Inspection on 10/03/08 for Glenhurst Manor

This inspection was carried out on 10th March 2008.

CSCI found this care home to be providing an Poor service.

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

Glenhurst Manor 22/06/09

Glenhurst Manor 03/12/08

Glenhurst Manor 04/06/08

Glenhurst Manor 06/11/07

Glenhurst Manor 29/06/06

Glenhurst Manor 03/03/06

Glenhurst Manor 17/05/05

Glenhurst Manor 26/10/04

Glenhurst Manor 27/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Glenhurst Manor 44a West Cliff Road Bournemouth Dorset BH4 8BB Lead Inspector Jo Palmer Key Unannounced Inspection 10th March 2008 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 Glenhurst Manor DS0000003939.V360395.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. Glenhurst Manor DS0000003939.V360395.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glenhurst Manor Address 44a West Cliff Road Bournemouth Dorset BH4 8BB 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) 01202 761175 01202 761164 info@glenhurstmanor.co.uk Mr Kevin Robin Ellis Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Glenhurst Manor DS0000003939.V360395.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th November 2007 Brief Description of the Service: Glenhurst Manor is registered to provide personal care and accommodation for a maximum of 36 people. The home is in the West Cliff area of Bournemouth, a short walk from the cliff top and not far from the facilities of the town centre and the Westbourne shopping area and is situated on a bus route for central Bournemouth. It is registered to Mr Ellis. The post of Registered Manager has been vacant since December 2006. Accommodation is arranged over three floors providing 29 single bedrooms and 4 bedrooms that may be used as double rooms. All rooms except one have en suite facilities. A passenger lift provides level access to all areas of the home. There is a large lounge and a separate dining room; both have views of the rear garden. To the front and rear of the property are well-maintained grounds for the use of residents; there are car parking spaces at the front of the house. Fees range from £582.53 to £907.38 per week. Glenhurst Manor DS0000003939.V360395.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. This unannounced inspection took place on 10th March 2008 between 10.00 and 14.30; this was the second key inspection of this home in the last 12 months. The last inspection in November 2007 resulted in 7 requirements being repeated from previous inspections and a further five being made. The purpose of this key inspection was to check that the residents living in the home were safe and properly cared for and to review progress in meeting the requirements and recommendations made at previous inspections. Mr Kevin Ellis, registered owner of Glenhurst Manor was not available although the deputy manager assisted capably throughout the inspection. The position of registered manager has been vacant since December 2006. The inspector spoke with six residents, with the deputy manager and briefly with a visitor. Relevant records were examined along with the homes medication systems and parts of the premises. What the service does well: Glenhurst Manor ensures that prospective residents are assessed prior to moving into the home and they are given sufficient information about their assessment to be confident that their care will be provided. Residents spoken with were happy with the care they receive and commented that there is a respectful and caring staff group Although it has been noted that here are some irregularities with assessments and care planning, residents confirmed that heir social and recreational needs are met by the home and there is sufficient to keep them occupied. Friends and family are able to visit freely and meals provided are well received with residents commenting that they are appetising, well presented and plentiful Residents are protected by the home’s policies and procedures relating to adult protection and complaints and recent staff training in safeguarding gives confidence in the homes systems. Glenhurst Manor provides its residents with well maintained premises which are furnished, decorated and cleaned to a high standard, one resident commented that ‘they keep it impeccably clean’. Residents confirmed that staff are available to assist them and that call bells and requests for assistance are answered promptly. Glenhurst Manor DS0000003939.V360395.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: • The following list of issues has been identified as giving cause for concern during this inspection, it is imperative that for resident safety these issues are addressed as a matter of urgency; the inspection findings have been referred to the Regional Enforcement Team Care plans do not provide care staff with detail of each resident’s assessed health and personal welfare needs and how these needs are to be safely met by staff and risk assessments do not include action plans informing staff of the necessary action to reduce or eliminate identified risks Medication audit trails need to be clear to evidence medicines that have been administered as prescribed. Staff recruitment procedures need to be more robust to ensure that references are verified and immigration checks are carried out, gaps in employment histories must be fully explored at interview and recorded. New staff must receive appropriate levels of induction and ongoing training to ensure they have and maintain the skills and knowledge needed to care for vulnerable people. The issues identified in this inspection highlight the importance of the home having appropriate leadership, a manager must be registered to ensure accountability and direction for the home. Quality monitoring systems need to be developed to ensure people who use the service can be heard and listened to and their views considered in annual development plans A fire risk assessment must be in place to ensure the safety of residents, staff and the premises • • • • • • • Please contact the provider for advice of actions taken in response to this Glenhurst Manor DS0000003939.V360395.R01.S.doc Version 5.2 Page 7 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. Glenhurst Manor DS0000003939.V360395.