Inspection on 20/04/05 for Glenholme Residential Care Home

This inspection was carried out on 20th April 2005.

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

Glenholme Residential Care Home 29/11/07

Glenholme Residential Care Home 27/09/06

Glenholme Residential Care Home 08/11/05

Glenholme Residential Care Home 28/10/04

Glenholme Residential Care Home 18/05/04

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

CARE HOMES FOR OLDER PEOPLE Glenholme Residential Care Home 4 Park Avenue Roker Sunderland SR6 9PU Lead Inspector Sam Doku Unannounced 20 April 2005 11:15 am 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 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. Glenholme Residential Care Home B52 B02 S15709 Glenholme V219455 20 Apr 2005 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Glenholme Residential Care Home Address 4 Park Avenue Roker Sunderland SR6 9PT 0191 549 2594 0191 548 6089 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Wellburn Care Homes Limited Christine Purvis Care Home only 34 Category(ies) of Old age - 28 registration, with number Mental Disorder - 2 of places Dementia - 4 Glenholme Residential Care Home B52 B02 S15709 Glenholme V219455 20 Apr 2005 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 7 October 2004 Brief Description of the Service: Glenholme is a large, redbrick Victorian detached villa. It was built in 1887 and was once the Vicarage for St Andrew’s Church. It has been extended and is now a residential care home, which provides services for up to thirty-four older people, some of whom may have dementia or mental health needs. The Registered Provider also operates a day centre for older people on the same site but managed separately from the home. The property is close to Roker Park in a mainly residential street close to the sea front. Sunderland city centre is a short distance away and this may be accessed by public transport, which passes frequently. Local facilities include a church and a small selection of shops. The accommodation is laid out over three floors, with additional mezzanine levels and there are thirty-four single bedrooms, some with en-suite facilities. The first and second floors are accessible by passenger lift, however the mezzanine levels can only be reached by stairs, therefore, is only suitable for mobile residents. There are also two communal lounge areas, a sunroom and two dining areas. External features include a large and secluded walled garden, which is well kept and equipped with outdoor furniture, sunshades and barbecue facilities. Glenholme Residential Care Home B52 B02 S15709 Glenholme V219455 20 Apr 2005 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspector made a point of speaking with the service users about how they wish to be known. All those spoken with indicated that they preferred the term Residents rather than Service Users. Consequently, the term resident is used throughout this report. The unannounced inspection was carried out at 11:15 in the morning to observe the mid-morning and afternoon practices in the home. The inspection process involved talking to residents, sitting in the lounge and observing staff interaction with the residents, discussions with the manager and care staff, tour of the building, inspection of the drugs administration system, examination of health and safety records and residents’ personal files including care plans. Three residents’ and two staff files were examined as part of the inspection process. What the service does well: What has improved since the last inspection? Since the last inspection, arrangements have been made to replace some of the armchairs in the bedrooms with more comfortable ones. The manager and her senior team continue to review the type of residents accommodated on the top floor to ensure that those residents are still able to manage the stairs unaided. The home has commenced a programme of redecoration of all the bedrooms. Glenholme Residential Care Home B52 B02 S15709 Glenholme V219455 20 Apr 2005 Stage 4.doc Version 1.30 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. Glenholme Residential Care Home B52 B02 S15709 Glenholme V219455 20 Apr 2005 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Glenholme Residential Care Home B52 B02 S15709 Glenholme V219455 20 Apr 2005 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3, 4, 5, The home maintains a robust policy in ensuring that assessments are completed prior to admission, ensuring that the needs of potential residents can be met by the home. EVIDENCE: The residents’ files that were examined included two residents who had recently been admitted to the home. All three files contained evidence of assessment documents from the residents’ social worker. The manager stated that she or a senior staff member would always carry out pre-admission assessments for any prospective residents before admission. According to the manager this enables the staff to assess the needs of the service user to ensure that the home can meet their care needs. It is also used as an opportunity to meet with the prospective resident in their own home and to invite them to visit the care home before