Inspection on 08/11/05 for Glenholme Residential Care Home

This inspection was carried out on 8th November 2005.

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

Glenholme Residential Care Home 29/11/07

Glenholme Residential Care Home 27/09/06

Glenholme Residential Care Home 20/04/05

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 Announced Inspection 8th November 2005 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 Glenholme Residential Care Home DS0000015709.V253397.R01.S.doc Version 5.0 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. Glenholme Residential Care Home DS0000015709.V253397.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Glenholme Residential Care Home Address 4 Park Avenue Roker Sunderland SR6 9PU 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) 0191 549 2594 0191 548 6089 Wellburn Care Homes Limited Mrs Christine Purvis Care Home 34 Category(ies) of Dementia (4), Mental disorder, excluding registration, with number learning disability or dementia (2), Old age, not of places falling within any other category (28) Glenholme Residential Care Home DS0000015709.V253397.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th April 2005 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 Andrews 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 DS0000015709.V253397.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an announced inspection and commenced at 10:00. As part of the inspection, service users and relatives completed questionnaires that were sent to the home to be distributed. Nineteen responses were received from relatives and one was from a service user. The respondents were complimentary of the care and the way the home is managed. Staff were described as friendly, helpful, and caring. Some described the service as excellent and being of the highest standard. The inspection process involved talking to service users, sitting in the lounge and observing staff interaction with the service users, discussions with the manager and care staff, tour of the building, examination of health and safety records and service users personal files including care plans. The Fire Safety Officers from the local Fire Brigade were in attendance in the home at the time of the inspection. Inspections relating to fire precautions were carried out as a joint inspection between the Fire Authority and the CSCI inspector. Recommendations from their inspection would be forwarded to the home separately from this report. What the service does well: The manager provides good leadership and direction for the staff. The manager and her senior staff team provide appropriate supervision for all staff. The company provides good training for the staff to equip them for their roles within a caring environment. The service users confirmed that they are well looked after and the care plans and daily records provided further evidence of the good care practices in the home. This was further confirmed by the comments made in the questionnaires that were sent to relatives as part of the inspection process. The service users are treated with respect and dignity and this was confirmed by the inspector’s observations and by comments from the service users and relatives. The home has a quality assurance system in place and had gained ISO9001:2000 status which is valid till 2007. This ensured that the home is run and managed according to its stated aims and objectives. Glenholme Residential Care Home DS0000015709.V253397.R01.S.doc Version 5.0 Page 6 Suitable arrangements are in place to ensure the safety and wellbeing of the service users. Documentary evidence showed that health and safety matters are properly dealt with, including suitable training for all staff. The home continues to maintain good levels of staffing that meets the needs of the service users. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Glenholme Residential Care Home DS0000015709.V253397.R01.S.doc Version 5.0 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 Glenholme Residential Care Home DS0000015709.V253397.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 4, 5. All service users are supplied with terms and conditions of residence, which highlight their obligations and what they can expect as part of their care. The needs of the service users are assessed by the home and the social worker, which may involve relatives. This ensured that the care needs are clearly identified and understood by the service user, staff and relatives. The home invites prospective service users and their families to visit the home before deciding on coming to live at Glenholme. EVIDENCE: The manager confirmed that terms of conditions of residence have been issued to all the service users. 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. Also stated in the term of conditions is the room number allocated to the service user and the fees payable and by whom. Glenholme Residential Care Home DS0000015709.V253397.R01.S.doc Version 5.0 Page 9 One service user who was recently admitted confirmed that she and her family had the opportunity to discuss the terms and conditions of residence with the manager and her daughter signed the document on her behalf. The family later stated that they found it useful to have a contract with the company as this gave them a written confirmation of their obligations and that of the company. Similar comments were made by other service users. Examination of records showed that appropriate assessments of need are carried out people trained to do so before admission is arranged. It is the policy of the home for social work assessment to be obtained, and for the home to carry out its assessment of need before admission is agreed. Three service users stated that the process enabled them to discuss with the social worker and the home what their care needs were. They said they feel that the process enables the staff to know what their needs are, and arrangements made by the home to meet those needs. All prospective service users are invited to visit the home to meet with other service users and staff. This arrangement is included in the Service User Guide, copies of which are available to all service users. Some service users and relatives described the experience of visiting the home before admission as a very positive experience, and were pleased to have visited the home before coming to live there. Glenholme Residential Care Home DS0000015709.V253397.