Inspection on 29/06/06 for Glenhurst Manor

This inspection was carried out on 29th June 2006.

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 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 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Glenhurst Manor 44a West Cliff Road Bournemouth Dorset BH4 8BB Lead Inspector Carole Payne Key Unannounced Inspection 29th June 2006 09:15 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.V302479.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.V302479.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 Mr Kevin Robin Ellis Mrs Helen Eve Sopp Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Glenhurst Manor DS0000003939.V302479.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd March 2006 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 DS0000003939.V302479.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection was carried out on the 29th June 2006 and took a total of 11 hours, including time spent in planning the visit. The inspector, Carole Payne was made to feel welcome in the home during the visit. The manager, Helen Sopp, was present on the afternoon of the visit. This was a statutory inspection and was carried out to ensure that the twenty-nine residents who were living at Glenhurst Manor were safe and properly cared for. Requirements and recommendations made as a result of the last inspection visit were reviewed. The premises were inspected and records examined. Time was spent in discussion with people living at the home, two relatives visiting the home and two staff members. Nine resident survey forms, two comment cards from members of the multi-disciplinary team, three comment cards from relatives and visitors to the home and four General Practitioner comment cards were received prior to the inspection. Both the manager and provider have given immediate attention to addressing issues raised within this report, which expresses their commitment to making a difference to the quality of life provided to people living at Glenhurst Manor. What the service does well: People considering moving into the home can be confident that their needs will be fully assessed. According to the assessment carried out, the home reassures people that their needs can be met. Prospective residents and their families are welcome to visit the home and assess the quality, facilities and suitability of the service. Comments received regarding the service included: ‘The home in general is excellent.’ ‘All the staff in the home are helpful.’ ‘I would thoroughly recommend the home.’ People living at Glenhurst Manor are treated with care and respect for their privacy and dignity. ‘Residents are treated in an understanding and sympathetic way.’ They are confident that their complaints will be listened and responded to. ‘There is always someone on hand to speak to.’ Glenhurst Manor DS0000003939.V302479.R01.S.doc Version 5.2 Page 6 Residents experience a varied lifestyle, which reflects their interests and needs. Relatives and friends are made welcome at the home and supported to play a part in the life of the service. Contacts are maintained with the local community according to the wishes of residents. People who live at Glenhurst Manor are enabled to make choices about the way that they live. Residents enjoy a varied and appealing diet, in delightful surroundings, at times that are convenient to them. They enjoy warm and comfortable surroundings and there is a high standard of decoration in the home. The numbers of staff working in the home satisfactorily meets people’s needs. What has improved since the last inspection? What they could do better: The registered person must ensure that residents care plans are reviewed at least once a month and clearly updated to reflect changing needs and current objectives for health and personal care, as well as any actions taken. Progress has been made in meeting this requirement. Evidence of consultation with the resident or their representative regarding the plan of care must be recorded. Glenhurst Manor DS0000003939.V302479.R01.S.doc Version 5.2 Page 7 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 appropriate action taken. A pressure sore risk assessment must be carried out in order to assess any risks to skin integrity, supporting the meeting of residents’ healthcare needs. A number of issues in relation to the safe handling of medicines, to protect residents, are outlined in this report. Since the last inspection a tablet counter has been obtained to prevent possible contamination or loss of medicines when counting tablets for stock balance purposes. Staff should have training in the use of the counter. Handwritten amendments and additions to medicine administration records should be signed and dated by the writer and by someone who has checked the entry for accuracy. This is the third time this recommendation has been made. Eye drops should be dated on opening, where they have a limited life when being used. They should be disposed of according to dispensing instructions, and stored in their original container. Residents living at Glenhurst Manor enjoy delightful surroundings. However, there are a number of safety issues within the environment, which the service has expressed commitment to addressing. At present there is one shared toilet on the ground floor, which is available for both residents and staff members. Future consideration of providing an additional toilet would enhance the shared facilities available. Some wardrobes in individual rooms are unsteady. These must be risk assessed and, if unsteady, must be suitably fixed to reduce the risk of harm to residents or staff. The home is in the process of addressing an immediate requirement made at the time of the inspection that water is delivered at a safe temperature, reducing the risk of scalding to service users. A plan is being implemented to ensure that 50 of care staff are trained to a minimum of NVQ level 2 in care. According to a summary of training being completed, 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 and adult protection and the carrying out of induction training in accordance with standards outlined by Skills for Care. 