Inspection on 07/11/07 for Glengariff

This inspection was carried out on 7th November 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 29/01/07

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 7th November 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.V354174.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.V354174.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 8426 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.V354174.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th January 2007 Brief Description of the Service: Glengariff is a registered care home providing personal care for up to 16 older people. Residents at the time of the inspection were mostly female although the home is registered for residents 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 residents is on both floors in fully furnished bedrooms. The home has two communal bathrooms, both of which have facilities to support residents with getting in and out of the bath. There are four other 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 resident. The home was fully occupied at the time of the inspection. Glengariff DS0000017534.V354174.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key unannounced inspection took place on Wednesday 7th November 2007 from 10:00 to about 16:45. The findings of the inspection are based on a tour of the premises, inspection of a sample of records and conversation with the manager, staff, residents and visitors to the home. A completed Annual Quality Assurance Assessment (AQAA) was also sent to the Commission as part of the regulatory process. This was used where appropriate in completing this report. Comment cards were also sent to get the views of people who use the service. 3 were received from relatives of residents and 7 were received from residents. I would like to thank all the residents and the visitors who returned comment cards and those who kindly spoke to me during the inspection. I am also grateful to the manager and her staff for their assistance during the inspection. What the service does well: The comment cards showed that most people who responded were satisfied with the service that the home provides. The home has a stable staff team, which ensures continuity of care. Residents and visitors to the home were complimentary about the standard of care provided to the residents and about the attitudes of members of staff. One resident commented that ‘staff seem interested and friendly’. A relative who responded to a comment card said that ‘Relatives are always made to feel welcome’. Another said that ‘the home provides a very caring and thoughtful service to the residents with plenty of personal attention’. The home has an open visiting policy and relatives of residents are kept informed about the wellbeing and healthcare of residents and are encouraged to participate in the care of the residents. The quality of meals that are provided to residents is suitable to meet their needs. The likes and dislikes of residents are taken into consideration when they are served their meals. The home provides a homely and clean environment, which is free from odours. Residents and their relatives are encouraged to personalise their rooms and to bring personal items of possessions in the home. The manager is experienced in running care services and in understanding the needs of residents and their relatives. Glengariff DS0000017534.V354174.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: All residents must have a comprehensive assessment of their needs prior to the formulation of care plans to identify the needs which they cannot meet independently and which require care planning. The risk assessments that are in place for residents must be dated and reviewed at least monthly or more often if required. A few issues with the management of medicines were noted which still need to be address to make sure that the system is safe for residents. The manager should consider providing training in end of life care to make sure that staff fully understand the end of life care needs of residents and how these can be addressed. Glengariff DS0000017534.V354174.R01.S.doc Version 5.2 Page 7 The abuse policy should be reviewed in line with the borough’s policy and procedures for the protection of vulnerable adults. The manager should continue with her plan to upgrade the environment of the home such as replacing the carpet in the communal areas and corridors of the home. These plans have been made for some time, but have not yet been met. The manager must consider doing courses, which would give her the qualifications that are mentioned in the minimum standards as necessary for registered managers. The quality management system in the home must be further developed to make sure that there is a quality system based on self-audit and on a plan-docheck approach, to demonstrate the home’s ability to monitor the quality of the service that it provides in view of improving this. The home must have an up to date LOLER certificates for the hoists available for inspection. 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.V354174.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.V354174.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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents and their relatives receive the necessary information to decide if they want to move into the home. The home accommodates residents whose needs it can meet. EVIDENCE: The service users’ guide was inspected and it was noted that it has been amended to include information about the fees that are charged by the home. The manager stated that copies are provided to all prospective residents and their relatives and that that they are invited to visit the home and to ask questions. She added that she then has the opportunity to discuss the service that the home provides and the ethos of the home with the residents and/or their relatives. The residents who are accommodated in the home are all privately funded and they all have copies of a contract/statement of terms and conditions. Glengariff DS0000017534.V354174.R01.S.doc Version 5.2 Page 10 Copies of preadmission assessments were in place for residents who have been recently admitted to the home. These were on the whole comprehensive and were completed by the manager. She said in the AQAA that she visits residents wherever that is convenient to the residents and their relatives, to assess the needs of the residents. One comment card from a relative said that the manager visited the resident at home and answered queries and that the whole process was friendly and informal. Residents are offered a trial period in the home to find out if the home is suited for them and whether they are satisfied with the service that they receive. Care records showed that the residents who are admitted to the home have elderly care needs and require personal care, which is the service that the home provides. Most members of staff have worked in the home for a number of years and are familiar with the needs of the residents. Feedback from residents and their relatives showed that they were satisfied with the standard of care that is offered to residents. Glengariff DS0000017534.V354174.