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 10, 11. Individual care plans set out the health, social and personal care needs of each service user and plans are formulated to meet those care needs. The service users are treated sensitively and with respect, and their right to privacy and dignity is respect by the staff. EVIDENCE: Three service users files were examined and were found to provide details of their care needs formulated in care plans and how those needs were to be provided by the staff. Some of the files show evidence of service users being involved in the planning of their care. The manager stated that service users and their relatives are encouraged to be in involved in their care plans and those who did have signed to indicate their involvement in the process. One service user stated that she is glad that the staff would always ask her view and involve her in decisions about her care, and she finds this very helpful. Risk assessments have also been carried out for those service users for whom it is thought necessary. These include falls, medication and pressure area risk Glenholme Residential Care Home DS0000015709.V253397.R01.S.doc Version 5.0 Page 11 assessments. This ensured that the care and welfare of the service users are maintained. The healthcare needs of the service users 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 engage the services of community nurses in the assessment of pressure area care, tissue viability, and for general advice and support. The service users confirmed that the staff treat them with respect and promote their right to privacy. This was also confirmed by visitors to the home. Practices observed also confirmed this. Staff were observed to knock on bedroom doors before making entry. Service users confirmed that appointments with GPs and other visiting professional such as speech therapy take place in the privacy of their room. A number of staff commented on the arrangements for caring for people who are approaching death. They described the general policy on caring for the dying. Staff described the care routines and the general support given to the family and the wishes of the service user at such times. Staff have good understanding of the need to provide the right kind of care in these circumstances. Glenholme Residential Care Home DS0000015709.V253397.R01.S.doc Version 5.0 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 the following standard(s): 12, 15. The home operates in a way that enables the service users to exercise choice and autonomy over matters relating to daily activities and healthy eating. This promotes a healthy lifestyle for the service users. EVIDENCE: Details in the files shows that the staff have identified the social care needs of the service users. The social activities file provided further details of all the activities that each service users had been engaged in and commented on how much they enjoyed each activity. The home continues to provide a wide range of activities for service users to choose from. On the day of the inspection the staff and service users were engaging in quiz games. Some service users choose not to take part and stayed in the other lounges or in their rooms to watch TV. There was also art and craft session on in the afternoon and some service users were involved in art work and making Christmas cards. Those involved in these activities said they found it useful and have always enjoyed taking part. Service users confirmed that a number of social and recreational activities are available to them. The records of recent activities included tea dance, life band music, shopping trip to local supermarket and bus drives along the Glenholme Residential Care Home DS0000015709.V253397.R01.S.doc Version 5.0 Page 13 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. One service user was pleased that she is still able to be involved in the activities of her church. She said she continue to maintain contact with the church and has regular visits from members of the church. Service users also commented on the service provided by the local church on a monthly basis. Service users continue to compliment 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 records relating to nutritional intake shows that these are reviewed regularly and changes made to the care plan when necessary. 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 service users. At lunch time the tables were beautifully set with appropriate cutlery, napkins, condiments and choice of drink. A number of service users commented that if they wish to have their meals in their bedrooms, staff would make the necessary arrangements for this to happen. The service users indicated that they find the meal time experiences enjoyable. Glenholme Residential Care Home DS0000015709.V253397.R01.S.doc Version 5.0 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 the following standard(s): 16, 17, 18. There are clear, accessible and effective complaints procedure which is understood by service users and their relatives and serves to protect the service users 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 service users and visitors to see. Some of the service users and relatives indicated that they are aware of the procedure and would know how to complain if they had a need to do so. In recent weeks one relative had made a representation to the company about the sitting arrangements in the lounges and this had been acknowledged by the company and the arrangements are being reviewed with the view to supplying a variety of chairs to suit individual preferences. Examination of the staff training record showed that staff have had training in adult protection. Staff who were interviewed 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 service users. Glenholme Residential Care Home DS0000015709.V253397.R01.S.doc Version 5.0 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 the following standard(s): 19, 25, 26. The home provides accommodation of a good standard. It is a safe, clean and comfortable environment, which promotes the service users’ privacy, independence and welfare. EVIDENCE: The 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 records showed evidence of regular fire alarm tests and maintenance of fire detection and fire fighting equipments. 