Inspection on 05/06/07 for Glengariff Residential Home

This inspection was carried out on 5th June 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 Residential Home 04/06/09

Glengariff Residential Home 18/06/08

Glengariff Residential Home 06/06/06

Glengariff Residential Home 02/02/06

Glengariff Residential Home 17/03/05

Glengariff Residential Home 24/11/04

Glengariff Residential Home 10/12/03

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

CARE HOMES FOR OLDER PEOPLE Glengariff Residential Home 45 Freeland Road Clacton On Sea Essex CO15 1LX Lead Inspector Neal Cranmer Key Unannounced Inspection 5th June 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Glengariff Residential Home DS0000017831.V342499.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 Residential Home DS0000017831.V342499.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glengariff Residential Home Address 45 Freeland Road Clacton On Sea Essex CO15 1LX 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) 01255 220397 01255 220880 Glengariff Company Limited Mrs Tina Amanda Smyth Care Home 55 Category(ies) of Dementia - over 65 years of age (15), Old age, registration, with number not falling within any other category (55) of places Glengariff Residential Home DS0000017831.V342499.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Persons of either sex, aged 65 years and over, who require care by reason of old age only (not to exceed 55 persons) Persons of either sex, aged 65 years and over, who require care by reason of dementia (not to exceed 15 persons) The total number of service users accommodated in the home must not exceed 55 persons 6th June 2006 Date of last inspection Brief Description of the Service: Glengariff is a care home for older people accommodating a maximum of 56 service users. The property is a three-storey converted hotel close to the town centre and seafront. The upper floors are accessed via a passenger lift. Most bedrooms are single occupancy and all have en-suite facilities. There is a choice of communal areas and a large garden at the rear of the building. The home provides written information about the service to prospective service users. Inspection reports are displayed on notice boards and in the manager’s office. Fees for this home, at the time of the inspection, ranged from £365.00 - £460.00 per week. Hairdressing, chiropody, personal items and outings are an additional cost. Glengariff Residential Home DS0000017831.V342499.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection of the home, which took place over one day in June 2007; the inspection process included discussions with residents living in the home, relatives, carers and the registered manager and their deputy; examination of a sample of staff and residents’ records and supporting documentation and other records required to be kept in the home. In addition to the day spent at the home, written evidence submitted to the Commission since the last inspection was reviewed in order to reach the conclusions identified in this report. Twenty-two of the thirty-eight older people’s standards were inspected, of which one was not applicable; sixteen were met, with the remaining five constituting minor shortfalls. What the service does well: What has improved since the last inspection? The pre-admission assessments are now sufficiently detailed to enable the home to reach a decision on its ability to meet the individuals’ needs. The Garden room has now been fitted and furnished appropriate to the needs of the residents. The home now has in place a quality assurance process, which is based upon the views of residents, and other interested parties. Glengariff Residential Home DS0000017831.V342499.R01.S.doc Version 5.2 Page 6 What they could do better: 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 Residential Home DS0000017831.V342499.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glengariff Residential Home DS0000017831.V342499.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents can be assured that pre admission assessments are sufficiently detailed to determine that their needs would be identified. EVIDENCE: A sample of residents’ files was sampled. The assessment documents covered all of the required areas of residents’ needs in a detailed and concise way; these assessments were then used as the basis for formulating the residents’ plans of care. Glengariff Residential Home DS0000017831.V342499.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents could not be assured that all care plans would contain sufficient detail or evidence of residents’ input to ensure that they are consulted about how their needs would be met. EVIDENCE: A sample of four residents’ care plans were sampled, the content of which was varied and inconsistent. Evidence indicated that this was dependent upon which member of staff had written the care plan. The plans seen lacked sufficient detail about residents’ individual, social and emotional needs. All the care plans sampled contained evidence of having been kept under review, and daily records were current. The home operates a key worker system and staff were well aware of the role of the key worker. Relatives and residents spoken with during the course of the inspection were aware of who their key worker was. Glengariff Residential Home DS0000017831.V342499.R01.S.doc Version 5.2 Page 10 All residents are registered with a General Practitioner, and records sampled in respect of residents’ healthcare needs suggested that these were well met. The home’s medication administration system is a Monitored Dosage System (MDS). Based upon the sample of records inspected the receipt, administration, storage and disposal of medication were found to be in order, apart from one resident’s record chart, where it was noted that medication administered had not been signed for. Staff responsible for the administration of medicines have all received training from the local pharmacist. Glengariff Residential Home DS0000017831.V342499.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to be provided with choices about how they spend their time, and participate in activities of their choosing. EVIDENCE: The home employs an activities coordinator five days a week. The coordinator was spoken with during the course of the inspection and spoke of providing the following activities: • • • • Sing-a-long sessions Activity sessions Trips out Arts and crafts. The home is situated close to the seafront and some residents spoke of being supported to sometimes going down to the front and sitting on the promenade. The home benefits from a lovely garden and patio area, and on the day of the inspection the inspector spent time in the garden, chatting with some residents Glengariff Residential Home DS0000017831.V342499.R01.S.doc Version 5.2 Page 12 and their relatives. Relatives spoke of being free to visit their relatives at any reasonable time of day, and always being made welcome. Residents’ personal rooms were seen to be full of personal possessions, and they were encouraged to bring with them personal pictures and personal items when moving in to the home. Residents wherever able are supported to take control for their own finances. Meals are provided three times daily, at least one of which is hot. The menus seen evidenced that a choice of at least two meals is available. Staff go around to residents each day with the menu to discuss their choice of meal. The menus seen were varied and nutritious. Glengariff Residential Home DS0000017831.V342499.