making their final decision about coming to live at Glenholm. The deputy manager who was present during the inspection also confirmed this arrangement. Glenholme Residential Care Home B52 B02 S15709 Glenholme V219455 20 Apr 2005 Stage 4.doc Version 1.30 Page 9 Two residents who were spoken with about their admission to the home also confirmed that they were visited by the manager and assessed by her before they came to live in the home. The assessments seen by the inspector were appropriate to residents’ needs. The manager described the homes admission procedure which was confirmed by staff and a number of residents. All prospective residents are invited to visit the home to meet with other residents and staff. This arrangement is included in the Service User Guide copies of which are available to all residents. The manager also stated that it is the home’s policy to regard the first four weeks of residency as a trial period. This is stated in the statement of terms and conditions and in the Service User Guide. She also stated that where an emergency admission had to be made, the manager or a senior staff member will obtain all the necessary information from the social workwer as soon as possible. A review of placement and re-assessment of needs is then undertaken within 48 hours of admission. Glenholme Residential Care Home B52 B02 S15709 Glenholme V219455 20 Apr 2005 Stage 4.doc Version 1.30 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10. The individual care plans set out the health, social and personal care needs of each resident and plans are formulated to meet those care needs. However, the home is failing to maintain accurate records of medication, potentially putting the residents at risk. EVIDENCE: The care plans of three residents were examined and were found to provide details of their care needs and how those needs were to be provided by the staff. There was evidence in the care plans that some residents who are able to, have been encouraged to be involved in the formulation of their care plans. Risk assessments have also been carried out for those residents for whom it is thought necessary. These include falls, medication and pressure area risk assessments. However, it was noted that risk assessment had not been carried out for one resident who clearly enjoys assisting staff in the kitchen. As commented in previous inspection reports, evidence from the residents files indicated that the home continues to ensure that their health care needs are met. There were details of contacts with healthcare professionals, including access to chiropody service, dentist, optician and other healthcare services. Entries in the report books provide evidence that the home continues to Glenholme Residential Care Home B52 B02 S15709 Glenholme V219455 20 Apr 2005 Stage 4.doc Version 1.30 Page 11 engage the services of community nurses in the assessment of pressure area care, tissue viability and for general advice and support. All the residents are registered with a GP service. The residents who were spoken with all confirmed that their healthcare needs are adequately met in the home and that the arrangements for their care are good. There was generally a good level of recording on the Medicine Administration Record charts seen by the inspectors. Drugs were safely and securely stored, including the returns to pharmacy. However, it was noted during the inspection of the medication system that in one case medication was signed as given but still remained in the cassett. In another case one tablet remained in the cassett but there was no record of the medication being omitted and the reasons for the omission. Another resident’s record showed that medication had been omitted on two occasions but there was only one tablet in the cassett instead of two. Practices observed on the day of the inspection indicated that staff promote privacy and dignity for the residents. Staff were observed to knock on residents’ door and wait for response before making entry. All the residents who were spoken with said they feel the staff respect their privacy. They also confirmed that consultation with GPs and other health professional take place in the privacy of their rooms. Some of the residents also stated that they have key to their rooms and are able to lock their bedroom doors if they wish. The residents indicated that this allowed them to maintain their independence and enjoy some level of privacy. Glenholme Residential Care Home B52 B02 S15709 Glenholme V219455 20 Apr 2005 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15. The home operates in a way that enables the residents to exercise choice and autonomy over matters relating to daily activities and healthy eating. This promotes a healthy lifestyle for the residents. EVIDENCE: The residents’ files that were examined showed evidence of residents’ interests. The social history section of the assessment form provided details of residents hobbies and what activities they enjoyed. The social activities file provided details of all the activities that each resident had taken part in and commented on how much they enjoyed each activity. A wide range of activities are on offer and