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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There has been an improvement in the content of care records, but these are not always easily accessible and the assessment of needs is not always comprehensive. Residents are supported by the home to make sure that their healthcare needs are being met. The end of life care needs of residents are in the main addressed although care plans could have been more comprehensive with regards to these. There has been an improvement in the management of medicines but a few issues were noted which needed addressing. EVIDENCE: The care records of four residents were inspected. The home kept a folder on each resident with the admission details and some information about each of the resident’s needs. There was then another file where the care plans for a number of residents were kept and a third book (a diary) where the daily progress notes for all residents were made. Glengariff DS0000017534.V354174.R01.S.doc Version 5.2 Page 12 As shown above the information about a resident was contained in three different files/books. This could pose some difficulty with regards to ease of access. It was noted that access to these records could perhaps be improved if residents had individual care files where all the information about one resident was kept. The book (diary) where daily progress notes were made for all residents sometimes on the same page, could also pose a problem with regards to confidentiality of information and access to the information. For example if the progress/daily notes for one resident was required/requested by an authority entitled to see these, then these would pose some problem with regards to ease of access and photocopying as the intimate care details of a number of residents were available on the same page. The manager agreed with these comments and said that she would bring immediate changes to address these issues. The assessment of needs of residents has improved as care plans contained more information about the actual needs of residents but an actual format for the assessment of the needs of residents was not in place. As a result the needs of residents may not be fully identified. For example a resident who had some psychological issues did not have all her needs assessed comprehensively. The manager showed the inspector a format for a needs’ assessment that she plans to introduce. The care plans were on the whole comprehensive and address the needs of residents and the action to take to meet the identified needs. These were reviewed at least monthly and there was evidence that residents/relatives were being involved in the care planning process. A sheet of paper has been introduced where residents/relatives sign to say that they have agreed to the care plans. One visitor mentioned that they have been shown the records and paperwork of their relative. Care plans contained a number of risk assessments. Nutritional, pressure ulcers and falls risk assessment have been introduced. The home is commended for progress made in this area. These must now be dated when drawn up and must be reviewed at least on a monthly basis or at a frequency as identified in the care plan. There was evidence that the GP, chiropodist and the optician saw residents as required. There was also evidence that district nurses attended to residents when this was required. During the inspection it was noted that residents who required personal care were attended to by members of staff in their bedrooms or in bathrooms as required. They were addressed appropriately and all residents and visitors who were spoken to or who gave feedback about the service in comments cards, stated that staff were attentive to their individual needs of residents. Glengariff DS0000017534.V354174.R01.S.doc Version 5.2 Page 13 Out of the 4 sets of care records inspected, 1 contained some information about the fears for the future and the arrangements in place to manage the death and funeral of the resident. While there has been some progress with addressing this aspect of care, the manager stated that staff do not always find this an easy subject to address with residents/relatives. It is recommended that training be provided to staff in end of life care to enable them have a better understanding of this subject. Following requirements imposed on the home during the last inspection with regards to the management of medicines, the home has introduced an action plan to make sure that these requirements would be met. A copy was available in the medicines charts. Medicines were on the whole signed when administered and a code was used when the medicines were not administered. On a few occasions however, medicines were not always signed when administered or a code used. The manager explained that on each occasion when a medicine is not taken, code ‘f’ is used and a note is made at the back of the medicines sheet, which describes the reason (code ‘f’) for not administering the medicines. It was noted that the code was described on some occasions but not on all occasions. It was noted that an eye drop was given for a period of 19 days when it was prescribed for 7 days as per the instruction on the label of the medicine. During the course of the inspection it was noted that one resident, who was at times sleepy in the morning, had a habit of refusing her medicines. The medicines chart showed that on a few occasions she had not taken her medicines. There was no information in the care records or in the medicines chart to show whether the resident was revisited later when she woke up and encouraged to take her medication. The manager stated that residents who do not take their medicines are referred to the GP. It