Inspection on 01/02/06 for Glengariff

This inspection was carried out on 1st February 2006.

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

Glengariff 14/10/08

Glengariff 07/11/07

Glengariff 29/01/07

Glengariff 07/10/05

Glengariff 22/03/05

Glengariff 21/08/04

Glengariff 27/02/04

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

CARE HOMES FOR OLDER PEOPLE Glengariff 59 Moss Lane Pinner Middlesex HA5 3AZ Lead Inspector Gail Freeman Unannounced Inspection 1st February 2006 01:00 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 Glengariff DS0000017534.V281475.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. Glengariff DS0000017534.V281475.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Glengariff Address 59 Moss Lane Pinner Middlesex HA5 3AZ 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) 020 8866 5804 020 8426 3357 Mr & Mrs D.E Spanswick-Smith Mrs Karen Spanswick Smith Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Glengariff DS0000017534.V281475.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th October 2005 Brief Description of the Service: Glengariff is a registered care home providing personal care and accommodation for up to 16 older people. The group of people living at the home at the time of the inspection were of mixed gender. There were two vacancies at the time of the inspection. The home is a family-run business, having been established by the owners in the 1960s. The manager is the daughter of the owners. She has been much involved in the business over a number of years, and became the home’s registered manager in 1995. The family own a similar care home, Abbotsford, at 53 Moss Lane. The home is situated in a quiet residential area of Pinner. It is fifteen minutes walk from local shops and public transport links. The forecourt has parking for a maximum of seven cars. The building has a ground and a first floor. Access is by passenger lift or stairs. All bedrooms are fully furnished, with some on the ground floor. The home has two communal bathrooms, both of which have facilities to support with getting in and out of the bath. There are four other individual toilets available. The home has a large lounge that offers three interconnected areas, one of which doubles as the dining area. The home also has a paved garden to the rear. Glengariff DS0000017534.V281475.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place on a cold day in February. It lasted until 5.30pm.The inspector would like to thank everyone in the home for their assistance during the afternoon. The inspector checked the financial records at a visit to Abbottsford on 13th February. The inspector met eight of the fourteen residents at the home at that time as well as the manager, a visitor and staff on shift. The inspection also included checking records and observing staff as they worked in communal areas. There were three staff on duty at the start of inspection with the manager on call. The staff group was dealing with the absence of three staff from sickness on the day of inspection and so there had been changes in expected numbers and identity of staff. There were no agency staff used. What the service does well: 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. Glengariff DS0000017534.V281475.R01.S.doc Version 5.1 Page 6 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Glengariff DS0000017534.V281475.R01.S.doc Version 5.1 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 Glengariff DS0000017534.V281475.R01.S.doc Version 5.1 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): 3. The home does not provide intermediate care. Residents’ needs are assessed before and after they arrive in the home so that the resident can be confident that the care provided meets the needs identified. EVIDENCE: Residents provided positive feedback about their life in the home. Their comments included ‘ they are kind and attentive’; ‘they leave you alone …..they are there when you want them;’ ‘it’s easy’. Three resident files were looked at. All included a completed preadmission assessment form which identified all the important issues in relation to care and health in brief summary. The manager talked about residents often coming to the home for preadmission visits. These usually do not include an overnight stay but the manager is considering providing this if appropriate. Glengariff DS0000017534.V281475.R01.S.doc Version 5.1 Page 9 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 and 9 were partially assessed. Residents have a plan of care that identifies and addresses needs but the plans do not include written planning of risk reduction. This is needed to ensure care planning is detailed enough. Medication administration recording has improved but needs further development to ensure recording is accurate. EVIDENCE: Standards 7,8,9,and 10 were assessed at the last visit. At this visit the inspector followed up on progress made in meeting requirements from the last inspection. The requirement about reviewing risk assessments after a resident has had falls has not been met. In the resident files inspected, there were risk assessments completed but there were no risk assessments explicitly about falls. One file did include accident reports about several falls within the last six months. The care plan for this person acknowledged the need for exercise and recorded consultation with the physiotherapist. One resident was identified in the preadmission assessment and the care plan as needing the bedroom door open at night. There was no risk assessment completed. The manager said that she would do this. Glengariff DS0000017534.V281475.R01.S.doc Version 5.1 Page 10 The inspector observed that staff enabled residents to move about the home by being alert to the residents wishes or requests and assisting them when required; for example helping them to get up from a chair. During the inspection staff were expecting a GP to visit a resident and this happened. The pharmacy inspector had required that the medicine