Inspection on 17/05/05 for Glenhurst Manor

This inspection was carried out on 17th May 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

Glenhurst Manor 22/06/09

Glenhurst Manor 03/12/08

Glenhurst Manor 04/06/08

Glenhurst Manor 10/03/08

Glenhurst Manor 06/11/07

Glenhurst Manor 29/06/06

Glenhurst Manor 03/03/06

Glenhurst Manor 26/10/04

Glenhurst Manor 27/05/04

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

CARE HOMES FOR OLDER PEOPLE Glenhurst Manor 44a West Cliff Road Bournemouth Dorset BH4 8BB Lead Inspector Gloria Ashwell Unannounced 17 May & 2 June 2005 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. Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Glenhurst Manor Address 44a West Cliff Road Bournemouth Dorset BH4 8BB 01202 761175 01202 761164 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) Mr Kevin Robin Ellis Mrs Helen Eve Sopp Care home only (PC) 36 Category(ies) of Old Age, not falling within any other category registration, with number (OP) of places Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 29 October 2004 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. Mrs Helen Sopp is the Registered Manager. 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. Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was one of the two statutory inspections required in accordance with the Care Standards Act 2000. The previous inspection took place on 26 October 2004; since that inspection no complaints against the home have been received or investigated. The inspection took place over two days; the inspector arrived (unannounced) at 14.20 on 17 May 2005. During the inspection she spoke to 21 residents, 3 care workers and 2 visiting relatives. The inspector observed staff interaction with service users, the carrying out of routine tasks and toured the premises, departing at 16.30. The inspector left a selection of ‘Comment Cards’ and prepaid envelopes (for return to the Commission) in the entrance hallway of the home. Additional information used to inform the inspection process included two subsequently completed Comment Cards and formal notifications of events provided to the Commission by the home. As agreed with manager Mrs Sopp, the inspector returned to the home at 10.00 on 2 June 2005 and together with the manager considered other evidence relating to the National Minimum Standards, as described in this report. The duration of the inspection (both days combined) was 7 hours and 50 minutes. What the service does well: The home provides good care to residents who are mainly of low and medium levels of dependency, and thereby able to remain actively involved in decisions regarding their lives and activities. Residents are assisted to maintain as much independence as possible and are encouraged to maintain contact with the local community. Meals are appetising and of good quantity and quality. The premises are comfortable, with spacious lounges and a large dining room, overlooking attractive gardens. Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 Page 6 Staff are kind and helpful to residents. Residents are treated with respect and their privacy is protected. 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. Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 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 Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 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) 1, 2, 3, 4, 5 & 6 The home does not have an adequate service user guide and Statement of Purpose despite related requirements having been made in previous reports. In consequence, prospective residents are not provided with sufficient information about the home, to assist them in their decision about where to live. A written contract is provided to each resident at the time they enter the home to ensure clarity regarding fees and what they do and do not cover. Prior to admission, the needs of each proposed resident are assessed to ensure the home will be properly able to meet them but the home does not then write to prospective residents confirming the ability to properly care for them. Prospective residents (or their representatives) are encouraged to visit Glenhurst Manor in advance of admission to establish their impressions of life at the home and the available accommodation. Standard 6 is not applicable for Glenhurst Manor; the home does not provide intermediate care. EVIDENCE: Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 Page 9 The home does not have a service user guide and Statement of Purpose providing all information described in the National Minimum Standards and the Regulations of the Care Standards Act 2000. The documents are currently being prepared; the manager expects them to be completed by the end of June 2005. The records of a recently admitted resident included details of pre-admission assessment of the residents needs carried out by the manager during various visits made to Glenhurst Manor by the prospective resident, to ensure her understanding of the person’s circumstances and health. The resident visited a few times, viewed the home and on at least one occasion ate lunch with residents and thereafter awaited availability of the room personally selected. A resident said that before moving into the home permanently, short stays had been made, and thereby “knew what I was coming to when I came here. This resident was entirely satisfied with life at Glenhurst Manor and said “If you have to stay anywhere, especially if you’re alone, this is as good as anywhere….I would say it’s very well run”. Following pre-admission assessment, if the home decides to offer a place to a new resident, they do not write to the person stating that Glenhurst Manor will be able to meet their assessed needs; a related requirement has been made to address this shortfall in practice. Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 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 and 10 Care needs are briefly and sometimes inadequately described in a written plan of care, which do not all ensure staff have information necessary to provide correct care to each resident. Nonetheless, the standard of care is good; residents feel well cared for. There is not a reliable system for identifying and minimising risks to residents prone to falling or other harm. Medicines prescribed by doctors are safely stored and carefully administered to residents by staff who have received some related training, thereby protecting residents from risks of medicine errors. Some improvements to the record keeping associated with medicine handling are necessary to ensure that residents continue to receive the correct medicines and that all medicines held in the home are properly accounted for. The provision of staff training in medicine handling should be improved, to ensure it meets established standards. Residents are treated with respect, their privacy is protected and staff understand and meet their needs. EVIDENCE: Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 Page 11 Care plans are very brief, comprising more a summary of needs than a comprehensive plan of care; the forms used provide insufficient space for details of changes in need and associated care provision. Essential information including possible deterioration in condition, emergency action to be taken by staff, and details of on-going care needs was not stated for two residents with special health needs. In discussion with the inspector the manager demonstrated good understanding of both conditions. Residents and their relatives said they are properly cared for; comments included “I feel very well looked after”, ”if you want to see a doctor they’ll take you there” (doctors also visit residents in the home), “I think (the resident) is beautifully looked after; if only every home was as good as this one”. All accidents are recorded, but subsequent actions taken to minimise the risk of recurrence are not always recorded; the home does not have a policy and procedure for accidents and does not periodically audit accidents to identify any trends or patterns (e.g. in time, place, person or activity) and subsequently to introduce measures to reduce the risks. The inspector described to the manager the importance of using an accident recording system suited to effective data protection and confidentiality of records. The home uses the monitored dosage system; the dispensing pharmacist provides tablets in cassettes and printed administration charts. Residents are assessed for their ability to manage their own medicines; at the time of inspection a number were doing this. The home has storage facilities for most medicines; there are no Controlled Drug storage or recording facilities and to date, these have not been needed. Staff involved in handling medicines have received training in this work from the dispensing pharmacists, but have not received accredited training in this regard. Records indicated that medicines had been accurately administered but the records must be improved to ensure that residents receive correct medicines and doses, and that the home can properly account for all medicines held. Medicine administration records (MARs) did not state the allergy status (to medicines) of each resident, stock balances were not recorded for Temazepam tablets, handwritten amendments to the printed MARs were not signed and dated, records did not state the amount actually given when a variable dose was prescribed, the reason for as required administration record was not always stated on the MAR and there was not a summary of all medicines prescribed for each resident, describing purpose and possible side-effects. Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 Page 12 Residents are treated with respect and their privacy and dignity is promoted; staff are kind and considerate, and keen to assist residents. Residents are confident they can receive help when needed; comments included “If you need them, they always come”, “When I’ve (been suddenly unwell) they’ve always acted so quickly”, “I feel safe, quite safe”. Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 14 and 15 Residents are encouraged to maintain contact with the local community and visits by their friends and relatives are welcomed by the home. The quality of daily life in the home is very good with residents assisted to maintain as much independence as possible. Meals are appetising and of good quantity and quality and are served in the dinging room or residents private rooms, in accordance with individual preference. EVIDENCE: The inspector spoke to a number of residents; all expressed great satisfaction with every aspect of the home, including the meal provision, staff and premises. Comments included “This is ideal for me”, “There’s no ‘Go here, do that”, and a resident due to depart after a short stay for respite care said “It’s been excellent – peace and quiet – which was what I needed”. Visitors are permitted to visit at any time and feel welcomed by the staff; one said “They all seem very friendly”. Residents can go out whenever they wish to; during the inspection a number were seen to be ‘coming and going’. Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 Page 14 Meals are served in the dining room or in residents’ bedrooms, at their individual preference. Residents said that food is of good standard, for quality, choice and quantity. Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed during this inspection. EVIDENCE: Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 22, 23, 24, 25 & 26 With the exception of the shabby carpets of a ground floor corridor and the ongoing redecoration of some corridor walls, the home is attractive, comfortable and well decorated, providing a pleasant living environment. All residents can use the well-appointed communal use rooms – a large lounge and separate dining room, and well maintained gardens to front and rear of the home. The home has not been assessed by an Occupational Therapist or similarly qualified person, to ensure it is suitable to meet the various needs of residents. The call system enabling residents to summon prompt assistance as required does not extend to the communal rooms. Residents’ bedrooms are suitably decorated and furnished; many residents have brought items of their own furniture and a number have private telephones installed. Risks of accidental scalding by radiators and exposed pipe-work have been assessed and a programme of installing covers is nearing completion. Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 Page 17 Arrangements have been made for the water installation to be inspected to ensure the safe supply of water to the home. EVIDENCE: Most of the home is attractively furnished and decorated, but the carpets of the ground floor rear corridor are worn and stained and sections of ground and first floor corridor walls are in poor repair, having been prepared for redecoration. The home does not have a written programme of redecoration and refurbishment, although this has been recommended in previous inspection reports. The report of the previous inspection (October 2004) recommended replacement of the shabby ground floor corridor carpets; this has not been done but the work is intended to take place during this summer. This report includes a requirement with a timescale for completion of this work. On the ground floor is a large lounge, partly divided into two sections by an arch, with an adjoining dining room. All these rooms are well appointed, with comfortable domestic style furnishings, good natural light and views over the rear garden. An engineer has arranged to inspect the water supply of the home on 23 June 2005; the report of this examination must be made available at the next CSCI inspection. The home stores hot water at 60C or higher, to prevent risks of Legionella contamination, but must be able to provide evidence of checks or tests to support this method. The home has not been assessed by an Occupational Therapist or similarly qualified person, to ensure it is suitable to meet the needs of residents; the currently accommodated residents are of varying dependency levels – most have low or medium dependency needs, but some have high needs. A call system is installed in all residents’ bedrooms and bathrooms enabling them to summon prompt assistance as required. The call system is not installed in the communal rooms (lounges and dining room) because staff are frequently present in these rooms and the registered provider considers it unlikely for one resident to be alone, and in need of assistance, in these rooms at any time. In accordance with the requirement of a previous inspection report, the absence of call bells in these rooms has been risk assessed; the documentation was not examined during this inspection. Residents’ bedrooms are comfortable, clean and well appointed. Rooms are provided fully furnished, but residents can bring suitable items of furniture into Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 Page 18 the home; one said that she and another resident had chosen to bring “our own pillows, armchairs, telephone…..”. In the basement there is a laundry, used only by staff. The laundry machinery was replaced during 2004, it is now suitably equipped with a large tumble dryer and two industrial style washing machines with disinfection programming capacity, enabling cross-infection risks to be minimised. Access to the basement is by hazardous steep narrow steps; all laundry must be carried up and down the steps. The laundry room is small and poorly ventilated; because it also accommodates the heating boiler it is frequently uncomfortably warm. The home must record risk assessment for use of this room, which may compromise staff health and safety. Arrangements for locking the door to the basement must be reviewed, to ensure residents are not placed at risk by inadvertently entering this area; the door is kept locked when no staff are in the basement, but when staff are working in the laundry the door, which opens directly onto the steep basement stairs, is left unlocked. Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 Page 19 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 and 30 Staffing levels are significantly below those recommended by the Department of Health guidance calculation. Staffing levels allow the meeting of residents’ health needs but residents feel staff are often rushed and under pressure and have too little time to talk to them. Recruitment and employment practices do not reliably protect against risks of unsuitable staff being employed. A related Immediate Requirement was issued during the inspection. There is insufficient time for staff to receive formal supervision, appraisal and training. EVIDENCE: The Department of Health calculation indicates that, based on the dependency levels of currently accommodated residents, at least 590 care staff hours should be provided each week; during the last two weeks of May 2005 the home provided care staffing at 393.5 and 417.5 hours. The home is seeking to increase care staffing by 18 hours each week; when filled, this will still leave the total hours significantly below the recommended amount. Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 Page 20 A Comment Card received by the Commission states “they do not always have time to listen or to respond to requests which are important to the resident”. Employment records of a recently employed care worker were examined and found to include only one reference; there was no POVA/CRB disclosure, an incomplete history of employment and no evidence of identity. Although staff work under the continuous supervision of senior carers, there is no process of formal and recorded supervision and appraisal, so individual weaknesses and training needs may not be identified. New staff receive a brief induction to the home; they do not undertake TOPSS standard training, so are not reliably prepared for the work they are to carry out. Only 4 of the 17 care staff employed possess a National Vocational Qualification (at Level 2 or above) in care; one carer already in possession of NVQ L2 is now training for L3, and another (with no NVQ) is also training for L3. When these courses are completed, the number of NVQ trained staff will have risen by only 1, to 5 – still significantly below the expected target of 50 of the 17 employed. In consequence, insufficient staff have received formal training in care work and this shortfall may adversely affect care standards.. Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 Page 21 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) 31 and 38 The registered manager is Mrs Sopp; she is suitably experienced and well regarded by residents and staff, who consider her approachable, fair and knowledgeable. When Mrs Sopp has completed the Registered Managers Award/NVQ 4 in Care & Management she will be able to fully discharge her responsibilities. Fire safety equipment is regularly checked and tested but risks identified during formal assessment must be minimised. Comprehensive safety assessment of the premises and working practices has not been recorded. EVIDENCE: Mrs Sopp has been the manager of Glenhurst Manor since December 2002, becoming registered during May 2003. She has extensive experience of care work at all levels, and has previously been the registered manager of other care homes for at least ten years. Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 Page 22 Mrs Sopp has commenced training for NVQ Level 4 in management but at present has indefinitely postponed completion of the course. Residents refer to Mrs Sopp as ‘Helen’ and feel confident in their dealings with her. During the inspection a number of residents approached her with enquiries ranging from the location of their own daily newspaper to arrangements for payment of fees; one said that in the event of dissatisfaction “anyone would feel free to put a complaint forward”. Staff hold Mrs Sopp in high regard; comments included that she is “very good…knows her job…right attitude – is very caring…fair, very kind to all staff…expects high standards…”. There are regularly recorded checks and test of fire safety equipment. A fire safety assessment report dated 30 June 2004 identified a number of “unacceptable” low and medium risks and stated “A review should be undertaken after 3 months by which time all deficiencies should have been corrected and Management Control Measures set up”. This has not been done. The home has developed guidance on Health & Safety risk assessment of the premises and working practices, but has not undertaken the assessment to identify potential risks and introduce measures to manage/reduce them. Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 Page 23 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 1 3 2 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 3 x 2 3 3 2 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 2 x x x x x x 2 Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 Page 24 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 1 Regulation 4 Requirement The Registered Person must produce a Statement of Purpose which conforms to schedule 1 of Care Homes Regulations. This is the 7th time that this has been required. Previous timescale of 31/03/05 not met. The Registered Person must prepare a Service Users Guide in accordance with according to the National Minimum Standard and Regulation 5. Once completed, a copy must be lodged with the Commission for Social Care Inspection and one given to each service user in the home. Previous timescale of 31/03/05 not met. Following pre-admission assessment, when the home decides to offer a place to a new resident, they should firstly write to the person stating that they will be able to meet their assessed needs. A comprehensive care plan must be recorded for each resident. The stock balance of Temazepam must be recorded following each administration of the medicine. Timescale for action 1/08/05 2. 