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to be protected by the home’s policies and procedures, and concerns and complaints are responded to appropriately. EVIDENCE: There have been no complaints received in respect of the home since the previous inspection. The home’s complaints procedure is clearly displayed, and the home has a process for recording complaints received. Staff were seen to treat residents well, and were well aware of issues relating to Adult Protection. Those spoken with were aware of the various forms of abuse that may take place. All staff barring the newest recruits to the home have received training in adult protection, and training is scheduled for the others. Glengariff Residential Home DS0000017831.V342499.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well maintained, and provides a homely welcoming environment to the people living there. EVIDENCE: On the day of the inspection the home was clean and tidy, with there being no evidence of any unpleasant odours. The garden room has now been repainted, although some additional work remains outstanding to make this room fully operational, and the kitchen area has been refurbished. Glengariff Residential Home DS0000017831.V342499.R01.S.doc Version 5.2 Page 15 The laundry room is situated on the ground floor and was fit for purpose, being equipped with industrial style washing machines and dryers; hand washing facilities were available and the floors and walls were easy to keep clean. Glengariff Residential Home DS0000017831.V342499.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents can expect to receive appropriate levels of support and protection from the number of staff available on shifts, who have been subject to satisfactory recruitment practices. EVIDENCE: There were forty three residents in residency at the time of the inspection, one of whom was in hospital. The staff roster indicated that there were eight staff on duty for the morning shift and afternoon. The staffing levels were sufficient to meet the needs of the residents accommodated. Additional catering and domestic staff are employed in sufficient numbers. One relative spoken with spoke of being happy with the care provided by the home to their relative, they spoke of staff being polite and respectful, and of nothing being too much bother for them. The relative spoke positively of the support provided by the manager and her team during a difficult personal period. Staff recruitment files sampled were generally in order, containing all of the appropriate checks, apart from the omission of one employment reference for one member of staff. Glengariff Residential Home DS0000017831.V342499.R01.S.doc Version 5.2 Page 17 At the time of the inspection the registered manager reported that the home employed twenty-five care staff, of whom two were qualified at N.V.Q level three, seven at level two (with a further four due to commence) and one was in the process of undertaking the level four award. Of the four staff files sampled, only one contained any evidence of induction, although further discussion with the registered manager indicated that induction for all new starters was in the development stage. Staff training records evidenced that the following training had been undertaken since the last inspection of the service: • • • Fire safety Manual handling Dementia activities. The following training is scheduled for the near future: • • • Dementia awareness Adult protection Health and safety. Glengariff Residential Home DS0000017831.V342499.R01.S.doc Version 5.2 Page 18 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can expect to receive good care from the staff team who benefit from good management and leadership from the manager, who is well supported by the proprietor. EVIDENCE: The registered manager has previous experience of working in the care sector, and is in the process of undertaking their N.V.Q level four management award; the manager is well supported by the provider and her staff team. The home monitors its quality assurance through the use of questionnaires. One of those seen raised a concern about staffing levels, particularly at Glengariff Residential Home DS0000017831.V342499.R01.S.doc Version 5.2 Page 19 weekends, whilst others rated the home as being good, one stating that ‘it would give the home a good reference anytime’. A report on the outcome of the October 2006 audit was seen, along with an action plan for how to address the issues raised. Staff meetings are held regularly, evidence was seen of three having taken place since the beginning of 2007. The home has a suggestion box for comments to be placed in. Three residents’ personal finances were sampled; the audit trail of expenses was clear and concise and was in order. The home’s policies and procedures support the safety of residents and staff, and certificates relating to equipment and services were in place and in order, including the following: • • • • • • • • • Weekly water temperature checks Fire safety weekly audit Record of visits by fire officer Record of fire alarm tests Emergency lighting checks Record of fire drills Electrical installation test certificate Gas installation certificate Passenger lift test report. Glengariff Residential Home DS0000017831.V342499.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Glengariff Residential Home DS0000017831.V342499.R01.S.doc Version 5.2 Page 21 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 15 Requirement Care plans must be detailed, to ensure they cover all aspects of residents’ identified care needs. The previous timescale set was not met. All residents’ medication administration records must be signed and current following administration, to ensure residents protection. Timescale for action 31/08/07 2. OP9 Schedule 3 (3i) 31/07/07 3. OP29 19 Schedule 2. 4. OP30 18 All of the documentary evidence 31/08/07 pertaining to the recruitment of staff must be maintained as specified under Schedule 2 of the Care Homes Regulations. This is to ensure that residents are adequately protected. All staff must undertake a 31/08/07 programme of induction upon commencement of employment at the home, this is to ensure that residents are supported by staff who are competent to do so. The previous timescale set was not met. Glengariff Residential Home DS0000017831.V342499.R01.S.doc Version 5.2 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP28 Good Practice Recommendations It is recommended that the home ensure at least 50 of its care team be qualified to N.V.Q level two or better. Glengariff Residential Home DS0000017831.V342499.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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 Residential Home DS0000017831.V342499.R01.S.doc Version 5.2 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!