Inspection on 21/11/05 for Glenmar

This inspection was carried out on 21st November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glenmar 02/03/09

Glenmar 23/04/08

Glenmar 29/05/07

Glenmar 08/05/06

Glenmar 21/06/05

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 Mrs Sally Gill Unannounced Inspection 21st November 2005 10:00 Glenmar DS0000021113.V265636.R01.S.doc Version 5.0 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 Glenmar DS0000021113.V265636.R01.S.doc Version 5.0 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 Adults 18-65. 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. Glenmar DS0000021113.V265636.R01.S.doc Version 5.0 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 glenmarjulia@aol.com 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) Grovestead Limited Mrs Julia Couzens Care Home 25 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (25) of places Glenmar DS0000021113.V265636.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of residents to be accommodated is twenty five (25) The people accommodated will be between the ages of eighteen and sixty five years on admission The people accommodated will have a past or present mental illness Date of last inspection 21st June 2005 Brief Description of the Service: Glenmar is registered to provide accommodation for up to 25 people suffering from a mental health issues and admits people with low to medium dependency needs. The premise was originally two terraced properties situated in St Leonards with single and double rooms on the ground and two other floors (some of which are ensuite, all have a wash hand basin). The home is undergoing ongoing refurbishment work, which is required. Clients have the use of two separate lounge areas on the ground floor (one of which is non-smoking) and there are two dining rooms within the basement. The home has a rear garden with seating and lawn area for residents to enjoy; the home is also situated opposite Gensing gardens. Car parking is available within the street outside. The building is located near to the town centre. The home is not suitable for those with mobility problems. Glenmar DS0000021113.V265636.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on Monday, 21st November 2005 between 10.25am and 12.45pm. Additional time was spent in preparation and report writing. During the inspection the Inspector spoke to five clients both in company and in private. Also, she spoke to the senior carer on duty, the cook and the maintenance person. Positive feedback was also received from one health professional involved in the home. The Registered Manager was not on duty at the time of the inspection. Feedback from clients during the inspection confirmed that they are satisfied with their care at Glenmar. Comments included “the staff are friendly”, “its clean”, “my bed is changed and my room is cleaned regularly”, “the manager has her finger on the pulse and knows what’s going on”, “service is good, staff friendly”, “there’s a good mix of staff”, “there’s no shortage of staff” and “X (member of staff) sorts things out”. The comments about the food were generally good including “the foods marvellous” and “she’s a good cook”. However there were some negative comments, which should be taken on board including “the food is OK lacking in variety” and “its same-e”. These comments could relate to those on special diets (vegetarian). The Inspector examined various records including day-to-day report writing, adult protection procedure, and the fire safety logbook and accident book. The complaints log could not be located at the time of the inspection. The Inspector accessed parts of the building including the kitchen, dining rooms, the laundry, the office, two bathrooms, a toilet and four bedrooms. After discussion during the inspection those that live at Glenmar will be referred to in this report as clients. The Inspector would like to thank both clients and staff who assisted during the inspection. As this report only covers a minority of the key standards it should be read in conjunction with the previous inspection report. What the service does well: Glenmar DS0000021113.V265636.R01.S.doc Version 5.0 Page 6 Apart from two negative comments about the food the clients at Glenmar are happy with the care they receive. Clients confirmed that routines are flexible and they are more or less able to do as they please. Staff spoken to demonstrated a commitment to the clients. What has improved since the last inspection? What they could do better: The home is still to obtain an up to date electrical wiring certificate to ensure the wiring is safe for those that live at Glenmar. The records of day-to-day life at Glenmar should be improved to evidence that opportunities are available for all clients. To ensure the good health of clients improvements must be made to improve infection control such as providing liquid soap, paper towels, readily cleanable chairs in bathrooms, renew rubber bath mats and address one isolated odour that was present on the day of the inspection. Clients could benefit from a safer environment, the Fire Safety Officer should be contacted regarding visual checks on fire extinguishers, the Environmental Health Officer must be contacted regarding handrails to both sides of stair ways this is particularly important given the future needs of the clients and also leading down to the basement. Cleaning products must be stored (when not in use) and handled in line with regulations. Glenmar DS0000021113.V265636.R01.S.doc Version 5.0 Page 7 A formal system should be introduced to allow clients and others involved in the home the opportunity to feedback on how well the home is doing particularly against its aims and objectives making ongoing improvements to quality of life wherever possible. 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 DS0000021113.V265636.R01.S.doc Version 5.0 Page 8 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 Outcomes Statutory Requirements Identified During the Inspection Glenmar DS0000021113.V265636.R01.S.doc Version 5.0 Page 9 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 the following standard(s): EVIDENCE: None inspected on this occasion – see previous inspection report. The Statement of Purpose and Service User Guide held by the Commission is dated July 2003 and may have already been up dated/reviewed but given some of the information highlighted during the inspection it is suggested that if not it is reviewed with a copy sent to the Commission to be held on file. Glenmar DS0000021113.V265636.R01.S.doc Version 5.0 Page 10 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 the following standard(s): EVIDENCE: None inspected on this occasion – see previous inspection report. Glenmar DS0000021113.V265636.