Inspection on 04/06/08 for Glenhurst Manor

This inspection was carried out on 4th June 2008.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Glenhurst Manor 22/06/09

Glenhurst Manor 03/12/08

Glenhurst Manor 10/03/08

Glenhurst Manor 06/11/07

Glenhurst Manor 29/06/06

Glenhurst Manor 03/03/06

Glenhurst Manor 17/05/05

Glenhurst Manor 26/10/04

Glenhurst Manor 27/05/04

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

CARE HOMES FOR OLDER PEOPLE Glenhurst Manor 44a West Cliff Road Bournemouth Dorset BH4 8BB Lead Inspector Catherine Churches Unannounced Inspection 4th June 2008 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Glenhurst Manor DS0000003939.V365744.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.V365744.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glenhurst Manor Address 44a West Cliff Road Bournemouth Dorset BH4 8BB Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01202 761175 01202 761164 info@glenhurstmanor.co.uk Mr Kevin Robin Ellis Manager post vacant Care Home 36 Category(ies) of Old age, not falling within any other category registration, with number (36) of places Glenhurst Manor DS0000003939.V365744.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th March 2008 Brief Description of the Service: Glenhurst Manor is registered to provide personal care and accommodation for a maximum of 36 people. The home is in the West Cliff area of Bournemouth, a short walk from the cliff top and not far from the facilities of the town centre and the Westbourne shopping area and is situated on a bus route for central Bournemouth. It is registered to Mr Ellis. The post of Registered Manager has been vacant since December 2006 but was filled in March this year by Mrs Lesley-Anne Clements RGN. Accommodation is arranged over three floors providing 29 single bedrooms and 4 bedrooms that may be used as double rooms. All rooms except one have en suite facilities. A passenger lift provides level access to all areas of the home. There is a large lounge and a separate dining room; both have views of the rear garden. To the front and rear of the property are well-maintained grounds for the use of residents; there are car parking spaces at the front of the house. Fees range from £595 to £695 per week depending on room size and view. Glenhurst Manor DS0000003939.V365744.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was an unannounced inspection, which took place on 4th June 2008. In total 5 hours were spent in the home undertaking the inspection. The inspection took place as part of the regular, programmed inspection schedule for the home. The last inspection was November 2007. The home has recently appointed a new manager whose application is in process with CSCI. The manager was present throughout the inspection. The purpose of this visit was to monitor the homes compliance with National Minimum Standards and progress with requirements and recommendations made during previous inspections. Also, to check that the home is 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 observing routines within the home and talking with residents, visitors and staff. What the service does well: Glenhurst Manor provides a homely, relaxed and comfortable environment with a welcoming and friendly atmosphere. The home is very well presented and has beautifully maintained gardens that residents reported they were very proud of. Residents say that staff are kind and caring and that their privacy and dignity is respected at all times. All residents, and visitors, spoken with were positive about the care and attention they receive. There is a good range of activities in the home and visitors are encouraged to come to the home whenever possible. Residents are encouraged to maintain their links with family and friends and visitors to Glenhurst Manor are made welcome. People are positive about the food at Glenhurst Manor. Food is well presented and staff are available to assist residents if help is required. Glenhurst Manor DS0000003939.V365744.R01.S.doc Version 5.2 Page 6 The staff group is stable and were observed to be respectful, caring and helpful. Financial procedures within the home ensure that resident’s interests are protected. What has improved since the last inspection? What they could do better: Glenhurst Manor DS0000003939.V365744.R01.S.doc Version 5.2 Page 7 Three recommendations have been made as a result of this inspection. Handwritten entries on medication administration records should be checked by a second person and both people should sign the record. This is to try to prevent medication errors occurring. When recruiting staff, one of the references should be from the applicant’s most recent employer to assist in verifying their suitability. Where a work permit is required the home should ensure that this is current and valid. Accident records should be analysed regular to look for any patterns or recurring problems as part of an accident and risk reduction strategy. 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. The summary of this inspection report can be made available in other formats on request. Glenhurst Manor DS0000003939.V365744.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.V365744.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A satisfactory pre admission procedure is now in place. Assessments are undertaken and this means that the home tries to ensure that only those residents whose needs can be met by the home are offered places at Glenhurst Manor. EVIDENCE: The files of two residents who had been recently admitted to the home were reviewed. Assessments had improved since the last inspection as the documentation has been expanded to meet the guidance in the National Minimum Standards. Glenhurst Manor DS0000003939.V365744.R01.S.doc Version 5.2 Page 10 Evidence was available that the resident and/or their representative had been involved. Letters to prospective residents confirming that, following an assessment the home can meet their needs were also available. Glenhurst Manor DS0000003939.V365744.