Inspection on 29/01/07 for Glengariff

This inspection was carried out on 29th January 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

Glengariff 14/10/08

Glengariff 07/11/07

Glengariff 01/02/06

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 Mr Ram Sooriah Key Unannounced Inspection 29th January 2007 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Glengariff DS0000017534.V326115.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. Glengariff DS0000017534.V326115.R01.S.doc Version 5.2 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 8428 2257 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.V326115.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 2006 Brief Description of the Service: Glengariff is a registered care home providing personal care and accommodation for up to 16 older people. Service users at the time of the inspection were mostly female although the home is registered for service users of mixed gender. 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 owns 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. Accommodation of service users is on both floors in fully furnished bedrooms. 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. The home charges £506.25 per service user. There were fifteen service users in the home at the time of the inspection. Glengariff DS0000017534.V326115.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report contains the findings of a key unannounced inspection, which took place on Monday the 29th January from 10:00 to about 18:00. During the course of the inspection, the inspector spoke to five service users, two visitors, the manager and four members of staff. He also received three comments cards from service users and four comment cards from relatives/visitors of service users, the content of which have been used in this report where possible. On the whole the provider aspires to provide a homely and caring environment to service users with dedicated and attentive members of staff. This is normally done on an informal basis. However there is a legislative framework within which care homes have to operate. There must therefore be evidence that the home is complying with the relevant legislation. In some instances records were lacking with regards to demonstrating the care that was provided to service users. The inspector would like to thank all visitors and service users who talked to him and the manager and her staff for a kind welcome to the home and for their support and cooperation during the course of the inspection. What the service does well: What has improved since the last inspection? Glengariff DS0000017534.V326115.R01.S.doc Version 5.2 Page 6 More attention is now given to the provision of activities in the home and a programme has been prepared. Copies of the GSCC codes of conduct are now offered to staff. The manager stated that any changes to the duty roster are recorded. What they could do better: Six out of ten requirements imposed during the last inspection, which took place on the 1st February 2006, remain unmet. Some of the requirements during that inspection were repeated from the inspection which took place on the 7th October 2005. It is the responsibility of the registered individual and the registered manager to ensure that requirements that have been imposed on the home are met within the timescales and for them to demonstrate compliance with the relevant Care Homes legislation. Care plans did not contain an assessment of the needs of service users, which was kept under review. Care plans were in place for service users but these were not reviewed monthly and there was little evidence that these were agreed with the service user or representatives. The action to take to meet the needs of service users was also not always clear. Risk assessments of service users continue to be lacking. There were no predictive risk assessments for falls, nutrition and pressure sores. These risk assessment and need to be in place and control measures must be identified in cases where service users have been identified at risk. The home must record the assessment of the social and recreational needs of service users to ensure that activities are tailored to the needs of the service users. Provision of activities in the home is linked to some extent to the staffing situation. The registered person should consider providing staffing hours dedicated to the provision of activities for service users. While the numbers of staff rostered to work in the home on paper, seem to be adequate, it was noted that few members of staff were actually working with service users, as they were engaged in non-care duties such as cooking, domestic work and laundry. The home has been a care home for more than forty years. Some areas were identified where improvement was required such as ensuring that wash hand basins be provided in the toilet and bathroom on the first floor and the provision of an overriding lock for one of the bathroom. The home does not yet have an effective quality system based on selfmonitoring and feedback from service users and visitors. There was no Glengariff DS0000017534.V326115.R01.S.doc Version 5.2 Page 7 evidence of monthly monitoring of the service by the responsible individual as Regulation 26 of the Care Homes Regulations 2001. While most of the health and safety certificates were in place in the home, the Fire risk assessment was not very comprehensive and prepared according to the guidance on risk assessment by the Health and safe Executive. A number of windows on the first floor did not have restrainers which might be putting service users at risk from falls from a height. 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. Glengariff DS0000017534.V326115.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 Glengariff DS0000017534.V326115.