was also noted that a risk assessment was not in place to manage the situation when the resident refuse to take medication. In cases where a variable dose of medicines was prescribed, the actual amount administered was recorded on some occasions but not on all occasions. It was also noted that the home did not always have a copy of a prescription for audit trail purposes and to evidence that the medicine has been prescribed. This is particularly important when a new medicine has been prescribed or when the dose or instruction for the administration of a medicine has been altered by the prescriber. The Royal Pharmaceutical Society guidance “The handling of medicines in social care” advises on page 24 that ‘written confirmation of the medicine a person is taking should be obtained from an authoritative source if possible’ and that ‘it is useful to record requests for prescriptions on behalf of a service user…. to check that all items ordered have been received and that no inadvertent unexpected changes to the medication have been made’. Glengariff DS0000017534.V354174.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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents have the opportunity to experience a lifestyle, which suit their expectations and preferences. Meals are provided to residents according to their needs and choices. EVIDENCE: The home has now introduced a section in the care records to record the social and recreational needs of residents and the things that they like to do. A plan was in place to address the identified needs of residents. The manager stated that she has sent a ‘life history’ form for residents’ relatives to complete and that there has not been much response from that initiative. A life history would have provided information about the background of residents and about ‘the person’. On the day of the inspection there was an entertainer who did a presentation for residents before lunch. He did a relaxation session and played some music. He said that he normally visits the home every two weeks. I noted that residents’ mood changed from being withdrawn and passive to being active and engaged during the presentation. In the afternoon there was a session of Glengariff DS0000017534.V354174.R01.S.doc Version 5.2 Page 15 bingo that was led by a member of staff. Some visitors said that there are other entertainers who visit the home. The manager stated in the AQAA that an activity session is carried out most afternoons and that staff have become more motivated and take this area of care more seriously. Comments cards from residents rate this area as ‘usually’ met as compared to other aspects of the service that the home provides, which are mostly rated as ‘always’ met. A note in a comment card said that ‘activities are available but residents are not pressurised to take part’. The AQAA mentioned that relatives are able to visit the residents whenever they wish to that they are welcome to stay for meals. A number of visitors were observed in the home and it was noted that they all knew the manager and her staff very well. I observed that some residents went out with their relatives and were then brought back in the home. The manager said the home encourages residents to go out whenever this is possible. In some circumstances the home will provide escorts and transport if residents have to attend social events. According to information in the AQAA, the clergy from the local church visit residents when required and transport is available to take residents to church or residents might attend church services with their relatives. The manager clarified during a conversation with her, that the home would make every attempt to meet the needs of residents who might be from other cultures, religions or ethnic minorities. I had the opportunity to observe lunch being served to residents. The dining area was prepared in a congenial manner and residents were encouraged to sit at the dining table. They were served their meals and drinks in an unhurried and appropriate manner. Support was provided discreetly as required. Lunch consisted of sausages with gravy, potatoes, broccoli and cauliflower. There was sponge and cream for desert. Those residents who did not want sausages were provided with other meals. The likes of dislikes of all residents were recorded in the care records and were also available in the kitchen. Kitchen staff were therefore aware that some residents might not eat some meals and alternatives were provided. Residents and visitors were satisfied with the range of meals provided by the home and said that the food tastes very good. It was noted that tea, coffee and biscuits were provided regularly and there were soft drinks available in the lounges for residents. Glengariff DS0000017534.V354174.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 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. A complaints procedure is available to residents and visitors, guiding them through the process of expressing their complaints if they have any. Allegations and suspicions of abuse are taken seriously by the manager and her staff. The abuse policy has been reviewed, but there were some areas where it could be made more comprehensive. EVIDENCE: A copy of the complaints procedure was available in the foyer of the home and given to residents and/or their relatives during admission. Visitors stated that they would speak with the manager if they had any concerns. The home has not received any complaints since the last inspection. People who responded to the comment cards stated that they were aware of the complaints procedure and that they have not had any need to use it. A few said that they discussed their concerns with members of staff and the manager and that these are resolved promptly. It was noted during the last inspection that the abuse policy was somewhat lacking. The manager has reviewed the procedure to deal with abuse and safeguarding adults. A copy was provided to the inspector. It was noted that the policy did not refer to the Harrow Procedure for safeguarding adults. The procedure mentioned that any allegations or suspicions of abuse must be reported to the deputy manager or manager. It does not say what the manager or deputy manager is supposed to do as a result of the reporting. Glengariff DS0000017534.V354174.R01.S.doc Version 5.2 Page 17 There was also a referral form, but it is normally recommended that the referral form devised by the borough be used in referring cases to the safeguarding adults team. As a result the manager must review the current policy in line with the Borough’s policies and procedures for the protection of vulnerable adults. There was evidence that staff have had training in ‘Protection of vulnerable adults’. The staff group has been fairly stable since the last inspection and the staff spoken to were aware of the action to take if they suspected abuse or if an allegation of abuse was made to them. Glengariff DS0000017534.V354174.