Inspection on 21/06/05 for Glenmar

This inspection was carried out on 21st June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Glenmar 02/03/09

Glenmar 23/04/08

Glenmar 29/05/07

Glenmar 08/05/06

Glenmar 21/11/05

Glenmar 10/02/05

Glenmar 16/09/04

Glenmar 16/09/02

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

CARE HOME ADULTS 18-65 Glenmar 2-3 Charles Road St Leonards-on-sea East Sussex TN38 0QA Lead Inspector Alexis Reilly Unannounced 21 June 2005 9.15 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Glenmar H59-H10 S21113 Glenmar V227228 210605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Glenmar Address 2-3 Charles Road St Leonards-on-sea East Sussex TN38 0QA 01424 436864 01424 446425 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Grovestead Limited Mrs Julia Couzens Care Home 25 Category(ies) of Mental disorder (MD) 25 registration, with number of places Glenmar H59-H10 S21113 Glenmar V227228 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of residents to be accommodated is twenty five (25) 2. The people accommodated will be between the ages of eighteen and sixty five years on admission 3. The people accommodated will have a past or present mental illness Date of last inspection 10 February 2005 Brief Description of the Service: Glenmar is registered to take twenty-five residents with a diagnosis of mental disorder under the age of 65 years of age on admission. The home is located opposite Gensing gardens in St Leonard’s on Sea and near to the town centre. The building has two lounge areas on the first floor, one for residents who choose to smoke, and one lounge is a no smoking lounge. There are two further dining rooms in the basement area. There is a garden area at the back of the building. Glenmar H59-H10 S21113 Glenmar V227228 210605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection began at 9.15 and lasted for two hours. The following documents were examined on the inspection: Adult protection policy, complaints book, and the records of medicines administered. No new staff had been recruited since the last inspection. Glenmar has admitted one resident who was spoken with during the inspection. Assessments documents and care plans were examined in relation to this resident. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Glenmar H59-H10 S21113 Glenmar V227228 210605 Stage 4.doc Version 1.30 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Glenmar H59-H10 S21113 Glenmar V227228 210605 Stage 4.doc Version 1.30 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 & 4 The service ensures it obtains the relevant information about a resident, prior to offering them a place within the service. EVIDENCE: One new resident has moved into Glenmar since the last inspection. The Manager ensured that they had obtained the relevant documents. These included a letter from the relevant G.P and assessments from the community mental health team. This ensured the service had made an assessment that they could meet this persons needs. The resident had the opportunity to visit the service and meet the staff before making a decision to move into glenmar. Glenmar H59-H10 S21113 Glenmar V227228 210605 Stage 4.doc Version 1.30 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, &9 The service creates plans of care for residents, and carries out comprehensive assessments. EVIDENCE: One new resident has moved in since the last inspection. The Manager had the following documents in place for this resident: an assessment and plan of care for the resident a risk assessment. A lifestyle choice and preferences form was completed. An Assessment of emotional well being and intellectual assessment was also completed. The resident had also completed questionnaires about their experience of moving into the service. These were a ‘service users feedback questionnaire on admission to the home’, and a ‘service users feedback questionnaire on living in the home’. Glenmar H59-H10 S21113 Glenmar V227228 210605 Stage 4.doc Version 1.30 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15,16,&17. Service users are involved in activities within the home. However these must be recorded. EVIDENCE: Varied menus are available for residents. There are alternatives for breakfast, lunch and dinner. Residents are involved in planning the original menus and alternatives. The residents are involved in various activities inside and outside of the home. Some of these take part in the local community, such as helping at the local hospice, attending and teaching subjects at the local day centre. Residents have friends that visit them at the service and families are also invited into the home. One resident will only access the community with support from a staff member. One staff member and three residents go to the local shopping area once each week. Glenmar H59-H10 S21113 Glenmar V227228 210605 Stage 4.doc Version 1.30 Page 10 Many residents have DVD players in their room. Various trips are offered to residents these include, trips to Rye, Bodiam Castle, and Camber Sands. During residents meetings the residents are asked if they wish to go anywhere in particular or if they would like any new activities offered. The staff must ensure that any activities that residents are involved in are recorded on an individual and daily basis. Glenmar H59-H10 S21113 Glenmar V227228 210605 Stage 4.doc Version 1.30 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,&20 Residents physical and mental health needs are monitored within the service. Residents are supported to remain well both physically and emotionally. EVIDENCE: The service has had 5 accidents since the last inspection. These were all recorded appropriately. Staff assist a nominal amount of residents with bathing and hair washing. Some service users only require encouragement and no physical help with bathing. Residents have allocated key workers within the service. However if they are unhappy for whatever reason with the member of staff being the key worker, alternative staff will be allocated. Three residents administer their own medication. A metal lockable first aid cabinet is in the individuals’ room. Medication is administered via the blister pack system and the correct procedure for giving out medication is followed. Glenmar H59-H10 S21113 Glenmar V227228 210605 Stage 4.doc Version 1.30 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 The service has an accessible complaints procedure in place. Residents are listened to and complaints are taken seriously. The service needs to amend the Adult Protection Policy. EVIDENCE: The service has had one complaint since the last inspection. This was in relation to one resident making a noise at night. The service has an Adult Protection Policy in place, however this must identify the correct procedure to follow in the event of a notification of abuse. Glenmar H59-H10 S21113 Glenmar V227228 210605 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed at this time. EVIDENCE: Glenmar H59-H10 S21113 Glenmar V227228 210605 Stage 4.doc Version 1.30 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35 &36. Staff receive a variety of in house training in addition to the statutory training. Staff are well supervised and supported by the staff team. EVIDENCE: Staff have job descriptions in place and terms and conditions of contract. The service employees 15 care staff in total. Three are completing NVQ level 2 and one staff member currently has NVQ level 2. Further staff will be completing NVQ level 2 training in September 2005. Staff complete a written induction and written exercises, these number 38 in total. The exercises cover areas such as infection control, health and safety and care planning. Fire training is carried out every three months. Written exercises are competed before staff can give out medication. Infection control is training is carried out in house. Glenmar H59-H10 S21113 Glenmar V227228 210605 Stage 4.doc Version 1.30 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 The service ensures all the necessary health and safety documents are in place. EVIDENCE: Residents do not have any involvement with staff recruitment within the home. However if residents are unhappy with any member of staff, or have any concerns, they are able to voice these on an individual basis or at residents meetings. Residents are consulted on all aspects of the home at the residents meetings. Health and safety records were examined on the day. Gas boilers are serviced each year in August. The two buildings are in the process of being completely rewired. Maintenance of fire equipment and alarms were tested in June 2005. Hot water outlets are temperature controlled and tested once each month. Fire points and emergency lighting are also tested monthly. Risk assessments are carried out for communal areas once each three months. A record of fire drills was also examined and found to be in order. Glenmar H59-H10 S21113 Glenmar V227228 210605 Stage 4.doc Version 1.30 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x 3 x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x 3 2 x 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Glenmar Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x H59-H10 S21113 Glenmar V227228 210605 Stage 4.doc Version 1.30 Page 17 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 13 23 Regulation 16(2)(m) 13(6) Requirement The service must record the activities offered within the service. The service must ensure it has the correct procedure for notification of an incident of abuse recorded. A certificate for an up to date electrical wiring is in place. Timescale for action 1 august 2005 1 august 2005 1 April 2006 3. 42 23(4)(a) 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 Good Practice Recommendations Glenmar H59-H10 S21113 Glenmar V227228 210605 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Glenmar H59-H10 S21113 Glenmar V227228 210605 Stage 4.doc Version 1.30 Page 19 - 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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