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 Glenhurst Manor DS0000003939.V360395.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): 3 (Standard 6 is not applicable) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The admissions procedure ensures that assessments are undertaken to ensure that only residents whose needs can be met by the home are offered places there. EVIDENCE: Since the last inspection, the deputy manager confirmed there has been only one admission to the home. The care file for this resident was reviewed and showed to hold a completed pre-admission assessment. The assessment addressed the resident’s needs in terms of personal care, communication, diet, mobility, social care and relationships and health care. A letter was held on file indicating that the home had written to the resident confirming that based on the assessment findings, the home was able to meet the residents needs. Glenhurst Manor DS0000003939.V360395.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The current systems for care planning to not provide care staff with detail of each resident’s assessed health and personal welfare needs and how these are to be met by staff in the home. Medication systems are generally well managed in the interests of residents although audit trails need to be clearer. Residents spoken with confirmed they are treated with respect and their dignity is upheld by staff practices. EVIDENCE: Under this section of the report, requirements have been made repeatedly in previous inspections, the last inspection in November 2007 repeating three requirements that required urgent attention. This inspection has evidenced that little progress has been made in ensuring that these issues have been addressed in the best interests of residents. Glenhurst Manor DS0000003939.V360395.R01.S.doc Version 5.2 Page 11 Four resident care files were examined and deficiencies were found in the following areas: File 1. - indicated that the resident retained a high level of independence in meeting her own care needs although in relation to personal hygiene needs, the care plan indicated that staff should ‘assist with a shower once a week’; the record of the residents personal care routine indicated that one shower had been assisted since January 2008. This residents care file also identified a risk of wandering, a record of a doctor’s visit stated that the doctor had been called due to ’deterioration in dementia’. There was no record on the resident’s assessment information concerning a diagnosis of dementia and no dementia care programme in place. Glenhurst Manor is not registered to care for residents with dementia type illnesses. A care plan review form for this resident was blank, there had been no review of care provided since October 2007. File 2. - indicated on the assessment proforma that the resident was ‘diabetic’ although the form went on to say that the resident ‘liked to eat in her room’; this is a statement of the residents wishes rather than an assessment of her need in relation to diabetic care. The care plan for this resident informed staff to ensure that a ‘sugar free diet’ was given and stated that the resident monitored her own sugar levels through daily urine testing which is recorded in a diary by the resident. The care plan informed staff that the district nurse was to be called if there were ‘any problems’ and for blood sugar testing. There was no implicit instruction regarding the action necessary should the resident become hypo/hyper-glycaemic or how to recognise this and no instruction to check the resident’s recording of urinalysis to ensure it remains within acceptable parameters. This resident had a moving and handling assessment completed which indicated a medium risk – there was no associated action plan informing staff how these risks should be reduced or eliminated. File 3. - indicated on a review of assessment that the resident required the use of a wheelchair at all times, this review was not dated, the care plan for this resident informed staff that the resident should use a walking aid and wheelchair when ‘feeling weak’. This file held a moving and handling risk assessment that indicated a high risk and a nutritional risk assessment that indicated the resident was ‘at risk’, there were no associated action plans. File 4. – was for a resident admitted for a period of respite care. A set ‘Standex’ proforma was used to hold this residents details although none of the assessment information had been completed and there were no care plans. Glenhurst Manor uses a standard recording format; this provides much of the necessary paper work needed to ensure all aspects of each resident’s needs are assessed and enables care routines to be programmed. The forms are not Glenhurst Manor DS0000003939.V360395.R01.S.doc Version 5.2 Page 12 used to their best advantage and areas of need that fall outside the given format are not addressed. For example, residents who retain control over their own medicines are not assessed regarding their ability to do so or any risks associated with self medicating. The forms provide a checklist for personal care routines. A review of these for each resident’s file seen showed that staff write a code daily to indicate whether the resident has had a wash, bath, hair wash, bed linen change etc, the daily record sheets provided are not routinely used by day staff