1 5 1/08/05 3. 3&4 14(1)(d) 3/07/05 4. 5. 7 9 17 13 3/07/05 3/07/05 Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 Page 25 6. 9 13 7. 19 16(2) 8. 22 16 & 23 9. 10. 25 26 13(3) 13(3) 11. 12. 26 26 & 38 13 (4) & 23 (3) 13 13. 29 19 & Schedule 2 14. 38 23(4) 15. 38 13 When a variable dose is prescribed the amount actually administered must be recorded on each occasion. The worn and shabby ground floor corridor carpets must be replaced and the corridor redecoration must be completed. There must be evidence of assessment of the premises and facilities, by an Occupational Therapist or similarly qualified person, to ensure it meets the needs of residents There must be written evidence of measures taken to prevent risks from Legionella. The home must provide evidence of compliance with the Water Supply (Water Fittings) Regulations 1999. Previous timescale of 31/03/05 not met. Risk assessment must be recorded for use of the laundry. Arrangements must be implemented for use of and locking the basement door, to minimise risks of accidental falling. There must be evidence that the home operates a robust recruitment procedure. New staff must not commence work in the home without evidence of suitable CRB and POVA disclosure. A similar Immediate Requirement was made in the report of the previous inspection, but remains unmet. There must be recorded evidence of minimising the risks identified by fire safety assessment. Comprehensive Health & safety assessment of the premises and working practices must be 3/07/05 1/10/05 1/10/05 1/10/05 1/10/05 03/07/05 03/07/05 2/06/05 3/07/05 1/10/05 Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 Page 26 recorded. 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 1 Good Practice Recommendations The statement on visiting included in the Statement of Purpose should be amended to include reference to service user choice in respect of receiving visitors, guidelines on visiting and the expectations of visitors conduct whilst in the home. (This recommendation was also included report of the previous inspection) Care plan documentation should be amended to provide more space for review outcomes and changes to needs and circumstances. The home should develop and implement a policy and procedure for dealing with accidents, to include periodic audit. The medicine administration records for each resident should clearly state any allergy to medicines, or none known. Handwritten amendments and additions to medicine admnistration records should be signed and dated by the writer, and countersigned by somewhat who has checked the entry for accuracy. All staff involved in handling medicines should receive accredited training in this work. Facilities for the correct storage and recording of Controlled Drugs should be provided. There should be a written summary of all medicines prescribed for each resident, describing purpose and possible side-effects. When a medicine is prescribed for administration as required the administration record should clearly state the reason for which it is required. The adult protection policy should be improved to include the telephone number of the relevant police station and social services authority, reference to the procedure for notifying CSCI of any allegations under regulation 37 of the Care Home Regulations 2001 and the procedure for referring staff to the Protection of Vulnerable Adults register (POVA). D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 Page 27 2. 3. 4. 5. 7 8 9 9 6. 7. 8. 9. 10. 9 9 9 9 18 Glenhurst Manor 11. 19 12. 13. 22 27 14. 28 15. 29 16. 17. 30 31 This recommendation was first made in the report of the previous inspection; the manager stated it has not been met. A written programme of routine maintenance and renewal of the fabric and decoration of the premises should be produced. This recommendation was also made in the reports of the two previous inspections. The service user guide should clearly state rooms which do, and do not, have the call system installed. Staffing levels should be reviewed in accordance with the residential forum calculation for the number of care hours provided. This recommendation was also included in the report of the previous inspection. The Department of Health target of achieving 50 of care staff qualified at NVQ 2 should be met. A similar recommendation was included in the report of the previous inspection. A record should be kept of the interview of each prospective staff member. This recommendation was also included in the report of the previous inspection. Care staff should receive supervision 6 times a year. This recommendation was also included in the report of the previous inspection. The manager should attain NVQ Level 4 in management by the target date of 2005. This recommendation was also included in the report of the previous inspection. 18. Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection Unit 4 New Fields Business Park Stinsford Road Poole Dorset BH17 0NF 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 Glenhurst Manor D55 S3939 GLENHURST MANOR V223644 170505 Stage 4.doc Version 1.30 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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