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): 19,24 and 26 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a clean and homely environment for residents. Some of the areas that have been previously identified as needing improvement have been addressed but a few areas still remain to be addressed. EVIDENCE: The grounds in front of the home and the parking areas were maintained. There were also a few flowerpots, which provided some colour and a pleasant ambience. The gardens at the back of the home were also maintained to a good standard. The exterior of the building was generally in good condition. Since the last inspection there has been some redecoration in the home. The kitchen has been refurbished and I was informed that 5 bedrooms have been redecorated. The home was on the whole clean and free from odours. One visitor commented: ‘Standards of hygiene very high, plenty of fresh flowers’. Glengariff DS0000017534.V354174.R01.S.doc Version 5.2 Page 19 In the report following the inspection on the 29th January 2007, I wrote the following on page 20, 2nd paragraph: “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”. During this inspection it was noted that the carpet in the communal areas have not been replaced and the flooring in the laundry has also not been replaced. The condition of the carpet in the bedrooms of residents was on the whole appropriate, but the carpet in a few bedrooms could be replaced as it was past its useful life. The manager stated that the home is in the process of receiving quotes to replace all the carpet in the communal areas, in the corridors and in some bedrooms. She added that the flooring in the laundry room has not been replaced because of a possibility of changing the equipment in the laundry. It was however noted that the home has carried out a number of improvements to the environment such as upgrading the electrical system and the fire detection system. The manager forwarded an action plan to the Commission about the future maintenance and redecoration of the home. The bedrooms of residents were personalised to a good standard. There were pictures, photos and personal items of decoration that have been brought in by the relatives of the residents. The manager stated in the AQAA that residents are encouraged to personalise their rooms with pictures, ornaments and items of furniture. There were toilet surrounds with hand support/rails in the toilets to assist residents with poor mobility. There was at least one toilet without the surrounds and the manager said that residents who used that toilet did not need the surrounds and that she would ask for one to be put in place if residents required one of these. The bathrooms/toilets that did not have wash hand basins in the past, have now been fitted with these and paper towel dispensers have also been provided by the home in the bathrooms and toilets. The manager reported that radiator covers were almost all in place. These were indeed seen in place, but I was not able to check whether all radiators to which residents had access to had radiator covers. It is the responsibility of the Glengariff DS0000017534.V354174.R01.S.doc Version 5.2 Page 20 manager to make sure that the safety of residents is safeguarded and that radiator covers are in place where required. There was evidence in the training records to show that some members of staff have received training in infection control. It was also positive to note that the manager has addressed issues with regards to providing appropriate facilities for hand washing to consolidate infection control practices. Glengariff DS0000017534.V354174.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): 27-30 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has a stable and suitably experienced staff group to care for residents and to provide continuity of care. EVIDENCE: Staff in the home have fixed duties every week. So they all know what shifts they are supposed to work. Any changes are then recorded in a diary. Normally there are 3-4 members of staff from 08:00-09:00 and 5 members of staff from 9:00-13:30. 2 are responsible for cleaning, 1 is responsible for cooking and serving lunch and 2 provide care to residents. From 13:30-18:00 there are 3 members of staff. 1 is responsible to provide activities, 1 does the laundry and another prepares the supper from 16:00. They all provide care to residents as required. There are 3 members of staff from 18:00 to 22:00 and then from 22:00-08:00 there is one member of staff and one sleeping member of staff. The manager is supernumerary. The manager stated that she was in the process of recruiting for an activities coordinator who will lead on the provision of appropriate activities for residents. The one who was previously recruited had left. Overall the staffing level seems to be adequate to meet the needs of the residents and it seems that more staff is provided according to the busy times of the day. Most comment cards suggested that residents and their relatives Glengariff DS0000017534.V354174.R01.S.doc Version 5.2 Page 22 were satisfied with the level of support that they receive. One comment card mentioned that ‘Sometimes have to wait a little, while waiting for attention during the day, but generally very good’. The personnel file of a new member of staff was inspected. There was an application form in place, which was appropriately completed. All records as required by legislation were also in place including 2 references. The home has its own induction but also uses the common induction standards as per Skills for Care. The home kept a training file with individual records for each member of staff. These were mostly up to date. I noted that the home has been providing a number of training sessions for staff including fire, manual handling, abuse training and food hygiene. A few have attended dementia care training and medicines training. Glengariff DS0000017534.V354174.