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 employment. 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 DS0000003939.V302479.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.V302479.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4, 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. People considering moving into the home can be confident that their needs will be fully assessed. According to the assessment carried out, the home reassures people that their needs can be met by the service. Prospective residents and their families are welcome to visit the home and assess the quality, facilities and suitability of the service. EVIDENCE: Pre-admission assessments were viewed for two residents. The assessments were detailed and included reference to the needs, wishes and preferences of people considering moving into the service. A copy of a letter was seen that had been sent to a resident, confirming that, according to the assessment, the home was able to meet their assessed needs. Glenhurst Manor DS0000003939.V302479.R01.S.doc Version 5.2 Page 10 During the course of the visit, the manager went to show a family around the home and she confirmed that people are welcome to come and look around at any time, spend time at the service and see if Glenhurst Manor is right for them. Comments from residents returning survey forms included ‘I visited with my family.’ ’My first impression was favourable so I decided to come here.’ Three residents commented that sometimes there was not anyone to talk to as some of the people living in the home have some degree of short-term memory loss or dementia. On the home’s pre-inspection questionnaire the manager has stated that there are currently four people living in the home who have dementia. The manager has coordinated a training programme for staff members in meeting and understanding the care needs of people suffering from dementia. Care support must be regularly reviewed to assess if these needs are the primary need for care. Should this arise the home will then need to be sure that the environment is able to meet these people’s needs and application will need to be made for variation to the home’s registration. At the time of the visit, people with some degree of forgetfulness, enjoyed amicable friendships with other people in the home and were sensitively and caringly supported by care staff members. Glenhurst Manor DS0000003939.V302479.R01.S.doc Version 5.2 Page 11 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, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is making progress in producing clear plans of care, which are reviewed and updated to reflect the personal and social cares needs of residents. By carrying out risk assessments in relation to skin condition and nutrition this will support the home’s firm commitment to meet the healthcare needs of residents. The service supports residents to take responsibility for their own medication, should they choose to do so. Improvements to medication handling will ensure that residents are fully protected by the home’s procedures for the safe handling of medicines. People living at Glenhurst Manor are treated with care and respect for their privacy and dignity. Some service users do not feel confident that the home’s laundry facilities satisfactorily ensures that they have their own clothes returned to them. Glenhurst Manor DS0000003939.V302479.R01.S.doc Version 5.2 Page 12 EVIDENCE: Since the last inspection visit the home has adopted a clear system of assessment / care planning. Following the pre-admission assessment an assessment / plan is devised including activities of daily living. A signature, indicating participation of a resident in the care plan was seen on one of the five files seen. Three relatives / visitors to the home returning comment cards said that if their relative / friend is unable to make decisions they are consulted about their care. Reviews of plans have also started to take place and had been reviewed in April on three of the five files viewed, one had been reviewed in May, the other at the beginning of June. Reviews which had taken place, were thorough and included details of how needs in relation to aspects of daily living may have changed, or how they were being supported by the home. Notes, within both reviews and daily records had not, at all times, resulted in updating of the care plan; for example needs in relation to a person feeling depressed or potential aggressive behaviour had not resulted in amendments to the plan of care. The service, therefore, is making progress in addressing a requirement issued in the inspection report of the last visit to the home, that care plans must be reviewed at least once a month and updated according to changing needs. Some risk assessments were in place, for