Inspection on 03/03/06 for Glenhurst Manor

This inspection was carried out on 3rd March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 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 Catherine Churches Unannounced Inspection 10:00 3 March 2006 rd 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.V285591.R01.S.doc Version 5.1 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.V285591.R01.S.doc Version 5.1 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.V285591.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17 May & 2 June 2005 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 both the town centre and also Westbourne. The Registered Provider is Mr Ellis and the Registered Manager is Mrs Helen Sopp. Accommodation is arranged over three floors providing 29 single bedrooms and 4 that may be used as doubles. All rooms except one have ensuite facilities. A passenger lift provides level access for residents to all areas of the home. There is a large lounge a separate dining room; both have views of the attractive and well-maintained rear garden. There are car parking spaces at the front of the house. Glenhurst Manor DS0000003939.V285591.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place during the morning of 3rd March 2006. The inspection took place as part of the regular, programmed inspection schedule for the home. This report should be read in conjunction with that from the inspection in May/June 2005 as all key inspection standards are reported on in these two reports. The purpose of this visit was to monitor the homes compliance with requirements and recommendations issued at the last inspection, to check that the home continues to run in a satisfactory manner and that the people who are living in the home are properly cared for. The premises were inspected and a number of records examined. Time was also spent time observing routines within the home and talking with residents and staff. What the service does well: What has improved since the last inspection? Fifteen requirements and eighteen recommendations were made at the last inspection. Thirteen of the requirements have been fully actioned. Leading to improvements as detailed below: Glenhurst Manor DS0000003939.V285591.R01.S.doc Version 5.1 Page 6 • • • • • • • • • • • • A Statement of Purpose and Service Users Guide have now been developed, therefore providing better information about the home for both residents and prospective residents. Pre-admission assessments are now followed up by a letter to the prospective residents confirming that the home can meet their needs. Care plans have improved therefore providing better information for staff and continuity of care. Storage and administration of controlled drugs has improved. Recording of medication administration has improved. The ground floor corridor has been redecorated and new carpet has been laid. An Occupational Therapist has assessed the building and resulting recommendations are being actioned. Work has been undertaken to ensure that water/plumbing is compliant with the necessary regulations. Risk assessments have been undertaken regarding use of the basement laundry and measures put in place to minimise risks. Fire safety risk assessments have been undertaken also reducing risks to residents and staff. Adult Protection policies and procedures have been amended as required. The manager is enrolled on an NVQ level 4 course. 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 DS0000003939.V285591.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glenhurst Manor DS0000003939.V285591.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were inspected on this occasion. Requirements and recommendations made at the last inspection relating to the above standards are reported on in the “what has improved since the last inspection” section of this report. EVIDENCE: Glenhurst Manor DS0000003939.V285591.R01.S.doc Version 5.1 Page 9 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 and 9 Systems for care planning and resident consultation are in place but could be reviewed and improved to provide more effective information and therefore further enhance evidence that the home meets the needs of residents. The home ensures that resident’s healthcare needs are met through seeking appropriate input from GP’s and other healthcare professionals. Internal procedures for monitoring health need to be improved to further promote good health. Medicines prescribed by Doctors are safely stored. They are administered to residents by staff that have received appropriate training thereby reducing the risks to residents from medicine errors. Some improvements to record keeping and handling of controlled drugs are required to further reduce the risk of harm to residents. EVIDENCE: Care Plans and related documentation regarding care for 3 residents were examined. After careful analysis and discussion, it was found that the required information was available although the methodology and documentation used by the home was at times hard to follow. Monthly reviews had not been Glenhurst Manor DS0000003939.V285591.R01.S.doc Version 5.1 Page 10 undertaken on 2 out of the 3 files examined. Management methods for one person with behavioural problems were not fully recorded. Evidence was available on file and through discussion that GP’s, district nurses, specialist nurses and other health professionals are called upon whenever the need arises. There was not nutritional assessment of residents and monthly recording of weights was not being done. The home has a good system in place for monitoring the administration of controlled drugs although systems for counting remaining balance involved staff removing tablets from the bottles giving rise to possible contamination. It was noted that where mistakes had been made on Medication administration charts this had been obliterated with sticky labels. Glenhurst Manor DS0000003939.V285591.R01.S.doc Version 5.1 Page 11 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 The social and recreational activities provided by the home meet the expectations of residents. Residents have the opportunity to choose their own lifestyle within the home and this means that their individual preferences and routines are respected. Open visiting arrangements are in place enabling residents to retain contact with families and friends. Great emphasis is placed on the provision of food in the home. Menus are well planned and provide an interesting, balanced and nutritious diet. EVIDENCE: Notices were displayed within the home giving information on the range of activities on offer. There are regular in house activities such as art classes, gentle exercise classes, quizzes and music. A number of residents mentioned the activities when speaking with the Inspector and all said they enjoyed them. One person was sketching in their room and explained to the inspector that they had recently taken up art as a result of the art lessons