residents can choose to take part if they wish. On the day of the inspection the staff and residents were engaging in quiz games. Some residents choose not to take part and stayed in the other lounges or in their rooms to watch TV. The records show the most recently organised activities which included tea dance, life band music, shopping trip to local supermarket and bus drives along the seafront. There is photographic evidence of some of these activities in the home. The residents who were spoken with confirmed these activities and indicated that they enjoyed taking part. They emphasised that no one is made to join in any organised activities if they did not wish to. Glenholme Residential Care Home B52 B02 S15709 Glenholme V219455 20 Apr 2005 Stage 4.doc Version 1.30 Page 13 Residents were very complimentary about the catering staff and quality of the meals provided in the home. Nutritional assessments have been carried out for those residents who require their diet intake monitored to ensure they receive adequate diet. The three weeks rotating menus provided evidence of varied and nutritious meals, including alternatives for the residents to choose from. The two dining areas are pleasantly furnished and provide spacious and congenial settings for the residents. At lunch time the tables were beautifully set with appropriate cutlery, napkins, condiments and choice of drink. A number of residents commented that if they wish to have their meals in their bedrooms, staff would make the necessary arrangements for this to happen. Glenholme Residential Care Home B52 B02 S15709 Glenholme V219455 20 Apr 2005 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16, 17, 18. The home has a clear, accessible and effective complaints procedure which is an effective part of the homes’ strategy to protect the residents from abuse and promote their wellbeing. EVIDENCE: The home has a written complaint procedure, which is regularly reviewed by the company. Summary of the complaint procedure is included in the Service User Guide and the terms and conditions of residence. There is also a “Whistle Blowing” policy in place and copies of these procedures are also posted in the foyer for residents and visitor to see. Four residents and a visiting relative were spoken with about the complaint procedure and they all indicated that they are aware of the procedure and would know how to complain if they had a need to do so. Examination of the staff training record showed that staff have had training in adult protection. Three care staff were formally interviewed and they all showed awareness of the home’s complaint and whistle blowing policies. They were able to describe the various forms of elder abuse and indicated how such abuses could be prevented in residential care settings. Such training and awareness amongst staff is one way of reducing the likelihood of abuse to residents. In recent anonymous complaint about the home, the manager and the company followed their complaint procedure and carried out a thorough investigation of the allegations and reported the findings to the Commission. Glenholme Residential Care Home B52 B02 S15709 Glenholme V219455 20 Apr 2005 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 24, 26. The home provides a homely, safe, comfortable and pleasant setting for the residents. EVIDENCE: A number of records relating to health and safety and general maintenance were examined and showed that safety measures relating to fire and environmental health matters were being observed. The fire-log book provided evidence of regular fire alarm tests and maintenance of fire detection and fire fighting equipments. The three care staff who were interviewed showed good knowledge of the fire procedures in the home. They were able to describe what to do in event of discovering fire in the home. The staff training record also indicated that all staff have had fire training. There was also record of regular testing of hot water in bedrooms and bathrooms to ensure that the water temperatures remain within the recommended range. These arrangements have been maintained to ensure the safety of the residents. All the bedrooms are single occupancy. A number of the residents who were spoken with stated that they found their rooms very comfortable and homely. Glenholme Residential Care Home B52 B02 S15709 Glenholme V219455 20 Apr 2005 Stage 4.doc Version 1.30 Page 16 Most have furnished their rooms with personal items thus ensuring homely and familiar environment for them. Residents commented on being happy with having personal belongings in their rooms. All parts of the home, including individual bedrooms are decorated to good standard and well maintained. There are sufficient communal spaces in the home to meet the needs of the residents. There are two lounges, a sun lounge and two dining areas. These provide choice of sitting areas for the residents. At the time of the inspection the home was noted to be clean and free from offensive odour. It was noted that all toilets had liquid soap dispensers. The laundry machines have facilities for sluicing and washing foul linen at very high temperature to avoid the spread of infection. This