example in relation to the risk of falls. On one file where a risk of falling had been identified the resident had been referred to a rehabilitation team. It was noted on some files and from discussion with residents and their relatives that some residents were vulnerable in relation to their skin integrity and nutritional status. The use of a nutritional screening tool and pressure sore risk assessment was discussed with the manager, so that risks can be periodically reviewed and appropriate action taken. Weights on two files seen had not been recorded since 2004 and there were no recordings on one other file. The manager said that a list is normally maintained of weights. This could not be found at the time of the inspection. It was advised that the weights are recorded on individual files, so that they can be individually monitored. During the visit the General Practitioner had been called to visit a resident who was unwell. Dental and optical services are accessed in the local community. A relative asked if their relative could see the chiropodist during the next planned visit. Eight people living in the home returning survey forms said that their medical needs were met, one that this was usually the case. Two recommendations were made in the last report regarding the safe handling of medicines. Since the last visit to the home the service has obtained a tablet counter. When using the counter during the visit, the staff member was not clear how to use it to avoid contact with the tablets. All staff members should now receive training in its use. It was also recommended Glenhurst Manor DS0000003939.V302479.R01.S.doc Version 5.2 Page 13 that two signatures are made on the Medication Administration Records when entries are being hand written. Two people had not signed three entries seen; three entries had two initials beside them. Medication Administration Records had been signed when medicines had been given. Medicines in use were stored in a locked trolley; stock medicines were stored in a locked cupboard. The service has a controlled drugs cupboard and appropriately stores Temazepam as a controlled drug. As good practice the home is also recording the administration of Temazepam as a controlled drug. The home has a record book for recording medicines received and a separate record of medication sent for disposal, which is counter-signed at the pharmacy. One set of eye drops with a limited life on opening had expired, two others were stored in the same box, and two boxes had not been dated on opening. The manager disposed of these eye drops at the time of the visit. A risk assessment for the self-administration of medication was seen for one resident, along with a form signed by the resident. No risk assessment had been carried out for a resident who was enjoying a short stay at the service. A resident showed the inspector the safe storage in their room, for the safe keeping of their medicines. On the pre-inspection questionnaire provided prior to the inspection details are provided that training of staff in the safe handling of medicines has been undertaken. Throughout the visit staff members provided sensitive and caring support to residents. Staff members could be heard asking residents if they were comfortable or needed any assistance. Staff members knocked on residents’ doors before entering, and one staff member sought the permission of the resident before entering their empty room. ‘Residents are treated in an understanding and sympathetic way.’ Four residents expressed concern that laundry items are sometimes not returned to them. One resident said that they had not experienced any problems. Two of the residents said that due to the problems they wash some of their clothes themselves. The manager had some clothing items had not been labelled and was keen to address this issue, so that residents could be confident that they would receive their own clothes, on return from the laundry. Glenhurst Manor DS0000003939.V302479.R01.S.doc Version 5.2 Page 14 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, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents experience a varied lifestyle, which reflects their interests and needs. Relatives and friends are made welcome at the home and supported to play a part in the life of the service. Contacts are maintained with the local community according to the wishes of residents. People who live at Glenhurst Manor make choices about the way that they live. Residents enjoy a varied and appealing diet, in delightful surroundings, at times that are convenient to them. EVIDENCE: Prior to moving into the home, and following admission, residents are asked about their interests and hobbies. A calendar of events is produced on a monthly basis. One resident said that they really enjoyed the art sessions, another the quizzes, and another the Scrabble. One resident said ‘I enjoy the Glenhurst Manor DS0000003939.V302479.R01.S.doc Version 5.2 Page 15 music in the afternoon.’ Social activities arranged include entertainment and special events, such as a cream tea, which had been held on the lawns of the home. The gardens of the home are a special place in the warmer weather and residents were enjoying sitting and enjoying its peace, green and landscaped surroundings. A manicurist visits every four weeks and a visiting library service every three weeks. Three residents said that they would like there to be more activities. One person returning a resident survey form said ‘5 or 6 activities a week but not all 5 days covered.’ The manager said that two residents go out to church each week and another two like to receive Communion at the home. Two residents commented that they enjoy being able to go out into the local community, perhaps into Westbourne to the shops and one resident had been down to the sea front early that morning. This resident said that they always have their breakfast early and enjoy being able to take a stroll, when they choose. There is, therefore, flexibility in the daily routine, according to residents’ wishes. Two relatives visiting the home were enjoying time with their family member in the lounge and in the privacy of a resident’s room. Two visitors were enjoying lunch. Both visitors spoken with said that they are made to feel welcome when they visit the home, and express their confidence that their family members are well cared for at Glenhurst Manor. The home has a pleasant dining room, looking out across the home’s gardens. This room is attractively decorated and furnished to a high standard. Tables are well presented to enhance the dining experience. The home has a varied menu. At lunch time alternatives to the meal choices were seen and were also recorded in the home’s records. A member of staff confirmed that some residents like to eat in their own rooms and this is respected. She also said that no current residents require support with eating. The manager spoke of one resident who likes to have an evening snack. Glenhurst Manor DS0000003939.V302479.R01.S.doc Version 5.2 Page 16 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, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents at Glenhurst Manor are confident that their complaints will be listened and responded to. A summary of training being undertaken will identify staff members in need of training in adult protection. This will support the home’s commitment to protect people from abuse. EVIDENCE: The home has a complaints log. No complaints have been received in the last twelve months. An open and responsive approach was demonstrated to any issue raised by a resident. The manager undertook to investigate concerns raised by a resident during the visit. Seven residents responding to the resident survey said that they knew who to speak to if they were not happy; two people said that this was usually the case. ‘There is always someone on hand to speak to.’ All relatives / visitors responding in comment cards said that they had never had to make a complaint. The home has a copy of the local adult protection protocol. According to training files sampled adult protection training last took place in 2004. This now requires updating. Some staff members are engaged in NVQ training, which includes training in abuse. Glenhurst Manor DS0000003939.V302479.R01.S.doc Version 5.2 Page 17 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, 21, 24, 25, 26 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. People who live at Glenhurst Manor enjoy warm and comfortable surroundings. There is a high standard of decoration in the home. Hot water temperatures, uncovered radiators and wardrobes, which are unsteady, potentially compromise the safety of residents. EVIDENCE: On the day of the visit the home presented as a pleasant, well-maintained environment. The home’s gardens offer quiet, secluded surroundings. During the day, some residents went outside to sit, or take a stroll, on the warm summer’s day. Both staff members and residents use the ground floor toilet. All individual rooms aside from one have en suite facilities. One resident commented in a Glenhurst Manor DS0000003939.V302479.R01.S.doc Version 5.2 Page 18 resident survey form returned that the ground floor communal toilet is sometimes locked. On the morning of the visit the person in charge said that this toilet was out of order and the plumber had been called and would be visiting that day. On the afternoon of the visit a staff member said that the toilet was soiled. A staff member said that staff members often use the toilet facilities in an empty room if a room is vacant. A recommendation is included in this report that the registered person should consider providing a separate staff toilet. Individual accommodation is pleasantly furnished and decorated to a high standard, providing personal surroundings, with which residents generally expressed a high level of satisfaction. One resident described how they had moved rooms and that the home had supported them to find a room in which they could experience independence. It was noted that wardrobes in some rooms were unsteady and presented a risk of harm. The manager has spoken with the inspector, since the day of the visit and has said that immediate action has been taken to address the issue of hot water temperatures in some of the en suite baths, which were as high as sixty degrees centigrade on the day of the visit. An Immediate Requirement was issued at the time of the inspection. It is understood that a programme is in place for covering radiators in the home, which may present a risk of scalding to service users. All residents said that the home is always fresh and clean. ‘Very good indeed.’ Glenhurst Manor DS0000003939.V302479.R01.S.doc Version 5.2 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 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, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The numbers of staff working in the home satisfactorily meets residents’ needs. Progress is being made in putting in place training and providing an ongoing programme consistent with good practice guidelines. This will ensure that staff members are well trained and competent to do their jobs, supporting residents to be in safe hands at all times. Further work is needed to ensure that residents are fully supported by the home’s recruitment policy and practices. EVIDENCE: One relative / visitor to the home commented that staff members are ‘always pleasant, helpful and friendly.’ From records of staff rosters seen at the time of the visit, observation of staff carrying out their work and discussion with the manager, the home maintains staffing levels, which meet the needs of residents living in the home. At the time of the visit twenty-seven residents were living in the home. The manager and five care staff are normally on duty in the morning, three care staff in the afternoon and two staff members are awake at night. Glenhurst Manor DS0000003939.V302479.R01.S.doc Version 5.2 Page 20 From the pre-inspection questionnaire provided prior to the inspection the home benefits from a largely stable, consistent staff team. Staff members spoken with and seen going about their duties, enjoyed companionable relationships with residents, who said that they felt well supported. One staff member said that they were very happy working at the home, and would not think of going anywhere else. They believed it was a place where they could genuinely care for residents and make a difference. Staff members are working hard to achieve National Vocational Qualifications in Care (NVQ.) The manager said that three members of staff currently hold an NVQ and six members of staff are undertaking the qualification. Two recruitment files were seen. One contained one reference, which was not from the last employer. The other file had two references, but a member of staff working in the home had provided one reference. Copies of a POVAFirst were present on both files and the Criminal Records Bureau check (CRB) was present on the file for one staff member. The other member of staff was working under supervision until the CRB was returned. The manager has compiled a form to use to record a summary of each staff member’s training. This will enable an overview of training to be completed and future training needs can be identified and training planned. At the time of the visit the manager was unable to find a record of induction undertaken by a member of staff who had recently started work in the home. The induction format is a clear record. Information regarding the Skills for Care website was provided at the time of the visit. This and other useful websites are detailed below: www.picbdp.co.uk; This is the Partners in Care website and provides information for funding streams for training, including NVQ, Life skills and Leadership & Management. www.skillsforcare.org.uk This is the Skills for Care web site and includes information regarding induction standards and there are downloadable knowledge sets and learning logs for: Dementia Infection Control Medication Workers not involved in direct care These knowledge sets are the first 4 of approximately 30 that are currently planned. They are designed to improve consistency in underpinning knowledge for the adult social care work force in England. They identify learning outcomes and are designed for use alongside the Common Induction Standards, which are also available from this web site. They also count as Glenhurst Manor DS0000003939.V302479.R01.S.doc Version 5.2 Page 21 underpinning knowledge towards NVQs and link to the Health & Social Care National Occupational Standards. www.traintogain.gov.uk This is a programme and funding stream supported by the Learning and Skills Council and Business Link, who provide a skills brokerage role. This project takes off from 1st August in Dorset and the brokers are currently engaging with care providers to establish what their needs are and how best to access funding and which training provider can best assist to meet the identified needs. www.lsc.gov.uk/bdp/employer/eggt_intro.htm This is the Employer Guide to Training website, which is aimed at assisting employers to choose the most suitable training provider to meet their workforce needs by the use of a search facility. A pilot is being run in the South West to enable employers to give their feedback on the training they have experienced. Records of training for two members of staff, which the manager confirmed reflects the current status of most people working in the home, stated that most mandatory training was last undertaken in 2004. The manager, therefore, plans to ensure that courses are arranged to update practice, as required. Glenhurst Manor DS0000003939.V302479.R01.S.doc Version 5.2 Page 22 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, 33, 35, 36, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Glenhurst Manor benefits from an experienced manager, who is approachable, well-organised and committed to listening and caring for residents. The management of the home, and the roles of staff are organised to benefit the people living in the service. The staff team work together to ensure that the home is run in the best interests of residents. Residents’ financial interests are satisfactorily safeguarded. Staff members receive good formal and informal supervision. The service plans prompt attention to areas of practice and maintenance, which will support health and safety in the home and protect residents. Glenhurst