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The care planning system has been improved. Each individual has a detailed, person centred plan of care and residents or representatives are involved where possible in its development and review. The care plan provides good evidence of the care that is being delivered. The health needs of residents are actively promoted with good consultation and communication with local health services. Management and administration of medication has improved leading to better healthcare for residents and reduced risk to residents from wrong administration of their medication. EVIDENCE: Glenhurst Manor DS0000003939.V365744.R01.S.doc Version 5.2 Page 12 The care documentation for four residents was reviewed. Each file contained up to date risk assessments, care plans, daily records and reviews. Care plans covered all areas required under the National Minimum Standards and were individual, person centred documents that were up to date and informative. The quality of the entries by staff in records has improved following training. Reviews were being undertaken at the required intervals and changes in need were reflected in an updated care plan. Nutritional screening has been introduced since the last inspection. Other risk assessments were in place and identified appropriate actions to reduce risk where a risk was identified. Evidence was available that the resident and/or family member had been involved in the creation of the care plan. Staff confirmed that residents have access to medical services. Records are kept of visits from GP’s, district nurses, chiropodist, optician and dentist. Medicines are stored securely and only those staff that have undertaken appropriate training in medicines administration are authorised to give medicines to the residents. Records were kept of the receipt, administration and disposal of medicines. Examination of records indicated that medicines are properly administered in accordance with the prescriber’s instructions. It was noted that handwritten entries were not always checked and signed for by a second person. The policy was not clear about the action staff should take regarding prescribed medication when a resident is admitted to hospital. Observation during this inspection and discussion with staff evidenced that resident’s privacy is respected and that they were treated with dignity. Staff were seen to knock at bedroom doors and treated residents with courtesy and kindness. Records noted resident’s preferred form of address and these were heard to be used by staff. All residents seen were well presented. Glenhurst Manor DS0000003939.V365744.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Glenhurst Manor provides a caring, homely and relaxed environment. Residents experience a varied lifestyle, which reflect their interests and needs. Open visiting arrangements are in place enabling residents to retain contact with families and friends. Relatives and friends are made welcome at the home and supported to play a part in the life of the services. Contacts are maintained with the local community according to the wishes of residents. The food in the home is of good quality, well presented and meets the dietary and cultural needs of people who use the service. Staff are trained to help those individuals who need help when eating and are sensitive in their approach. EVIDENCE: Glenhurst Manor DS0000003939.V365744.R01.S.doc Version 5.2 Page 14 Prior to moving into the home, and following admission, residents are asked about their interests and hobbies. One person had moved into the home for respite care and owned a number of animals. The manager had worked with a charity to ensure that the animals were looked after and were brought to the home for visits with their owner. This clearly meant a lot to this person and possibly helped with their rehabilitation as well as enriching other residents lives who seemed to enjoy seeing the animals which were visiting at the time of the inspection. A calendar of activities is produced on a monthly basis. This included trips out in the people carrier that is shared between Glenhurst Manor and another home also owned by Mr Ellis. Social activities include musical entertainment, quizzes and art classes. The home also benefits from very beautiful, wellmaintained gardens. A number of people were in the garden enjoying the sunshine on the day of the inspection. There are no organised religious services of any denomination. Two people receive weekly visits from clergy at their request. The home has a large dining room which looks out across the gardens at the rear of the home. It is attractively decorated and furnished to a high standard. Tables are nicely presented, as is the food which is produced by a qualified chef. Food records reflected a varied and nutritious diet is provided for with the provision of plenty of fresh fruit and vegetables as well as home cooked items rather than frozen or convenience food. Glenhurst Manor DS0000003939.V365744.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints and abuse policies and procedures should reassure anyone raising concerns that they would be listened to and acted upon. EVIDENCE: Glenhurst Manor has a satisfactory complaints procedure that is displayed in the home as well as included in the Service Users Guide. The manager stated that she has identified some improvements which could be made and will be amending the policy in due course. This will then be reissued to residents and included in an updated Service Users Guide. Satisfactory policies and procedures for adult protection and whistle blowing are in place at the home. Most staff have received training in the protection of vulnerable adults / abuse awareness and the programme showed that all staff would be trained by the end of June 2008. Staff and the manager had identified one person whom they thought might be vulnerable and had made the appropriate reports to the local Social Services department. Glenhurst Manor DS0000003939.V365744.R01.S.doc Version 5.2 Page 16 Glenhurst Manor DS0000003939.V365744.