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): 1-4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users to the home receive the necessary information prior to deciding if they would like to move into the home. The home was able to demonstrate that on the whole, only service users whose needs can be met by the home were admitted. EVIDENCE: The home had a service users’ guide and a statement of purpose. These have not yet been updated with regards to the Amendment to the Care Homes Regulations 2001, requiring that the prices of the placement be detailed in the service users’ guide. The manager wrote after the inspection to say that there is a section in the service users’ guide where the fees could be written in a gap. Upon examination of the service users’ guide it was noted that, that section was in the contract section to describe the fees that a service must pay. The contract is included in the service users guide to offer information about the terms and Glengariff DS0000017534.V326115.R01.S.doc Version 5.2 Page 10 conditions of the placement. A completed contract with the fees is normally offered once a service user/representative accepts a placement. However, the service users guide is offered to all prospective service users. It must therefore have a section on the range of fees charged by the home with details of what they cover, to enable prospective service users make a decision about whether they want to move into the home. Once they move into the home, they can then be offered a contract. The manager stated that all service users in the home were privately funded in the home and that they all have copies of a contract, which is agreed at the point of admission. All service users who responded to the comments cards confirmed that they were offered contracts to sign. The inspector looked at the care records of a service user who has been recently admitted to the home. A pre admission assessment was in place and there was some information available from her previous place of stay. A service user stated that the manager visited her in the hospital to offer information about the home and to answer her questions. The home manager and her staff have worked in the home for a number of years and were familiar with the needs of older people. They knew the service users well and all service users appeared well cared for. Comments cards sent by the Commission and feedback from service users and visitors to the home show that service users and/or their realtives are happy with most of the service. As a result the inspector concluded that the home is able to meet the needs of the service users that are admitted to the home Glengariff DS0000017534.V326115.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): 7-11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users looked appropriately cared for. Care plans did not always clearly identify the needs of service users and the action to take to meet their needs. The care plans were not always reviewed monthly and were not agreed with service users or their relatives. Medicines management in the home was not as thorough as it should have been to ensure the safety of service users. Care plans had little information about the future of service users with regards to their expectations, end of life care and death. There was therefore no guarantee that the needs of service users with this aspect of care would be met. EVIDENCE: The inspector looked at the care records of four service users. The records were kept in plastic wallets in a locked cabinet. Progress notes were also available for inspection. Glengariff DS0000017534.V326115.R01.S.doc Version 5.2 Page 12 It was noted that the home did not have an assessment of needs to describe the needs of service users, their abilities, normal habits and level of independence with the activities of daily living. As a result there was no information about the lifestyles of service users such as information about the times that service users get up or go to bed, likes and dislikes, level of cognition and about the family and social circle of the service user. There was a list of care plans which was completed for each service user. It was noted that these were not always reviewed on a monthly basis with a record of the evaluation of the care that has been provided to the service user. These in some instances were generalised and did not always clarify the action that need to be taken to meet the needs of service users. For example one care plan mentioned that the likes and dislikes of the service users should be found out, but has not identified what these were. Another mentioned that the service user should have every thing that she needed for bed, but did not mention what she actually needed. The home did not have predictive risk assessments for nutrition, falls and pressure sores to identify service users who were at risks and for control measures to be put in place to manage the risks. One service user had a risk assessment for falls but it was to manage the risk after the service user had falls. The approach was reactive rather than proactive. Care records did not contain evidence that service users or that their representatives were involved in drawing up and in reviewing the care plans. The manager stated that her staff and herself were available to discuss the care of service users with them or their relatives. Service users or their representatives must sign the care plans to show that they have agreed to it or a note must be made when this is not possible or when the care plan has been verbally agreed. One service user in the home had a pressure sore. There was evidence of the input of the district nurse in managing the pressure sore, but a care plan was not in place to describe how staff should be caring for the service user in the home. There was evidence that service users were seen by the GP and other healthcare professionals as required, the inspector was informed that service users are referred to the dentist if that is needed. Records showed that a service user who had a particular problem was being regularly monitored by the GP. All service users presented as appropriately dressed and cared for. The hairdresser was in the home on the day of the inspection. Most of the service users were in the communal areas during the day and there were a number of areas that they could sit in. The inspector observed that staff had a good Glengariff DS0000017534.V326115.R01.S.doc Version 5.2 Page 13 rapport with service users, that they listened to the service users and that they addressed the service users