Manor DS0000003939.V302479.R01.S.doc Version 5.2 Page 23 EVIDENCE: Mrs Helen Sopp is the manager of the service. The manager and her deputy are at present undertaking the Registered Manager’s Award. On the morning of the visit Jennifer Hudson, was the person in charge of the home. She liaised well with staff members, ensuring that the home was well organised and staff felt well supported. She was confident and knowledgeable about the service and committed to making a difference to the quality of life of residents. On the afternoon of the visit, Mrs Sopp was in charge of the home. Her office is an open door and both staff, residents and their relatives, come to her with any concerns and felt confident and comfortable that they would be listened to and taken seriously. The manager has put in place various structures for delegation of duties, and staff members understand their roles and went about their work confidently and supportively. The manager has compiled a system to ensure that the best service is provided. Questionnaires have been sent out to staff, residents and people involved in the life of the home, to ask them what they think about the home. The manager listens to comments received and acts upon any items, which can enhance the quality of the service provided. She said that she has planned a residents’ meeting for August and has already sent out letters to people to ask them what they would like to be included on the agenda for discussion. The manager confirmed that the service does not hold any monies on behalf of residents. The home’s pre-inspection questionnaire details training which has taken place in the last twelve months, which includes emergency aid. Six staff members are also taking NVQs, which includes areas of health and safety. The manager is compiling a summary of training completed and from this will arrange updating of courses such as manual handling as necessary. (See staffing.) This will also be helpful in providing an overview of fire training completed and drill practice. The manager confirmed that she now ensures that staff members complete the training at the required intervals. The manager has confirmed following the inspection that a comprehensive Health and Safety assessment of the premises has been updated as required in the last inspection report. Areas of health and safety, which require attention, are detailed in the Environment section of this report. Glenhurst Manor DS0000003939.V302479.R01.S.doc Version 5.2 Page 24 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 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 2 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 2 3 X 2 X X 2 1 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 3 X 2 Glenhurst Manor DS0000003939.V302479.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The registered person must ensure that residents care plans are reviewed at least once a month and clearly updated to reflect changing needs and current objectives for health and personal care as well as any actions taken. (Previous timescale 30.04.06 not met) Progress has been made in meeting this requirement. Evidence of consultation with the resident or their representative regarding the plan of care must be recorded. 2. OP8 14 The registered person must 31/08/06 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 appropriate action taken. (Previous timescale 30.04.06 not met) DS0000003939.V302479.R01.S.doc Version 5.2 Page 26 Timescale for action 30/09/06 Glenhurst Manor A pressure sore risk assessment must be carried out in order to assess any risks to skin integrity. 3. OP24 13 The use of wardrobes in individual rooms must be risk assessed and, if unsteady, must be suitably fixed to reduce the risk of harm to residents or staff. Action must be taken to ensure that water is delivered at a safe temperature reducing the risk of scalding to service users. This was issued as an immediate requirement at the time of the inspection. 4. OP28 18 A plan must be developed and implemented to ensure that 50 of care staff are trained to a minimum of NVQ level 2 in care. Progress is being made in meeting this requirement. 5. 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 employment. According to a summary of training being completed, 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 and adult protection. 31/07/06 30/09/06 31/07/06 4. OP25 13 05/07/06 6. OP30 18 30/09/06 Glenhurst Manor DS0000003939.V302479.R01.S.doc Version 5.2 Page 27 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. Handwritten amendments and additions to medicine administration records should be signed and dated by the writer and by someone who has checked the entry for accuracy. This is the third time this recommendation has been made as evidence was found that they are not complying. 3. OP9 Eye drops should be dated on opening, where they have a limited life on opening; disposed of according to dispensing instructions, and stored in their original container. The registered person should consider the provision of a separate staff toilet. The manager should obtain an NVQ level 4 in management by 2005. The manager confirmed that she is currently studying for this qualification. 2. OP9 4. 5. OP21 OP31 Glenhurst Manor DS0000003939.V302479.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole 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 DS0000003939.V302479.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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