also contributes to the health and safety of the residents. Glenholme Residential Care Home B52 B02 S15709 Glenholme V219455 20 Apr 2005 Stage 4.doc Version 1.30 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29, 30. The home continues to maintain adequate staffing levels to meet the needs of the residents. Suitable arrangements for staff training and supervision are in place to ensure that staff are equipped to provide good quality service that benefits the residents. EVIDENCE: Details of staff rotas were examined during the inspection. It was noted that the home had consistently maintained adequate staffing levels to meet the needs of the residents. Two residents commented that they feel there is always sufficient staff on duty. One said she always manages to get staff attention if she needed assistance. The staff training log was examined by the inspector. The list of training provided for the staff included fire training, moving and handling, first aid, protection of vulnerable adults, health and safety, food hygiene and nutrition. The staff who were interviewed confirmed the training they had received and felt that these had equipped them to do their jobs better. The manager confirmed that all newly appointed staff undertake the TOPPS training provided by the company. Two staff records were examined with the view to determine whether or not the company adheres to proper employment policies in recruiting staff. It was evident from the two staff files that proper recruitment policies had been followed by the manager including completion of application form, job description, contract of employment two satisfactory references, interviews, and Criminal Records Bureau checks. These procedures are in place to ensure Glenholme Residential Care Home B52 B02 S15709 Glenholme V219455 20 Apr 2005 Stage 4.doc Version 1.30 Page 18 further protection of residents from possible abuse from applicants who would otherwise be deemed as unsuitable to work with vulnerable people. Glenholme Residential Care Home B52 B02 S15709 Glenholme V219455 20 Apr 2005 Stage 4.doc Version 1.30 Page 19 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 35, 36, 37, 38. The manager provides good leadership and direction for the staff. This ensures that the service is run for the interest of the residents, promoting and safeguarding their rights and wellbeing. EVIDENCE: The manager has six years experience of managing a care home. She has NVQ level 4 in care and management. The staff who were spoken with indicated that the manager manages the service and her staff team well. A similar comment was also made by a visiting relative who were spoken with. The home has ISO 9001:2000 accreditation which, ensures regular review of the service against the company’s quality assurance system. The manager confirmed that monthly audit system had enabled her to review all aspect of the service ranging from care plans to health and safety in the home. Examination of the residents’ finances indicated that the weekly audit required Glenholme Residential Care Home B52 B02 S15709 Glenholme V219455 20 Apr 2005 Stage 4.doc Version 1.30 Page 20 to be undertaken as part of the quality assurance system has ensured proper accountability of monies held by the home on behalf of the residents. The manager has continued to maintain evidence of proper maintenance of the home. Maintenance certificates for the servicing of electricity, electrical equipment, gas, heating, lift servicing and hoists were available and up to date. Records of the regular internal maintenance of the home and equipment are also kept. This ensures safe and secure environment for the residents. This was further reinforced by the provision of health and safety training including first aid, fire training, moving and handling and food hygiene to all staff. Glenholme Residential Care Home B52 B02 S15709 Glenholme V219455 20 Apr 2005 Stage 4.doc Version 1.30 Page 21 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 2 3 3 3 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 Standard No 16 17 18 Score 3 3 3 x 3 3 x 3 3 3 3 Glenholme Residential Care Home B52 B02 S15709 Glenholme V219455 20 Apr 2005 Stage 4.doc Version 1.30 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 12(3) Requirement Risk assessments must be carried out for residents who choose to work or assist in the kitchen. The Medication system must be reviewed to ensure proper recording and accountability for medicines held in the home. Timescale for action Immediate 2. 9 13(2) Immediate 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 19 Good Practice Recommendations Pull cords in rooms identified in the report shoud be extended and untied to ensure easier access for the residents. Glenholme Residential Care Home B52 B02 S15709 Glenholme V219455 20 Apr 2005 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Baltic House Port of Tyne, Tyne Dock South Shields NE34 9PT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Glenholme Residential Care Home B52 B02 S15709 Glenholme V219455 20 Apr 2005 Stage 4.doc Version 1.30 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. 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