263 579164 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) info@glendonhouse.fsnet.co.uk Mr Rhoderick Smart Mrs Frances Smart Position Vacant Care Home 36 Category(ies) of Dementia - over 65 years of age (36), Old age, registration, with number not falling within any other category (36) of places Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Thirty-six (36) Older People may be accommodated. Thirty-six (36) people with dementia may be accommodated. The total number not to exceed thirty six (36) Date of last inspection 10th January 2006 Brief Description of the Service: Glendon House is a care home providing care and accommodation for 36 older people who are suffering from dementia. Mr Rhoderick Smart and Mrs Frances Smart own the home. The day prior to the inspection the manager resigned and the Proprietor will now appoint a new manager. In the interim period the senior registered manager will take some responsibility for managing the home. Details of the services offered within the home can be found in the Service User Guide. The fees within the home range from £375-£500. Details of services included within this fee and those excluded are identified in the Service User Guide. The original house was built in 1917, and has been tastefully extended and adapted over the years. The home has 30 single bedrooms and 3 double rooms. Twenty-eight of the single rooms have en suite facilities and all of the double rooms have en suite facilities. A large part of the grounds has been made into a safe and secure garden area for service users. The home provides comfortable good quality accommodation in an attractive setting in a small coastal village, being very close to the sea. Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place on the 04/04/06 and was over a period of 9.25hrs. Two inspectors completed the inspection, one of whom who has particular knowledge in respect to dementia care. Since the last inspection the CSCI has received four concerns about the service. The first three were related to; the alleged poor practice of one member of staff; the temperature of part of the home over a short period of time and the well being of a particular resident. These areas have been addressed and the home was co operative in investigating these matters and working with other professionals. These matters have now been resolved. The fourth concern was anonymous and related to four areas of concern. None of these were founded although an area relating to the cleanliness of the kitchen was addressed. The manager had not returned the pre inspection questionnaire so areas relating to this could not be discussed in the inspection. Four feedback forms were received from relatives. All said that they were satisfied with the overall care provided. One off the comment cards felt that there was not always enough staff and three commented that staffing was sufficient. Positive comments were made about the general service. “I have found everything in the home geared towards residents well being and stimulation.” “The home itself is first class.” The inspectors were able to speak with staff, service users and relatives as well as look at some documents and having a tour of the building. Overall the quality of care received by service users was good. What the service does well: The environment is of good quality with spacious and comfortably furnished private and communal facilities. Service users are able to bring in some of their own furniture if this can be accommodated in their rooms. The ambience of the home gave a good feel on the day of inspection and service users presented as happy and content in their environment. A relative who often visited unannounced said that she always found her relatives bedroom and communal areas to be clean, tidy, smelling fresh and being well cared for. All of those relatives spoken to were very complimentary about the staff saying that they cared for their relatives in a way that was caring and promoted dignity. Examples were given such as. “Mum’s hair is always nice and she is Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 Page 6 always dressed well and her clothes are always clean.” “Staff always have time to talk to you and do their up most to help people.” Relatives felt that they were always welcomed within the home. One relative said that she was pleased that her husband’s pet dog was also welcomed as a visitor within the home. Complaints received had been dealt with appropriately following the homes complaints procedure. Some care plans showed evidence of good practice and this now needs to be transferred to all care plans. What has improved since the last inspection? What they could do better: The home needs to appoint and retain a manager who will be able to lead the service and support staff and promote and maintain good practice. The home needs to ensure that it always follows its recruitment policy and procedure. The home needs to develop or purchase more training relating to the specific needs of service users with dementia. Some training has taken place but this needs to be ongoing. The dementia care magazine could be ordered on a regular basis and a library of books relating to dementia could be purchased to assist and support staff in developing their knowledge in this area. Care plans need to include nutritional screening and service users weight and wellbeing needs to be recorded and monitored for all service users. Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 Page 7 All care plans need to be person centred and need to identify ways that staff can support and work with individuals and the different behaviour that each individual’s dementia presents. This was evident within two of the plans of care inspected but was not as clear in two others that were inspected. The home needs to develop a system to collate and publish information with regard the quality of the home and identify measures of how this will be maintained and improved. 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. Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 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 Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 and 6 The quality in this outcome is good. The home has a Statement of Purpose and Service User Guide to inform prospective service users and their families of what the home has to offer. The quality in this outcome is good. Prior to admission prospective service users have their needs assessed to ensure that the home can meet those specific needs. The quality in this outcome is adequate. The home does, for most of the time, meet the needs of the service users within the home. Intermediate care is not offered within the home. EVIDENCE: The home has a Service User Guide and Statement of Purpose that both give service users and their families the information needed to ensure they can make an informed choice as to whether the home would be to their preference and meet their needs. They include the information required in regulation 4 Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 Page 10 and 5 of the Care Home Regulations 2001. Due to some changes since the creation of the Service User Guide and Statement of Purpose some minor alterations should be made when next reviewed. Care plans were inspected and pre admission assessments were seen within the care plans. Once admitted, a further assessment is completed, and this is the first process of the care plan. Information is received from other professionals when available. Within one running record the staff member completing the record recorded that the information available about the person was limited. It is important, especially with service users with dementia that as much information as possible is collated prior to admission and made available to the carers. All of those service users living in the home were within the registration of the home. Staff have had some training to meet the specialized needs of older persons with dementia and more training is planned. Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 The quality in this outcome area is good. All service users have an individual care plan. The aim of the care plan is to identify how the health, personal and social care needs of the individual can be met within the home and what resources are needed to meet these needs. The quality in this outcome area is good. No service users are able to administer their own medication. The home has a policy and procedure to ensure that all aspects of dealing and administering medication are completed in a way that protects service users. The quality in this outcome area is adequate. Some service users were seen being cared for in a way that promoted dignity and respected their privacy. Some service users were seen to be cared for in a way that did not fully promote their dignity. EVIDENCE: Four care plans were fully inspected and case tracking took place to enable a comprehensive understanding of how the care plan did or did not meet need. Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 Page 12 Very good practice was seen in some care plans with very detailed information that supported good quality care to the individual. Other care plans had less detail and were not clearly identifying individual needs and how these could be met. Nutritional charts were not seen in the care plans. In one care plan there was significant detail of how to meet the particular needs of the service user and the difficulties their dementia presented to them. In other care plans the detail was limited. There did not seem to be a link between the home and the local CPN service and it may be good to make links in this area. A recommendation has been made in this area. For two service users English was not their first language and there was no evidence to suggest any cultural needs or preferences had been addressed. The home has the format to have very good care plans for all service users and with a little further work this could be achieved. Care plans are reviewed on a monthly basis. The home has a medication policy and procedures for the administration of medication. Only staff who have had medication training are involved in the administration of medication. Medication details of four service users were inspected in some detail and good practice was evidenced. Medication was stored appropriately and records of administration had been completed fully. The home does not use the medication administration record (MAR sheets) provided by Boots Pharmacy, as they believe it to be difficult to read. The MAR sheet the home uses is fine but could be used in a way that makes auditing medication more clear by using a separate MAR sheet for each four week batch of medication received by Boots. A recommendation has been made in this area. Good practice was seen with regard promoting dignity. An example of this was when a service user became hot and took off their jumper, shirt and vest to keep cool. A staff member gently suggested to the service user that he could keep his clothes on and she would open a window to enable the temperature of the environment to be more suitable to his needs. On another occasion a service user became agitated due to a misunderstanding of her situation and this developed into an angry interaction between two service users. Staff were seen to deal with this in a calm way gently distracting the distressed service user offering to take them away from the situation and to offer them other activity and conversation. This defused the situation in a way that did not compromise the service users dignity. A less positive interaction was observed when a staff member was assisting a resident to eat their tea. The member of staff did this without talking or interacting with the service user at all. The service user was offered mouthfuls of food with little time for her to complete the last spoonful. When the meal had been eaten the staff member walked away without saying anything to the service user who was left looking bemused and confused about what had happened. This was evidence of poor practice. Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 Page 13 Overall privacy and dignity was promoted and this was supported by the conversations had with relatives on the day of inspection. Those service users who spend time using their bedrooms during the day have their door left unlocked. Those service users who do not return to their bedrooms within the day have their rooms locked to promote privacy and ensure nobody has access to their room when they are not using it. Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The quality in this outcome area is good. Those service users in the home on the day of inspection appeared relaxed and comfortable which suggested that the home was meeting their preferences and expectations. The quality in this outcome area is good. Several service users were seen with their relatives and friends and this contact is supported and encouraged. The quality in this outcome area is good. Evidence was seen of service users being able to make choices and have control over their lives. The quality in this outcome area is good. Food provided is wholesome and nutritious and the home has a large, airy communal dining area that accommodates all who choose to eat in there. Service users can choose to eat in their own rooms or a different lounge. EVIDENCE: The service users within the home all appeared to be relaxed and comfortable with their surroundings. One resident was sitting, knitting; others had a newspaper, whilst others were able to walk around the home. A relative said that her husband had opportunities do be involved in activities and said that he attended the Monday art class, took part in a recent quiz and enjoyed the Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 Page 15 musical evening. Another relative said that the home had some time without an activity person and felt this had a detrimental effect, however, since the appointment of a new full time activity person the activities and social interaction within the home had greatly improved. Two service users were not English and their was nothing in their care plans to suggest any particular cultural needs had been identified or whether or not staff had spoken to these service users to ascertain if their were any special needs or preferences that could be provided. A recommendation has been made in this area. Several visitors were spoken to and all said that they were made very welcomed and encouraged to visit the home. One relative said that both she and her dog were welcomed and how important this was to her husband who enjoyed seeing the dog. Also other service users enjoyed having the dog in the home. If service users have any links with the community these would be supported and encouraged. Service users were seen to be given choices and to make decisions about their own lives. The cook walked around the home speaking to all service users informing them of the choice for lunch and asking what their preference was. Service users were seen to be having their breakfast at different times. Service users were able to walk around the home freely choosing to spend their time in the communal area of their choice. There had recently been a concern about the cleanliness of the kitchen and a requirement had been made in this area. On the day of the key inspection the kitchen had been cleaned and provided a clean safe environment to work in. The dining airy is large and airy offering a comfortable environment for service users to eat their meals. The second cook was on duty on the day of inspection. The menu has been seen and offers a varied and nutritional diet. The kitchen has a two-menu system and this could make it difficult to be sure what is cooked on each day. There are some useful and informative books that have been written with regard to providing food for people with dementia and the cooks in the home would benefit from have access to at least one of these. A recommendation has been made in this area. The nutrition needs of older people in general is being focussed upon nationally and the home was advised of the new malnutrition and universal screening tool guidelines (MUST) guidelines that have recently been developed and are being used to monitor the nutritional needs of older people. Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality in this outcome area is good. The home has a complaints policy and procedure and there has been recent evidence that the home is good at responding to complaints. The quality in this outcome area is good. The home has a policy and procedure to protect service users from abuse and the home has recently had experience of using this policy and using the procedures. EVIDENCE: The home has a complaints procedure and this is given to all service users and/or their advocates at the time of admission. The home has recently followed through a complaint from a relative and the outcome of this was satisfactory for all involved. The home acknowledged that there had been an omission on their part and were able follow their complaints procedure with a positive outcome for the service users and satisfaction for relatives. The home has a policy and procedures for the protection of service users. The senior manager within the company has recently experienced the local adult protection procedures. Initially these were not fully followed, as the home did not refer to the local Adult Protection Team prior to completing their own investigation. However, lessons were learnt, and the senior manager is now very clear on the steps that need to be followed in this area. Staff spoken to were aware of the whistleblowing policy. Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 23, 24 and 26 The quality in this outcome area is good. Service users live in a safe, wellmaintained environment that meets their needs. The quality in this outcome area is good. The home has a variety of communal areas of different size and ambience to meet individual preferences. The quality in this outcome area is good. Bedrooms seen were individual and reflected the preference and needs of the occupants. The quality in this outcome area is good. On the day of inspection the home was clean and hygienic free from any offensive odours. EVIDENCE: Most areas of the home were seen and overall the environment was warm comfortable being well maintained and decorated. There is a large patio area with patio furniture that offers additional communal space in the warmer weather. The home has two handypersons who work in the house and gardens. Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 Page 18 They have an account with a local building company and are able to purchase anything they need on a daily basis to ensure that the home is well maintained. Most radiators are covered but there are still some in the service users bedrooms that need to be covered. The senior manager said that these are awaiting covers. It is expected that these will be covered in the very near future. Communal areas are well furnished and comfortable. There is a welcoming entrance with two cosy seating areas, two lounges, a large dining area and conservatory. There is a lack of signage or ways of identifying particular areas of the home. For example toilet doors look the same as any other door and for a person with dementia it could be difficult to find a toilet. This could lead to a continence difficulty that is related to the environment and not the individual. Bedroom doors do not identify, in any meaningful way, whose bedroom it is. A recommendation has been made in this area. There are creative ways of making different areas of the home identifiable to individuals. Since the last inspection a double room that had a problem with odour and limited furniture has been refurbished and now offers a pleasant environment with new fixtures and fittings. The carpet has been replaced and there is now no odour in the room. Bedrooms seen were well decorated and furnished with several having some furniture in that the occupant had chosen to bring from home. The quality of the fixtures and fitting is generally very good. For example the quality of curtains and bedroom furniture was noted to be good. Many of the bedside light were touch sensitive that enabled service users with dementia to be able to use their bedside lights without the need of having to find a switch. This was seen as thoughtful and good practice. On the day of inspection the home was clean, warm and well cared for, free from any offensive odours. Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 Page 19 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 and 30 The quality in this outcome area is adequate. The home aims to have enough staff on duty at any one time to meet the needs of service users but on occasion when staff sickness is high or there is a staff shortage this aim is not always fully met. The quality in this outcome area is adequate. The home aims to have a trained work force to ensure that service users are in safe hands at all times. The quality in this outcome area is adequate. The home has a policy for the recruitment and selection of staff to ensure that service users are protected. This procedure had not been fully followed on all occasions. The quality in this outcome area is good. Evidence was seen of a comprehensive induction programme that aims to ensure staff are competent and have the knowledge and understanding to do their job well. EVIDENCE: The rota, when fully staffed, offers enough staff on duty to meet the needs of service users. The sickness levels of staff appear to have been quite high in recent weeks and this has had an impact on the staff rota. It was noted that in a recent week there were 21 period of sickness. The home does not usually employ agency staff and depends on its own staff group to cover sickness. This is not always achieved and at times the staff on duty have to work hard to meet needs. This appears to happen more on the afternoon and evening Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 Page 20 shifts. It was suggested by a member of staff that on these occasions it was only the personal and health needs of service users that were being met and there was no opportunity for social interaction. The home has enough domestic staff to keep the home clean. Relatives made positive comments about the cleanliness of the home. A new full time activities person has recently been employed. The home encourages all staff to complete their NVQ level two to ensure they have a general knowledge and competence within the care field. The home has yet to achieve 50 of staff trained to NVQ level two or above. This may be because there has been a fairly high turnover of care staff in recent months. Six staff files were inspected and not all procedures had been followed in all cases. Application forms were seen on all files. Some members of staff commenced work prior to the POVA first check being completed and others commenced work before references had been returned. One staff member who had been employed from an agency that offers staff for work from overseas had written both of his references. There was no evidence to suggest that he has translated original references into English although this may have been the case. A requirement has been made with regard the need to collate all relevant information prior to a member of staff commencing work. An example of the homes disciplinary procedures being used was seen on a file and this was documented and recorded appropriately. Of the four files inspected two had evidence of induction and two did not. For those without evidence on file it was likely that the staff had their own record of induction but this had not been noted on file and was therefore not possible to check. Those staff spoken said that they worked alongside more experienced staff as part of their induction and had received basic training prior to working as part of the rota. This training included fire training, manual handling and a video and talk from a member of the Alzheimer’s Society. Overall the staff group showed that they had received some training and had interest and commitment in their role. All of the relatives spoken to were positive about the care their loved ones received from staff and these comments were mirrored within the comment cards received from relatives. The home has had several management changes in the last couple of years and this does not have a good impact on staffing as there is no consistent and permanent leadership. This staff group could develop further with good, permanent leadership. Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 Page 21 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, 33, 35 and 38 The quality in this outcome area is adequate. The home does not have a registered manager but within the interim period the Proprietor plans to have the senior registered manager within the company to manage the home or for her to supervise senior staff in this position until a new manager is appointed. The quality in this outcome area is adequate. The home aims to run in the best interests of the service users and has begun to develop a quality assurance system to measure this. There is further work to do in this area. The quality in this outcome area is good. Service users finances are protected in as much as the home takes no responsibility for the finances and this is delegated to a relative or financial advocate. The quality in this outcome area is good. The homes policies and procedures aim to ensure that the health, safety and welfare of service users are promoted and protected. Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 Page 22 EVIDENCE: The home has not had a registered manager since the summer of 2005 and the most recent manager left their post the day prior to this inspection. In the interim time the senior manager within the company, Lisa Rutter, will take responsibility for the management and/or supervision of a temporary manager or senior member of staff. It is hoped that a permanent manager will be appointed in the near future. Self -auditing and quality assurance systems are expected from all residential care settings. The home has started to gather in relevant information and uses feedback forms and team meetings have been used as ways to gather views and suggestions from staff, service users and their families. The home needs to continue to develop this area and look at ways of collating and publishing its findings. The Proprietor needs to ensure that visits and reports are completed about the home as described in section 26 of the Care Home Regulations 2001. A requirement has been made in this area. The home does not take any responsibility for the finances of the service users. All service users have a family member or advocate take responsibility for their monies. When the service users needs to spend any money the home pays the bill, for example the hairdresser, and then invoices the person responsible for the service users finances. If a service user wanted to have some monies on their person this would be fine but the home could not guarantee its safe keeping, as many of the service users could not take responsibility to keep any monies safe. All staff receive the manual handling training and fire safety training. The control of infection is discussed within their induction and those who work in the kitchen have their food hygiene certificate. Hazardous substances are stored safely. Most radiators have now been covered with only a few more to be completed in some of the resident’s bedrooms. All upstairs windows have a window restrictor and the temperature of water at all outlets is within recommended guidelines. The premises is secure and risk assessments relating to the building were seen on the file of service users who were at risk of leaving the building without the knowledge of the staff. Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 Page 23 The inspector does not feel competent to fully inspect against standard 38.4 but it is believed that the home meets this element of the standard. The home has an incident and accident book and some incidences identified within running records were cross -referenced and evidenced showed that they had also been recorded in the incident and accident book. Overall the home aims to ensure the safety and well being of staff and residents. Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 3 x N/A 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 3 x x 3 3 x 3 STAFFING Standard No Score 27 2 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 3 Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 Page 25 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 OP29 Regulation 19 Requirement The registered provider must ensure that the home’s policy and procedures for recruitment and selection are always followed to ensure the protection of service users. The registered provider must ensure that the home’s develops a system of measuring the quality of its service, collating and publishing this information. Timescale for action 05/04/06 2 OP33 24, 26 01/06/06 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 OP8 Good Practice Recommendations That the manager makes a link with the local nutritionist to address ways of ensuring that the nutritional needs of service users are met and that nutritional charts are included in all care plans. That the manager continue to develop care plans ensuring that they are person centred and provide all of the DS0000027384.V288673.R01.S.doc Version 5.1 Page 26 2 OP7 Glendon House 3 4 5 6 OP9 OP10 OP12 OP19 relevant information needed to ensure that all care needs can be met. That the manager completes medication administration records in a way that enables easy auditing of medication. That manager ensures that all staff are trained to promote privacy and dignity. That any special needs or preferences of service users who have a different cultural background are recorded within their care plans. It would be good practice for the home to use signage of some sort to enable service users to identify facilities such as toilets and their own bedrooms. Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Glendon House DS0000027384.V288673.R01.S.doc Version 5.1 Page 28 - 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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