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The manager is caring and experienced in running the service, but she has to address future training that is required for all registered managers. The quality management system is not that robust to give feedback about the quality of the service. Health and safety issues are on the whole addressed as appropriate, but a few issues were noted which could compromise the safety of people who use the premises. EVIDENCE: The manager runs the home with the support of staff and her family. She knows all the residents and their relatives very well and is aware of all the issues in the home. Glengariff DS0000017534.V354174.R01.S.doc Version 5.2 Page 24 She is registered but does not yet have the registered managers’ award. She has an advance certificate in care management. She stated that she has not yet looked at enhancing her current qualification with regards to having the registered managers’ award and the NVQ level 4 in care. Skills for Care, the sector training organisation, recommends that any qualification is compared with the Registered Managers Award and NVQ level 4 in care and that any shortfalls, if any, be made up by taking the relevant NVQ units. The manager has met many of the requirements which have been imposed on the service particularly those that have been repeated a number of times and she stated that she has also considered the recommendations made to the service during the last inspection. The home has a quality assurance procedure. Currently the main focus for ensuring improvement is the satisfaction questionnaires. A report is normally produced after a survey. The manager stated that the last survey was conducted about a year ago and said that she would forward a copy to the commission. She added that the home was due for another survey. The home does not yet have a quality control system based on selfassessment and on a cycle of plan-do-review. Without this or an external quality control system it is unclear how the quality of the service that is provided will be evaluated to identify areas for improvement. The manager clarified that the home does not have residents and relatives’ meetings and that most of the interactions between residents, relatives and staff are on a one to one basis. Staff and the manager herself are indeed available for talking to residents and visitors to the home when required but it is recommended that relatives and residents’ meetings be arranged as an additional way of consulting and involving residents and their relatives to a greater extent, in the running of the home. The home does not keep any of the personal money of residents. Residents and /or their relatives are responsible for managing the personal money of the residents, for paying the bills and providing the things that the residents need while living in the home. Any expenditure incurred by the home on behalf of residents are addressed by invoicing residents on a monthly basis. The health and safety risk assessment was in place. A fire risk assessment and a fire emergency plan have been prepared for the home and were also in place. A PAT testing certificate, electrical wiring certificate and a gas safety certificate were available for inspection. While an up to date LOLER certificate was available for the lift, up to date six monthly LOLER certificates were not in place for the hoists in the home Glengariff DS0000017534.V354174.R01.S.doc Version 5.2 Page 25 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 3 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 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 2 2 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Glengariff DS0000017534.V354174.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 14(1,2) Requirement The registered person must ensure that there is a record of the assessment of the needs of residents as the basis for care planning, which is kept under review. All risk assessments must be dated and reviewed at least monthly or more often if required. All medicines, including eye medicines must be administered as prescribed. All medicines must be signed when administered or a code must be used to clearly describe the reason for the medicines not having been administered (Repeated requirementtimescale 31/03/07 partly met). To ensure the safety of residents, risk assessments must be in place to manage the situation when a resident regularly refuses to take her/his medicines. In cases when a variable dose of medicine has been prescribed DS0000017534.V354174.R01.S.doc Timescale for action 31/01/08 2 OP7 14(1,2) 31/01/08 3 OP9 13(2) 31/12/07 4 OP9 12(1) 31/12/07 5 OP9 13(2) 31/12/07 Glengariff Version 5.2 Page 27 6 OP9 13(2) 7 OP18 12 (1) (a) the actual amount of medicine administered must be recorded (Repeated requirementtimescale 31/03/07 partly met). The registered manager must consider keeping a copy of prescriptions, particularly for new medicines that have been prescribed or when there has been an alteration in the dose or instruction for administering a medicine. 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 and 30/04/07 not met) The manager must ensure compliance with the decoration and maintenance plan to make sure that the home provides a high quality environment for residents. 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, 01/06/06 and 30/04/07 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 (Previous Requirement-timescale 31/03/07 not met). To make sure that the hoists are safe, the registered person must ensure that there are up to date LOLER certificates in place as per a schedule of maintenance. DS0000017534.V354174.R01.S.doc 31/12/07 31/01/08 8 OP19 23(1)(a) 31/03/08 9 OP26 23(2)(b) 31/03/08 10 OP33 24 31/01/08 11 OP38 13(4) 31/12/07 Glengariff Version 5.2 Page 28 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 OP11 OP31 Good Practice Recommendations That the registered arrange for end of life care training for staff to make sure that they are trained to address these needs of residents 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. It is recommended that relatives and residents’ meetings be arranged as an additional way of making residents and their relatives more inclusive in the running of the home. 3 OP33 Glengariff DS0000017534.V354174.R01.S.doc Version 5.2 Page 29 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.V354174.R01.S.doc Version 5.2 Page 30 - 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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