with respect. Care plans of service users had a section in the care plan pro-forma to address death and dying. This on most occasions stated that ‘no known issues were identified’. While the inspector acknowledges that this may be an uncomfortable part of the care plan to deal with, death and dying is an inescapable part of life and should be addressed as far as possible. It is also not only about dying but also about the aspirations, fears and thoughts of service users for the future. Medicines in the home were inspected. These were stored in a cupboard in a small area before the kitchen. The home uses the Nomad system for the management of medicines. Members of staff administer the tablets from cassettes which are filled by the Chemist. The cassettes are filled on a weekly basis. Some medicines, which are prescribed for short courses or for other reasons, are stored in normal medicines containers. It was noted that the amounts received for these medicines were not always recorded. There were omissions of signatures when medicines had been administered, and in some cases the medicines had not been administered according to the instructions on the medicines charts. Staff were also using a number of codes in the medicines charts which they had not defined and therefore it was not clear why service users were not receiving their medicines in these circumstances. In cases where a variable dose of a medicine was prescribed, the actual amount administered was not always recorded. One service user was on two forms of the same medicines and one of them had not been crossed out. Glengariff DS0000017534.V326115.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): 12-15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has made attempts to address the recreational needs of service users but more input is required with regard to this aspect of care. Meals provided to service users in the home are suitable to meet their needs. EVIDENCE: The manager has prepared a programme of activities. On the day of the inspection the hairdresser was also in the home. The inspector was informed that the hairdressing was the activities for the day. While a few service users were having their hair done, there were no other social or recreational activities where service users were involved and engaged. Service users were sitting most of the time in front of the television and for some time in the morning there were no staff in the communal areas. Two out of the three comment cards from service users showed that activities was an area which could be further improved. The care plans of service users did not contain an assessment of the social and recreational needs of service users and information about their backgrounds and life history. As a result there was no guarantee that the programme of Glengariff DS0000017534.V326115.R01.S.doc Version 5.2 Page 15 activities addressed the needs of the service users and that the provided activities were tailored to the needs of the service users. The manager wrote to say that the usual work/tasks in the home have been delayed on the day of the inspection because of ongoing work by the Water Company in Moss Lane. Although the inspector was not informed of any problem in the home in relation to water shortages on the day of the inspection and was not aware of any problem or impact on the daily life of service users, he acknowledged this, but based on the evidence from care records and comment cards, he concluded that activities is an area where more improvement can be achieved. The manager informed the inspector that service users are well supported by a network of their relatives and friends and that some of them are able to go out with their relatives. Service users were also able to go to the other home which belonged to the provider for activities together. This included times when outside entertainers were booked in. Meals were provided to service users in the dining area. Tables and chairs were provided in adequate numbers for all service users to sit at the table. Most service users were encouraged to use these facilities and to socialise with the other service users. Lunch consisted of pork casserole, mashed potatoes and cabbage. There was only one meal for lunch but the staff had already ascertained that all service users would eat that meal. The meals were presented appropriately and service users were observed enjoying their meals. Although the likes and dislikes of service users were not always recorded in the care records, staff were aware of these. Glengariff DS0000017534.V326115.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 adequate. This judgement has been made using available evidence including a visit to this service. The manager and her staff take complaints and allegations and suspicions of abuse seriously. The abuse policy of the home was not up to date and needed to be reviewed. EVIDENCE: The home has not had any complaints. Copies of the complaints procedure were available in the bedrooms of service users and in the service users’ guide. The manager stated that she is always available to talk to visitors and service users. The inspector noted that service users and visitors to the home knew the manager very well and those who spoke to the manager said that they would speak to the manager if they had any concerns. The inspector looked at the abuse policy for the home. It contains a number of information that was not in line with the Borough’s procedures and policy for managing allegations and suspicions of abuse. For example it says, “Do not assume abuse, neglect, investigate” and further down says “investigate in a relaxed manner”. It should be noted that the first step with any allegation or suspicion of abuse is the safety of service users, safeguarding evidence and reporting to the appropriate authorities. Investigation should only be carried out after this has been decided within a strategy meeting when the investigator would also be identified. At the end of the policy it says informs Glengariff DS0000017534.V326115.R01.S.doc Version 5.2 Page 17 the police. This part should be at the front of the policy, as any police investigation would take precedence over all other investigations. As a result of the above, the inspector concluded that the abuse policy needed to be completely reviewed to reflect the Harrow policy and procedures for safeguarding adults. The inspector was informed that members of staff have had training on abuse. Staff in the home said that they would speak with the manager if there were any suspicions and allegations of abuse. The manager knew that she had to make contact the safeguarding adult coordinator for the Borough. Glengariff DS0000017534.V326115.