to evidence care as provided, any observations or indicate aspects of the residents life in the home. Occasional entries by the deputy manager were made in relation to specific events or health changes. The daily record sheets are used regularly by night staff who provide good descriptions of resident’s night routines and any significant occurrences. Of the four files examined, three contained limited care plans that did not address all of the resident’s personal, health, safety and social care needs, risk assessments had no action plans and assessments and care plans were not reviewed or updated. Medication systems were examined; a locked medicines trolley is kept in the dining room and additional locked storage is available for stocks. The contents of the cabinet were noted to be in order with records supporting the use of the monitored dosage system. The monitored dosage system is used for most medications although where medicines are not suited to this type of packaging, they are issued in boxed or bottled containers, these had not been dated on opening and did not all audit with records of medicines held and administered for residents. Some liquid medicines had the instruction to store below 20 degrees centigrade although there was no thermometer available to monitor the temperature of the storage. Medication administration records had been signed appropriately. A locked cabinet in the office area of the home holds stock medicines and controlled drugs storage, and a secure box in the refrigerator is used to store eye drops; these were checked and found to be in order. Residents spoken with complimented the care they receive and stated that they are treated respectfully by a kind and caring staff group. Glenhurst Manor DS0000003939.V360395.R01.S.doc Version 5.2 Page 13 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. The absence of effective assessments and care recording systems leaves staff without formalised action plans to follow in order that each service users assessed needs in relation to social, cultural, religious and recreational activities are met, this also limits evidence that residents are able to exercise choice and control over their lives. Residents however perceive generally that the services meet their needs. Family and friends are able to visit at any time. Meals in the home are well accepted by residents who confirmed their dietary needs are well catered for. EVIDENCE: Resident’s needs are not fully assessed (See previous sections of report) and care is not planned around individual social needs. Residents spoken with generally confirmed that they felt there was sufficient to keep them occupied and that their needs in relation to recreational and social activity were met. Residents confirmed that family and friends were able to visit openly and those Glenhurst Manor DS0000003939.V360395.R01.S.doc Version 5.2 Page 14 spoken with confirmed that they were able to go out with family and friends as they pleased. In the home, residents spoken with stated that they kept themselves occupied with books, newspapers, television and each other’s company in the lounge, as they felt appropriate. Meals are provided from a central kitchen, the kitchen, food supplies and records of food provided were not examined. Care plans associated with nutritional assessments were not available for staff reference in order that individual nutritional requirements could be met. Residents spoken with confirmed that the provision of meals was good and that food was well presented and appetising. Records of food provided evidenced that there is a set midday meal and although choices are not available, alternatives would be given if it were known that the resident did not like a particular dish. The evening meal is provided by choice, residents are asked during the course of the day what they would like and this is provided, records showed the evening meals to consist of a variety of soups, sandwiches, toast, cheese and biscuits etc. Residents confirmed that they are able to enjoy a glass of wine or fruit juice with their meal. Glenhurst Manor DS0000003939.V360395.R01.S.doc Version 5.2 Page 15 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. Policies and procedures are in place to protect the residents living at the home although to ensure that any incidents will be managed appropriately staff training in adult protection needs to continue. EVIDENCE: A complaints procedure is available to residents and visitors to the home. This details the action necessary should any complaints be received; The deputy manager confirmed that no complaints have been received. The deputy manager also confirmed that an adult protection policy is in place with procedures detailed for contacting the appropriate authorities should any concerns or allegations be made and that this had not changed since the last inspection, the procedure was not examined as 0part of this visit. A requirement of the last inspection has been partly addressed as 5 members of staff have now undertaken training in issues relating to abuse and adult protection, it is a statutory obligation for all staff to attend this training and the registered person is urged to continue with this training programme for all staff. Glenhurst Manor DS0000003939.V360395.R01.S.doc Version 5.2 Page 16 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. Residents live in a clean, comfortable, safe and well-maintained environment, which meets their individual needs. EVIDENCE: Residents spoken with confirmed that they are comfortable in their rooms and are able to bring personal effects to make their space more homely, a tour of the premises and viewing of some of the rooms confirmed this. The communal lounge and dining areas are comfortable, well furnished and pleasantly decorated. All rooms have en-suite