they had taken since moving to the home. Glenhurst Manor DS0000003939.V285591.R01.S.doc Version 5.1 Page 12 The visitor’s book showed that there is a constant stream of visitors to the home and discussions with staff confirmed this as well as the fact that many residents are taken out by visitors. Discussion with residents and staff as well as examination of records also evidenced that residents are assisted appropriately to exercise choice and control over their lives. The home employs two chefs who work hard to provide a wide range of freshly prepared meals and will provide various alternatives to the main menu should residents request this. Many residents have expressed particular likes and dislikes and it was evident from discussion with one of the chefs, the manager and residents that these are respected and catered for. All residents spoken with were very positive about the quality of meals provided in the home. Glenhurst Manor DS0000003939.V285591.R01.S.doc Version 5.1 Page 13 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 and 18 The home has a satisfactory system for making complaints. This means that residents and others involved in the home that may wish to make a complaint should feel confident that they would be listened to and matters of concern will be acted upon. Arrangements for protecting service users from abuse were satisfactory: staff had a good knowledge and understanding of Adult Protection issues. This means that Glenhurst Manor is a safe environment that will protect residents from abuse. EVIDENCE: The home has a satisfactory complaints procedure that is displayed in the home as well as included in the Service Users Guide. Those spoken to said that they would feel comfortable in making a complaint but also commented that they could never foresee such a need arising. No complaints had been made either to the home or the Commission since before the last inspection. Staff have received training in recognising and preventing abuse as well as the action to take should they believe abuse has taken place. It was evident from discussion that they were clear about their responsibilities Glenhurst Manor DS0000003939.V285591.R01.S.doc Version 5.1 Page 14 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): None of these standards were inspected on this occasion. Requirements and recommendations made at the last inspection relating to the above standards are reported on in the “what has improved since the last inspection” section of this report. EVIDENCE: Glenhurst Manor DS0000003939.V285591.R01.S.doc Version 5.1 Page 15 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): None of these standards were inspected on this occasion. Requirements and recommendations made at the last inspection relating to the above standards are carried over to the next inspection. EVIDENCE: Glenhurst Manor DS0000003939.V285591.R01.S.doc Version 5.1 Page 16 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): 33, 35 and 38 The management arrangements for the home support good care practice for the residents. Quality monitoring systems need to be better defined and coordinated in order to demonstrate that the home is run in the best interests of the residents. Sound practices and procedures are in place regarding residents’ finances. Residents, staff and visitors to the home are potentially being put at risk due to poor practice in relation to some areas of fire prevention. EVIDENCE: The home has a brief policy regarding quality assurance. This lacked in detail, self-monitoring surveys were out of date and there was no analysis of previous responses or annual development plan. Glenhurst Manor DS0000003939.V285591.R01.S.doc Version 5.1 Page 17 Mrs Sopp confirmed that residents are encouraged to retain control of their own finances for as long as possible. Where they state that they no longer wish to or they lack the capacity to do so then the home ensures that either family or other representatives such as solicitors take on this role. No cash or valuables are held in the home for residents. Staff training in fire prevention and the action to take in the event of a fire was out of date. Glenhurst Manor DS0000003939.V285591.R01.S.doc Version 5.1 Page 18 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 X 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 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 1 Glenhurst Manor DS0000003939.V285591.R01.S.doc Version 5.1 Page 19 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. Standard Regulation 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. 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. The registered person must ensure that the home operates a robust recruitment procedure. New staff must not commence work in the home without evidence of a suitable CRB or POVA disclosure. 3/3/06 This requirement is carried over to the next inspection, as it was not reviewed on this occasion. The registered person must ensure that receive training, at the required intervals, in fire prevention and the actions to take in the event of a fire. DS0000003939.V285591.R01.S.doc Timescale for action 1 OP7 15 30/04/06 2 OP8 14 30/04/06 3 OP29 19 & schedule 2 30/04/06 4 OP38 23 30/04/06 Glenhurst Manor Version 5.1 Page 20 5 OP38 13 6 OP36 18 7 OP28 18 The registered person must ensure that a comprehensive Health and Safety assessment of the premises and working practices must be recorded. 3/3/06 The home has a written assessment but this has not been reviewed since March 2002. This requirement is therefore still outstanding. It is required that all care staff receive formal supervision at least 6 times per year. 3/3/06 The manager confirmed that this is not being done. This is now made as a requirement as the home has had recommendations twice before regarding this matter. 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. 30/04/06 30/05/06 30/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard OP7 Good Practice Recommendations It is recommended that systems for care planning and resident consultation are reviewed and amended so as to provide greater compliance, and evidence of compliance, with the National Minimum Standards. It is recommended that a tablet counter be obtained 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 by someone who has checked the entry for accuracy. DS0000003939.V285591.R01.S.doc Version 5.1 Page 21 1 2 OP9 3 OP9 Glenhurst Manor 4 OP37OP9 5 OP36 3/3/06 This is the second time this recommendation has been made as evidence was found that they are not complying. Errors and alterations to records must not be obliterated either by use of obliteration fluid or sticky labels. The manager should obtain an NVQ level 4 in management by 2005. 3/3/06 The manager confirmed that she is currently studying for this qualification. Glenhurst Manor DS0000003939.V285591.R01.S.doc Version 5.1 Page 22 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. 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