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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is very well presented: it is nicely decorated and furnished and has a homely atmosphere. The grounds are also very well maintained, providing lots of colour and interest as well as a variety of places to sit and relax. The home maintains a good standard of hygiene and all areas seen were clean and free from offensive odours. EVIDENCE: Residents at the home enjoy the delightful surroundings of the Manor and its well-maintained gardens. All rooms have a unique character, and are furnished to a high standard. Matching soft furnishings complement each Glenhurst Manor DS0000003939.V365744.R01.S.doc Version 5.2 Page 18 room, which are refurbished as they become vacant. The lounge has recently been refurbished. One double room, which was being used as a respite room, was noted to be in need of redecoration. The manager confirmed that decorators had already been booked to come to the home the next time the room was vacant. Dorset Fire and Rescue Service have visited the home and confirmed that it complies with their requirements. Previously it has been identified that there is no permanent staff toilet. Currently staff use ensuite facilities of a nominated vacant room. Mr Ellis confirmed that plans are being drawn up to create a permanent staff toilet and work was due to start in the next two weeks. It was noted that the windows on the main landing and in one bedroom were not limited. This was rectified almost immediately. Individual accommodation is pleasantly furnished and decorated to a high standard, providing personal surroundings, with which residents expressed satisfaction. All rooms have ensuite facilities. A number of residents were spoken with in the privacy of their own rooms. All were very happy with the environment, commenting on how they had been assisted to bring furniture with them, the dedication of the cleaning staff and the pleasure that the beautiful surroundings gives them. All areas of the home visited were clean, hygienic and free from offensive odours. Glenhurst Manor DS0000003939.V365744.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The number of staff working in the home meets residents’ needs. The home has identified staff training needs and implemented a training programme to address areas of weakness. The home has a good ratio of care staff who have achieved National Vocational Qualifications and has introduced the Skills for Care Induction training; thus working to ensure that residents are in safe hands at all times. People living at Glenhurst Manor are satisfactorily supported and protected by the home’s recruitment policy and practices. EVIDENCE: Examination of the staff rota and observation throughout the inspection demonstrated there was a sufficient number and skill mix of staff to meet the needs of residents. All residents spoken with confirmed that staff were always available, kind and helpful. Glenhurst Manor DS0000003939.V365744.R01.S.doc Version 5.2 Page 20 At the time of the visit six staff members of the fifteen care staff working in the home held a National Vocational Qualification at a minimum of level with some higher. A further 2 staff were currently studying the level 2 course and more were waiting to start. Three new staff have been recruited since the last inspection. All of their files were seen. The files contained items as required by legislation. It was noted that in one case a reference had not been obtained from the applicants most recent employer and in another evidence of a current work permit was not available. The manager has completed an analysis of staff training needs and has implemented a training plan, which includes mandatory subjects, to address these. The new Skills for Care induction programme has been implemented in the home and the three new staff had undertaken this with the appropriate documentary evidence available. Glenhurst Manor DS0000003939.V365744.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The proposed manager holds appropriate management qualifications as well as having many years experience in nursing. She is a competent, approachable and committed manager. This results in a home where residents, staff and visitors feel supported and consulted and visible improvements are being made to the service. The management arrangements for the home support good care practice for the residents. Quality monitoring systems are being improved and this will provide further evidence that the home is run in the best interests of the residents. Resident’s finances are safeguarded with clear policies and procedures and management guidance. Glenhurst Manor DS0000003939.V365744.R01.S.doc Version 5.2 Page 22 The health, safety and welfare of residents and staff is protected by the systems that the home has in place for staff training, maintenance and risk assessment. EVIDENCE: The management arrangements for the home support good care practices for the residents. The proposed manager has demonstrated, in the three months since her appointment, that she is a competent manager. She has the relevant qualifications and experience and has already addressed many issues of concern within the home which have been outstanding for some time. Recruitment practices are suitably robust (see Staffing). Systems for quality assurance and resident consultation are being developed with the aim of ensuring that the home is run in the best interests of the residents and that performance issues are identified and addressed. A satisfaction survey and regular meetings have been implemented for residents and a suggestion box placed in the main hallway. The proposed manager 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. Fire records and accident books were examined and found to be up to date and detailed. It was advised that accident books should be audited regularly to identify anyone with frequent problems or areas of the home, times of day etc that might be of particular concern. As stated elsewhere, staff training is being reviewed and programmes put in place. It was noted that training in emergency aid was also required. Glenhurst Manor DS0000003939.V365744.R01.S.doc Version 5.2 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 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 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Glenhurst Manor DS0000003939.V365744.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 Timescale for action 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 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. References should be obtained from an applicant’s most recent employer. Work permits should be checked to ensure that they are current. Accident records should be regularly analysed to establish any patterns or problem areas. All staff should have up to date training in emergency aid. 2. 3. OP29 OP38 Glenhurst Manor DS0000003939.V365744.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Glenhurst Manor DS0000003939.V365744.R01.S.doc Version 5.2 Page 26 - 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. 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