facilities except one which has exclusive use of a private bathroom; are clean and well maintained. Call points are sited appropriately around the home and residents spoken with confirmed these are answered promptly by staff. Glenhurst Manor DS0000003939.V360395.R01.S.doc Version 5.2 Page 17 Residents confirmed that the laundry system is effective with clothes etc being taken for laundering and returned the following day, pressed and in good condition. Infection control procedures are observed with provision of proper hand washing facilities. Glenhurst Manor DS0000003939.V360395.R01.S.doc Version 5.2 Page 18 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 poor. This judgement has been made using available evidence including a visit to this service. Staffing levels may meet the needs of the people using the service, needs have not been thoroughly assessed and care delivery is not planned, staffing levels are therefore subjective. Safe staff recruitment procedures are not used in assessing the suitability of newly appointed staff which could leave residents vulnerable. Staff training programmes are developing although more work needs to be done to ensure all staff are kept up to date with the necessary skills needed to meet residents needs. EVIDENCE: Overall resident dependencies have not been measured and individual assessments and care plans for residents do not give a clear indication of actual need, the numbers of staff on duty is therefore subjective. Rotas seen confirmed that there are between five and six care staff on duty each morning, three each afternoon and two each night. A senior member of care staff is also on duty throughout the day. There is a domestic housekeeper in the home each weekday morning and a chef to prepare the midday and evening meal. Residents spoken with indicated that there are sufficient numbers of staff Glenhurst Manor DS0000003939.V360395.R01.S.doc Version 5.2 Page 19 available and requests for assistance are answered promptly although the absence of comprehensive assessments makes staffing requirements difficult to measure. Staff training has been provided in the following areas although many staff are due for up-dates/refresher courses to ensure their knowledge and skills remain current. • • • • • • • • Health and Safety: - 6 staff First Aid: - 1 staff Moving and Handling: - 9 staff Infection control: - 1 staff Adult protection: - 5 staff Food hygiene: - 10 staff Medicines management: - 4 staff Additionally, some training has been provided in the following areas of care: Continence (1 staff), Older persons Mental Health (6 staff) The deputy manager confirmed that five members of staff have attained NVQ level 3. Whilst it was evident that training programmes are in place, it is necessary for all staff to have basic training in the areas identified. Two staff files were examined, on both files there were gaps in the applicants employment history and no indication where the references had been obtained from. On one file there was work permit/visa demonstrating the applicants rights to employment. There is no Skills for Care Induction programme in place for newly appointed staff. Glenhurst Manor DS0000003939.V360395.R01.S.doc Version 5.2 Page 20 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 poor. This judgement has been made using available evidence including a visit to this service. The absence of a registered manager has left the home, its residents and staff vulnerable and without clear direction or leadership. Quality monitoring systems are in their infancy and need to be developed to ensure residents and stakeholders can have their say about services provided People are supported to manage their own money where possible; there financial interests are protected by the home’s policy Health and safety policies and procedures are not reviewed to ensure the protection of residents, staff and the premises EVIDENCE: Glenhurst Manor DS0000003939.V360395.R01.S.doc Version 5.2 Page 21 Glenhurst Manor has been without a registered manager for over a year. At this inspection the deputy manager confirmed that a person had been appointed who was to manage the home and apply for registration with the Commission in due course; this person was due to commence employment later during the week of inspection when satisfactory POVA and CRB had been received. Although the appointment of a manager is imminent, the requirement remains that a person must be registered with the Commission to manage the home and take the lead in ensuring the home meets the National Minimum Standards. Quality Assurance programmes are in their infancy, the deputy manager confirmed that questionnaires have been sent to residents prior to a residents meeting, suggestions made on the returned questionnaires, she confirmed, were acted upon and a suggestions box is available in the homes entrance in which residents and visitors can leave their comments. There is no formalised system of measuring and ensuring the home’s quality of provision in relation to its care and services, the requirement of the last inspection is repeated. In order to protect residents, the deputy manager confirmed that it is the policy of the home not to have any involvement with their personal finances. Therefore, any resident unable or not wishing to handle their own affairs has a relative or other representative to deal with their finances etc. There was no Fire Risk Assessment available, internal testing of fire alarms, emergency lighting and fire fighting equipment is carried out at regular intervals. The last staff fire training was in June 2007 although not all staff attended this meaning there are staff on the premises who have not received the required level of fire training Risk assessments were in place relating to general risks associated with use of the laundry, hot