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. They were also able to point out the exit routes throughout the home. The staff training record also indicated that all staff have had fire training, health and safety, COSSH, first aid, food hygiene and moving and handling. There was also record of regular testing of hot water in bedrooms and Glenholme Residential Care Home DS0000015709.V253397.R01.S.doc Version 5.0 Page 16 bathrooms to ensure that the water temperatures remain within the recommended range. These arrangements have been maintained and ensured the safety and welfare of the service users. 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 service users. Glenholme Residential Care Home DS0000015709.V253397.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, 30. The home provides adequate staffing which to meet the needs of the service users. Suitable arrangements for staff training and supervision are in place, which ensured that staff are equipped to provide good quality service that benefited the service users. EVIDENCE: Details of past staff rotas indicated that the home consistently maintains adequate staffing levels and these meet the needs of the service users. The staff training records included moving and handling, first aid, protection of vulnerable adults, health and safety, fire safety and food hygiene. Staff confirmed the training they had received and felt that these had equipped them to do their jobs better. Service users commented that the staff are properly trained and therefore are able to provide them with good quality care. There is a commitment by the provider to train all care staff to NVQ Level 2 or above. Staff who have already acquired this training indicated that NVQ training had equipped them to provide better care for the service users. They also indicated that the training had boosted their confidence and are therefore confident in their care practices for the benefit of the service users. Glenholme Residential Care Home DS0000015709.V253397.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,37, 38. Staff receive regular training and supervision from the manager which ensured that their practices support the health, welfare and safety of the service users. EVIDENCE: The manager has long experience of working in a care home and has had extensive management experience in care settings. She has acquired the registered managers award. This training has further enhanced her skills for the benefit of the service and the service users. The staff described the manager as efficient, and indicated that she runs the service for the benefit of the service users and has positive relations with the staff. Similar comments were also made by some of the service users and relatives. Glenholme Residential Care Home DS0000015709.V253397.R01.S.doc Version 5.0 Page 19 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 service users finances indicated that the weekly audit required to be undertaken as part of the quality assurance system has ensured proper accountability of monies held by the home on behalf of the service users. There are detailed corporate Health and Safety policies in the home. These serve as training manual and reference documents for staff to use. These cover policy areas such as fire prevention and Care of Substances Hazardous to Health (COSHH). These policies ensured that health and safety of the service users and the staff are maintained at all times. All portable appliances have been tested. A record is maintained of monthly water temperature tests in the home. There is evidence of regular servicing of fire equipment, passenger lift, hoists, gas and electrical appliances. Up to date servicing and maintenance of these services and equipments ensure a safe environment for the service users and the staff who work there. Glenholme Residential Care Home DS0000015709.V253397.R01.S.doc Version 5.0 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 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 X X X X X 3 3 STAFFING Standard No Score 27 3 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X 3 3 Glenholme Residential Care Home DS0000015709.V253397.R01.S.doc Version 5.0 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 OP19 Regulation 23(2)(c) Requirement Timescale for action 15/01/06 2 OP19 23(2)(j) Pull cords identified in the toilet/bathrooms on the first floor must be extended and made accessible to service users. Hot water supply must be 15/01/06 available in all toilets to promote adequate hygiene in the home. 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 OP16 Good Practice Recommendations The displayed complaints procedure should be reviewed to include the correct name of the regulatory authority, CSCI. Glenholme Residential Care Home DS0000015709.V253397.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection South of Tyne Area Office 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 DS0000015709.V253397.R01.S.doc Version 5.0 Page 23 - 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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