policy should be made available to staff. This requirement has not been met. The inspector noted that the policy was not in the policy file but the manager said it had been reviewed and would insert the policy in the file that day. The pharmacy inspector had also required that staff should explain on medicine administration records why the code ‘o’ was used instead of a signature. At this inspection the inspector noted that the manager had placed the written statement of this requirement in the front of the medication administration records file but that, although sometimes the staff recorded the reason for non administration of medication, they did not always do so. Glengariff DS0000017534.V281475.R01.S.doc Version 5.1 Page 11 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, and 14 Residents do maintain contact with their family and friends as they wish. Residents have some choice about how they spend their time. However the range of choices would be extended by provision of a more developed activity programme. EVIDENCE: Residents confirmed that they were able to receive their visitors in private. They talked about visits from friends and family to the home and visits to the shops or other places with their friends or family. One resident was out of the home with family on the day of the inspection and returned just before the inspector left. One resident had a visitor whilst the inspector was at the home. The inspector observed the visitor being made welcome. Care plans in resident files referred to contact with family and friends and In one file identified how to help the resident maintain contact. The manager confirmed that residents are able to choose who they see and who they do they do not see, and that the home does not impose any other restriction on visits Residents said that they could choose when they got up and went to bed. One resident said that living in the home was ‘easy’. Two of the residents talked Glengariff DS0000017534.V281475.R01.S.doc Version 5.1 Page 12 about staff responding to their requests and that staff would check if they wanted to go to their rooms in the evening and respond appropriately to a yes or no response. Residents, when asked, did say that there was no choice of food at lunch but were clear that they had no complaints. One person said she liked not having to worry about this. Staff said that they knew resident preferences about food and when they did not they checked with the resident. Staff also said that they responded to any requests for change by residents, or to residents not eating something, with an alternative. Staff keep a record of food eaten. The inspector arrived during lunch and noted that there was little waste. The manager said that she had undertaken a survey about food in the home before Christmas and had a positive response. She had responded to the request within the responses to provide more stewed fruit. The inspector’s observation of the afternoon was that the atmosphere was quiet and relaxed. There were two televisions available in communal areas. One resident chose and watched a programme in one area and in the other area the TV was on after lunch with some residents having their eyes closed and some watching. It. Residents spoken with said they did not choose the programme but had a TV in their room and so did not worry about this. Staff keep an activities diary. Recent entries included ‘manicure’, ‘hairdresser’, ‘music man’, ‘a little sketching’. One staff spoken to at the end of the inspection reported that that afternoon the conversation and music activity she had organised had been a success. Residents spoken with said they were happy with the level of activity in the home and one resident said that one of the best things about the home was that there was always someone to chat with. However, there was one comment from one person spoken with that there were not enough activities. The manager also identified this as an area for development. She has been considering the provision of an activities coordinator as a way forward. Glengariff DS0000017534.V281475.R01.S.doc Version 5.1 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 and 18 Residents concerns and complaints are listened to and acted upon. The home works to protect residents from abuse but need an up dated policy and training to ensure they are effective in this. EVIDENCE: Residents said they could speak to staff if they had worries or complaints. They said that staff did not change. The complaints policy is available to staff and includes information about CSCI. The manager was known by the visitor. The home’s complaints file did not have an entry since January 2001. The manager confirmed that the home has not received a complaint since that date. The inspector observed staff being sensitive to resident’s concerns; for example after lunch one resident had not drunk her tea and staff identified the problem, it had sugar in it, and changed the tea immediately. The manager said that staff had had training about protection of vulnerable adults about eighteen months ago. This was confirmed by staff spoken with and one staff file inspected included a record of this training in October 2004. The manager said she is about to arrange a refresher course for staff. The adult protection policy is available to staff and includes some helpful information however it is not up to date . It does not include information about the need to involve the local authority and to link in with the Council’s adult protection strategy process. The manager is aware of the process and said she has been trying to get a copy of the Council’s policy without success. Glengariff DS0000017534.V281475.R01.S.doc Version 5.1 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): 19,21,25,26 were partially inspected The up grading of the homes facilities is planned and will start shortly. EVIDENCE: Standards 19.21,25 and 26 were assessed at the last visit. At this visit the inspector followed up on progress made in meeting requirements