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, 21,22, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a warm environment for service users. However some attention is required to ensure that the environment continues to be suitable for the needs of the service users accommodated in the home. EVIDENCE: The grounds in front and the back of the home and the car park areas were maintained. The exterior of the building was also maintained. The inside of the home was on the whole clean, airy and free from odours. There was evidence of some redecoration having taken place. One bedroom has been recently redecorated while it was empty. The home did not have a programme of routine maintenance and renewal of the fabric and decoration of the premises. A few issues were identified during Glengariff DS0000017534.V326115.R01.S.doc Version 5.2 Page 19 the last inspection and these have not been met yet. A plan and programme for achieving compliance has also not been produced and followed with records kept. This would have allowed closer monitoring of progress being made in this area. The communal areas consisted of three areas: two lounges and one dining/lounge area. There were adequate seating for all service users and service users could choose to sit where they wanted. The manager stated that the carpet in the communal areas were due to be replaced. This was looking old and dated. The flooring in the laundry room has been identified for replacement during an inspection in 2005. This has not been replaced yet. The manager said that it would be replaced at the same time as when the carpet in the communal area is replaced. The carpet in a bedroom inspected at random, was stained and the manager stated that the carpet in the room was due to be shampooed. The home has a call bell system. It consisted of normal electrical switches that service users would switch to ring the bell. The switches were mostly on the wall next to service users’ bed. Some service users also had a cord at the end of which an electrical switch was attached. The bell apparently rings only when pressed and would only ring in the kitchen. It is not clear how the one member of staff on nights would hear the bell if she was in another part of the home, away from the kitchen. The call bell system does not seem to have a reset button to switch the bell off and to offer a guarantee that the service user’s call has been heard and acknowledged by staff and would be attended to. The home has at least a bathroom and a toilet on each floor. There were handrails in most of the toilets for service users to hold on, except for one. One bathroom did not have a lock to ensure privacy of those who are using the toilet. One of the bathrooms on the ground floor had a window which gave on the patio on the side of the home. The window was not made of frosted glass. There was a blind in the bathroom for people using the bath/toilet to pull down. The requirement with regards to ensuring that the bathroom and toilet on the first floor have wash hand basins has not yet been met. It was noted that the home did not have paper towel dispensers in the bathrooms or toilets. It was therefore not very clear how staff were washing and drying their hands to prevent cross infection. There has been a requirement in the past that radiator covers be provided to radiators where service users have access in the home. The inspector noted these have not yet been placed. Instead there were individual risk assessments in the care records of service users. These did not cover the radiators in the corridors, bathrooms and toilets against which service users may fall and sustain burns. Further more the control measures in place to Glengariff DS0000017534.V326115.R01.S.doc Version 5.2 Page 20 manage the risks were not always adequate to manage the high risks that service users faced with regard to burns should they come into prolonged contact with the radiators. As a result the registered person must place radiator covers on all radiators to which service users have access to as the most effective control measure to minimise the risk posed by hot radiators. Glengariff DS0000017534.V326115.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Members of staff in the home are appropriately experienced and trained to meet the needs of service users, although the numbers during the day seem to be lacking. EVIDENCE: There were 3-4 members of staff from 08:00-09:00 to help get service users up, to prepare and to serve breakfast. Five members of staff were on the roster for the morning shift (9:00-13:30). Two were responsible for cleaning, one was responsible to cook and serve lunch and two were required to care for service users. From 13:30-18:00 there were three members of staff. One was responsible to prepare the supper, the rest would be responsible to care for service users and to do the laundry. There were three staff from 18:00 to 22:00 and then from 22:00-08:00 there was one member of staff and one sleeping member of staff. The inspector was informed that there were no service users in the home who required two members of staff for assistance with mobility and transfers. While in principle there seemed to be a good number of staff on duty, mostly during 09:00 and 18:00, a significant number of them were engaged in noncare duties. This could explain why at times the communal areas were left unattended and why there was little in the form of activities which was offered to service users who were not having their hair done or who had finished Glengariff DS0000017534.V326115.R01.S.doc Version 5.2 Page 22 having their hair done. The manager wrote to say that the above does not usually happen and that on the day of the