water, slips, trips and falls, use of the hoist and risks of residents wandering; caution is needed to ensure these are regularly reviewed an updated. Glenhurst Manor DS0000003939.V360395.R01.S.doc Version 5.2 Page 22 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 1 8 1 9 1 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 3 29 1 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 X 3 X X 1 Glenhurst Manor DS0000003939.V360395.R01.S.doc Version 5.2 Page 23 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 OP8 Regulation 14 Requirement Where assessments of moving and handling needs, pressure sores and mental health identify risks, action must also be taken and recorded to reduce or prevent the hazard. This is the third time that requirements have been made regarding pressure sore assessment and care. This inspection evidenced that where risk assessments are completed, no action plan is available for staff detailing what action needs to be taken to reduce or eliminate identified risks. This issue will now be referred to the Regional Enforcement Team Timescale for action 2. OP29 19 & schedule 2 The registered person must ensure that the home operates a robust recruitment procedure. Two written references, one of which is from the person’s last employment, must be received prior to commencement of DS0000003939.V360395.R01.S.doc Version 5.2 Page 24 Glenhurst Manor employment. This is the third consecutive inspection that has resulted in this requirement and other previous inspections have also raised this matter. This inspection also noted that staff are employed prior to references being verified and without necessary immigration checks. This issue will now be referred to the Regional Enforcement Team 3. OP30 18 All new staff must receive induction training as directed by Skills for Care. This is the second inspection that has made this requirement, failure to address this issue may result in referral to the Regional Enforcement Team 4. OP7 15(1) Each resident must have a comprehensive plan of care, generated from detailed assessment, which details all of their health, personal and social care needs and how these are to be met. The poor quality of care plans has been an ongoing issue and this is the 4th consecutive inspection which has resulted in a requirement. This issue will now be referred to the Regional Enforcement Team 5. OP8 14 The registered person must ensure that nutritional screening of residents is undertaken on admission and subsequently on a periodic basis, a record must be maintained of nutrition, including weight gain or loss, and DS0000003939.V360395.R01.S.doc Version 5.2 Page 25 Glenhurst Manor appropriate action taken. This is the 4th consecutive inspection that has resulted in a requirement regarding this matter. This inspection evidenced that where nutritional risk assessments are completed, no action plan is available for staff detailing what action needs to be taken to reduce or eliminate identified risks. This issue will now be referred to the Regional Enforcement Team 6. OP9 13 Medicine records and audit trails must be regularly monitored, the outcome and action taken recorded to ensure that medicines are given as prescribed and accurately recorded. The provider must appoint a suitably qualified, competent and experienced person to manage the home and put them forward for registration with the Commission. Effective quality monitoring systems must be put in place to measure the homes success in meeting its stated aims, objectives and statement of purpose. This is the second inspection that has made this requirement, failure to address this issue may result in referral to the Regional Enforcement Team Staff members must be updated in all areas of mandatory practice, as required. This must include updating in manual handling, health and safety, infection control, emergency aid DS0000003939.V360395.R01.S.doc Version 5.2 Page 26 7 OP31 8(1) 8 OP33 24(1) 9 OP38 12(1) Glenhurst Manor and basic food hygiene. Whilst this inspection found there to have been some improvement in staff training profiles, this requirement remains as records evidenced just one member of staff having received infection control training and one having emergency aid training and four staff members have not received fire safety training in over a year This is the third consecutive inspection that has resulted in this requirement. This issue will now be referred to the Regional Enforcement Team 10 OP38 12(1) There must be a Fire Risk Assessment in place, reviewed regularly and staff must receive the required level of fire safety/awareness training 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 OP9 Good Practice Recommendations It is recommended that staff members should have training in the use of the tablet counter to prevent possible contamination loss of medicines when counting tablets for stock balance purposes. This recommendation is repeated as the deputy manager confirmed that there is no tablet counter available, a saucer is used. 2. OP9 Handwritten amendments and additions to medicine administration records should be signed and dated by the DS0000003939.V360395.R01.S.doc Version 5.2 Page 27 Glenhurst Manor writer and by someone who has checked the entry for accuracy. This recommendation is repeated as not all hand written amendments were double signed The registered person should consider the provision of a separate staff toilet. Progress is being made and feasibility studies have been undertaken. This recommendation is repeated as this issue isnot yet addressed 3. OP21 Glenhurst Manor DS0000003939.V360395.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Glenhurst Manor DS0000003939.V360395.R01.S.doc Version 5.2 Page 29 - 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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