from the last inspection. The registered people have clarified in writing to the CSCI what refurbishment plans the home are. The manager explained that whilst covering of radiators will start soon and be on going the kitchen refurbishment will start in the spring. The resident files inspected included risk assessments relating to uncovered radiators. The manager said that new washing machines with a sluice cycle are already installed. The manager also confirmed that she intends to discuss the laundry with the Environmental health Officer and then install washing facilities. Glengariff DS0000017534.V281475.R01.S.doc Version 5.1 Page 15 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): 29 The recruitment process for the home is thorough. EVIDENCE: The manager said that staff turnover is low and that staff often return and staff spoken with confirmed this. The inspector looked at three staff files. The three files looked at included that of a newly recruited care worker. Files included completed application forms that included job history, two written references achieved with verbal follow up as necessary and ‘PoVA’ first and CRB checks. Files for confirmed staff included a copy of the statement of terms and conditions signed by the care worker, and records confirmed staff had a copy of the employment handbook for the home. There was no evidence on file of staff being given copies of the GSCC code of conduct and practice. This is required. The manager said that new staff are shadowed by senior staff and staff spoken with confirmed this. One staff file included the induction record which is completed by the senior worker undertaking this task. The manager said that there are no volunteers at the home. Glengariff DS0000017534.V281475.R01.S.doc Version 5.1 Page 16 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 and 35. Standard 33 was partially inspected. The home is managed by an experienced and trained manager. EVIDENCE: Standards 32,33,36 and 38 were inspected at the last inspection. At this inspection the requirement relating to standard 33 was followed up. This requirement related to a quality assurance review of the home. The manager stated that she had started this and would be reporting on the findings of this review. The manager is an experienced manager who has successfully undertaken the Advanced Management in Care Award . She told the inspector that she undertakes training with her staff but is looking at what training to undertake t ensure her management practice stays up to date. The manager and staff are clear about the lines of accountability in the home. Staff on shift report directly to the manager and report any concerns, changes, or occurrences to her. For instance staff telephoned the manager when the Glengariff DS0000017534.V281475.R01.S.doc Version 5.1 Page 17 inspector arrived. The staff on shift work as a team with task allocation agreed with in the shift team. Staff felt this worked well. The manager now undertakes care management over the two homes owned by the registered providers. The two homes are close geographically. The registered provider manages the building and maintenance aspects of the work; for instance the up grading of the facilities. The manager said that the home does not manage any residents’ money. If residents require money for purchases the home completes the purchase and invoices the resident or the resident’s family as appropriate. If necessary the home does store residents’ valuables for safe keeping in the short term. Records viewed at a follow up visit confirmed the process is organised and up to date. Staff stated that the manager checks the records at intervals. A recording of the check by date and initial is recommended Glengariff DS0000017534.V281475.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 x 2 X X X 2 2 STAFFING Standard No Score 27 X 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X X Glengariff DS0000017534.V281475.R01.S.doc Version 5.1 Page 19 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP9 Regulation 13(2) Requirement The two requirements arising from the Pharmacist Inspection must be addressed. (previous timescales of 14/10/05 not met) The activity programme must be planned and varied The homes policy for protection of vulnerable adults must refer to and include the local authority policy and process The registered person must ensure that the upstairs bathroom and toilet nearby have sinks installed (previous timescales of 1/10/05 and 1/02/06 not met) Upgrades to the home must include the covering of radiators to minimise risk of scalding. (Previous timescales of 01/10/05 and 01/12/05 not met) The floor covering of the laundry room must be replaced due to a significant crack in it across the room. (Previous timescales of DS0000017534.V281475.R01.S.doc Timescale for action 01/03/06 2 3 OP12 OP18 16(2)(m) (n) 12 (1) (a) 01/03/06 01/03/06 4 OP21 16(2)(j) 23(2)(j) 01/06/06 5 OP25 13(4) 23(2)(a) 01/06/06 6 OP26 23(2)(b) 01/06/06 Glengariff Version 5.1 Page 20 7 8 OP29 OP27 18(1)(a) 17(2)sch. 4 part7 01/12/05 not met) Staff must be given copies of the GSCC code of conduct The manager must ensure that the record of which staff worked which shifts is kept fully recorded and up to date. (Previous timescale is 01/12/05)not inspected It is necessary for the manager to provide a report to involved people about the review of care at the home that includes consultation with service users and relatives. (Previous timescale of 01/11/05 not met) Improvements are needed to service user risk assessments (Previous timescale of 01/09/05 not met) 01/06/06 01/03/06 9 OP33 24 01/03/06 10 OP7 15 01/03/06 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 OP34 Good Practice Recommendations A recording of the check of financial records by date and initial is recommended Glengariff DS0000017534.V281475.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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. 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