inspection, a number of jobs/tasks have not been completed in the home, because of ongoing works by the Water Company in Moss Lane (see section under activities), which affected the water supply. As a result staff were trying to complete all the tasks and duties that needed to be done. The inspector was not told of a problem with water supply, on the day of the inspection. If there was a cut in the water supply, the water supply may have resumed when the inspector visited at about 10:00 as he did not note any problem in the home in relation to that. The arrangement with regards to the staff roster consisted of staff working exactly the same shifts each week. The manager stated that this has always been the arrangement in the home and that staff in the home prefer this arrangement. She added that a record is kept of any changes to the usual staffing rosters such as in cases of sickness or annual leave Two personnel files were inspected. There have not been new members of staff in the home and the staff team is very stable. There were some lacking in the files but then they were employed prior to the current legislation. The inspector was therefore unable to assess the home with regards to compliance with the current legislation and minimum standards. The manager stated that she knows that she has to keep a number of records for any new employees as per legislation. The inspector was informed that members of staff were given copies of the GSCC codes of practice. The inspector was informed that some members of staff in the home were trained nurse and that they worked as carers. He was also informed that there were 2 carers with an NVQ level 2 qualification and another 2 carers with NVQ level 3 qualification. As a result of the above information the inspector concluded that the home has more than 50 of its staff qualified to NVQ level 2 in care. The inspector was unable to check compliance with standard 30 because a training plan and records of training were not submitted to the inspector. Glengariff DS0000017534.V326115.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has a manager in place. A number of requirements in the home remain unmet. The home does not have a formal quality management system to monitor the quality of the service that it provides. Health and safety issues are taken seriously but a few issues were identified which needed addressing. EVIDENCE: The manager has an advanced certificate in care management. She has managed the home for a number of years and is closely supported by her family in this role. Skills for Care, the sector training organisation, recommends that any qualification is compared with the Registered Managers Award and NVQ level 4 for care and that any shortfalls, if any, could be made Glengariff DS0000017534.V326115.R01.S.doc Version 5.2 Page 24 up by taking the relevant NVQ units. This can normally be done by a local college. It is noted that six out of the ten requirements imposed on the home during the last inspection in February 2006, have not yet been met and that the home continues to be in breech of regulations. It seems that not enough was done in order to meet the relevant regulations and minimum standards. A satisfaction survey has been conducted but a report and an action plan was not available to summarise and address the findings of the survey. There were no monthly regulation 26 visits. The inspector was informed that the responsible individual lives very close to the home and does not do formal regulation 26 visits. Regulation 26 of the Care Homes Regulations 2001 however does require providers to visit their establishments at least monthly and to record their findings with regard to evaluating the service that the home provides by talking to staff, service users and visitors, by looking at a sample of records and assessing the quality and safety of the environment. The home does not have a quality system based on self-assessment and on a cycle of plan-do-review. It is therefore difficult for the home to formally evaluate the quality of its service. However the manager stated that she is always approachable and available to talk to visitors and to service users and would deal with any issues if these were brought to her attention. The inspector was informed that the home does not keep and do not manage the personal money of service users. The relatives/representatives of service users are responsible for this. Any expenditure that is made for a service user is passed to the service user/representative during monthly invoicing. The home had an electrical wiring certificate and gas safety certificate available for inspection. The manager stated that all electrical portable appliances have been tested (PAT) and that stickers were applied to them, a certificate was not available. The home had a health and safety risk assessment and a fire risk assessment. However the 5 steps to risk assessment approach as per guidance from the Health and Safety Executive (http:/www.hse.gov.uk/pubns/indg163.pdf) was not used in the Fire risk assessment. There was evidence that weekly fire tests were taking place and that a fire drill was being conducted three monthly. There were also monthly fire discussions among staff to reinforce the fire procedures in the home. It was noted that the home did not yet have a Fire Emergency Plan as per guidance from the Communities and Local Government and the London Fire Emergency Planning Authority following the Regulatory Reform (Fire Safety) Order 2005 which came into force on the 1st October 2006. Glengariff DS0000017534.V326115.R01.S.doc Version 5.2 Page 25 While touring the premises the inspector noted that at least two windows on the first floor did not have restrainers. There is therefore a risk that service users may fall from a height. Glengariff DS0000017534.V326115.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 2 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 2 3 X X 2 2 STAFFING Standard No Score 27 2 28 3 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x 3 x x 2 Glengariff DS0000017534.V326115.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 2 Standard OP1 OP7 Regulation 5 14(1,2) Requirement The service users’ guide must be updated with the range of fees which is charged by the home. The registered person must ensure that there is a record of the assessment of the needs of service users as the basis for care planning, which is kept under review. Care plans must detail the action to take to meet the needs of service users. Care plans must be reviewed at least monthly or more often as and when the needs of service users change. The registered person must as far as possible keep evidence of the involvement of service users or of their representatives in drawing up and reviewing care plans and risk assessments. A note must be made when this has not been possible. Improvements are needed to service user risk assessments (Previous requirementtimescales of 14/10/05 and 01/03/06 not met). Service users must have appropriate DS0000017534.V326115.R01.S.doc Timescale for action 31/03/07 30/04/07 3 OP7 15(1,2) 30/04/07 4 OP7 15(1) 30/04/07 5 OP7 OP8 14(1,2) 30/04/07 Glengariff Version 5.2 Page 28 6 OP8 17(1)(a) 7 OP9 13(2) 8 OP9 13(2) 9 OP9 13(2) 10 OP9 13(2) 11 OP9 13(2) 12 OP9 13(2) 13 OP11 15 assessments of their nutritional status and risk assessments with regard to falls and developing pressure sores. Care plans must be in place in cases of service users who have pressure sore(s) with regards to promoting healing of the pressure sore(s) and preventative action. The amount of all medicines received into the home and which are not contained in the Nomad cassettes must be recorded. All medicines must be signed when administered or a code must be used to describe the reason for the medicines not having been administered. All medicines must be administered as prescribed to ensure that service users are able to fully benefit from these medicines. Codes used in the medicines charts to describe the reasons for medicines not having been administered must be appropriately defined and the same codes must be used consistently wherever possible (Previous requirementtimescales of 14/10/05 and 01/03/06 not met). In cases when a variable dose of medicine has been prescribed the actual amount of medicine administered must be recorded. The registered person must ensure that in cases when a new form of a medicine has been prescribed that the old form of the medicine is discontinued on the medicine chart. Care plans of service users must address the views of service users and their relatives/friends DS0000017534.V326115.R01.S.doc 31/03/07 31/03/07 31/03/07 31/03/07 31/03/07 31/03/07 31/03/07 30/04/07 Glengariff Version 5.2 Page 29 14 OP12 16(2)(m) (n) 15 OP18 12 (1) (a) 16 OP19 23(1,2) 17 OP21 16(2)(j), 23(2)(j) with regard to the future, expectations, end of life care and death. There must be a comprehensive assessment of the social and recreational needs of service users. The registered person must consider providing staffing hours dedicated for the provision of activities. The homes policy for protection of vulnerable adults must refer to and include the local authority policy and process (Repeated requirement-timescale 01/03/06 not met) The registered person shall provide a plan with regards to the redecoration and refurbishment of the home and with timescales. The registered person must ensure that the upstairs bathroom and nearby toilet have wash hand basins installed (Repeated requirementtimescales 1/10/05, 1/02/06 and 01/06/06 not met) Upgrades to the home must include the covering of all radiators to which service users have access to, as the most effective control measure to minimise the risk of burns. (Repeated requirementtimescales 1/10/05, 1/02/06 and 01/06/06 not met) The floor covering of the laundry room must be replaced due to a significant crack in it across the room. (Repeated requirementtimescales 1/12/05 and 01/06/06 not met) DS0000017534.V326115.R01.S.doc 30/04/07 30/04/07 30/04/07 30/04/07 18 OP25 13(4), 23(2)(a) 30/04/07 19 OP26 23(2)(b) 30/04/07 Glengariff Version 5.2 Page 30 20 OP26 13(5) 21 OP27 18(1) 22 OP31 10(1) 23 OP33 24 24 OP38 13(4) 25 Glengariff OP38 23(4) The registered person must ensure that there are disposable paper towels in bathrooms and toilets and where there are wash hand basins, to dry the hands after washing them, according to good infection control procedures. The registered person must consider reviewing the number of staff on duty and the number of staff allocated to care for service users. Consideration must also be given to the provision of some staff hours dedicated to the provision of activities in the home. The registered individual and the registered manager must ensure compliance with care legislation by complying with the relevant requirements within the timescales. 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 requirementtimescale of 01/11/05 and 01/03/06 not met) The registered person must consider the introduction of a quality system based on selfassessment and on a check-actreview cycle to improve the quality of the service. The registered person must consider the provision of window restrainers for all the windows to which service users have access to, to reduce the likelihood of falls from a height as per guidance from the Health and Safety Executive. The registered person must ensure that there is a fire DS0000017534.V326115.R01.S.doc 30/04/07 30/04/07 31/03/07 30/04/07 31/03/07 30/04/07 Page 31 Version 5.2 emergency plan for the home available for inspection. The registered person must consider reviewing the fire risk assessment to reflect the five steps to risk assessment as per guidance from the Health and Safety Executive. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP22 OP31 Good Practice Recommendations The registered person should review the call bell system in the home. The registered manager should compare the advance certificate in care management with the registered managers award and make any shortfalls, if any, by taking the required NVQ units. The registered person should consider carrying out regulation 26 visits on a monthly basis. 3 OP33 Glengariff DS0000017534.V326115.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Glengariff DS0000017534.V326115.R01.S.doc Version 5.2 Page 33 - 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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