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 12, 13, 14, 15 Clients appear to have some opportunities for appropriate leisure activities, are able to access the wider community but there is a lack of records to evidence this. Clients maintain good links with friends and families. Daily routines are flexible to suit clients. EVIDENCE: The Inspector viewed the daily records recorded by staff however these do not reflect how clients spend their time only an organised outing in the summer was recorded for those that went and enjoyed the day. Staff advised the Inspector that planned activities such as bingo are no longer run in house because clients did not want them however where opportunities are offered to clients and refused these should also be recorded. Clients confirmed that they spent their time reading, watching television (including satellite), visiting family and friends, shopping, at a daycentre, sitting in the garden in nice weather and at the pub. One client has a voluntary job locally. A requirement that records should reflect activities offered was made at the previous inspection and remains outstanding. Glenmar DS0000021113.V265636.R01.S.doc Version 5.0 Page 12 Clients confirmed that they visit family and friends and that also their family and friends are made welcome within the home. Clients confirmed that they their choice is respected when choosing to spend time alone or in company. The Inspector was informed that clients are able to smoke in their bedrooms as well as the smoking lounge. Staff informed the Inspector that clients are also offered the opportunity of participating in their own household chores and laundry but choose not to. Glenmar DS0000021113.V265636.R01.S.doc Version 5.0 Page 13 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 the following standard(s): EVIDENCE: None inspected on this occasion – see previous inspection report. Glenmar DS0000021113.V265636.R01.S.doc Version 5.0 Page 14 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 the following standard(s): EVIDENCE: None inspected on this occasion – see previous inspection report. The adult protection procedure, which has been reviewed resulting in a clear procedure for all to follow should they suspect anyone, is being abused or neglected. Staff on duty were unable to locate the record of complaints. Glenmar DS0000021113.V265636.R01.S.doc Version 5.0 Page 15 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 the following standard(s): 24, 26, 30 Clients are benefiting from the ongoing refurbishment/redecoration within the home. To ensure clients have a completely safe environment further advice should be sought. Improvements are required to ensure a clean and hygienic home for clients. EVIDENCE: The home is gradually being rewired when completed it will be able to obtain an up to date electrical wiring certificate. The Inspector was advised that this work should be completed within the requirement timescale. The Inspector viewed the fire safety logbook, which showed tests carried out were up to date. The last service of emergency lighting had highlighted six units not working and although the Inspector was informed that these had been repaired the worksheet could not be found. A copy of the worksheet must be forwarded to the Commission. The Inspector also advises that the home must contact the local Fire Safety Officer to confirm whether monthly visual checks are required for fire extinguishers. On tour of the home it was noticed that stairs do not have handrails both sides of any stairs and therefore the home must contact the Environmental Health Glenmar DS0000021113.V265636.R01.S.doc Version 5.0 Page 16 Office for guidance. If this is not a requirement it is strongly suggested that this is reviewed for stairs to the basement. One bathroom and four bedrooms have been completed since the last inspection to a good standard. One bedroom highlighted at a previous inspection as requiring redecoration has not yet been completed the Inspector was advised. The Inspector was told that in future all bedrooms will be painted in the same colour and brightened with curtains and bedding. Two clients spoken to also confirmed that they had not chosen the colours for their newly decorated bedroom although they like the décor. It is suggested that the home needs to consider whether real choice is being offered to clients in an area where it could. Each bedroom has a call bell, television and wash hand basin if not ensuite facilities. The part tour highlighted areas where hygiene and infection control should be improved including renew bath the mat that was mouldy, replace bathroom chair that are not readily cleanable, supply liquid soap and paper towels (or equivalent) in all communal bathrooms and toilets. There was also an area with one apparent odour, which needs to be addressed. Apart from these highlighted concerns the home was clean something which clients also confirmed. Glenmar DS0000021113.V265636.R01.S.doc Version 5.0 Page 17 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: None inspected on this occasion – see previous inspection report. Glenmar DS0000021113.V265636.R01.S.doc Version 5.0 Page 18 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 42 A formal quality assurance system should be implement to ensure client’s views underpin the homes development. Minor improvements are required to daily records to reflect opportunities for clients. EVIDENCE: The Inspector was advised that three monthly house meetings are held however the minutes of these could not be located. A suggestion box had previously been in place but however staff advised after review taken out. The Inspector was advised that there is a lack of formal quality assurance system, internal audit involving clients, relatives and other stakeholders to feedback through either group or individual discussion or anonymous questionnaires. This data would then be used to measure the home against its aims and also feed a development plan for the home. The results of the survey should be published and made available. See standard 14 regarding a lack of records. Glenmar DS0000021113.V265636.R01.S.doc Version 5.0 Page 19 See standard 24 regarding fire safety and electrical wiring. During the part tour of the home it was observed that cleaning products were left unattended in the hallway. Cleaning products must be stored and used in line with COSHH regulations. If cleaning products are to be left accessible to clients then a risk assessment must be completed and recorded however the Inspector was advised this is not currently in place. Glenmar DS0000021113.V265636.R01.S.doc Version 5.0 Page 20 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 X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 2 X X X 2 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Glenmar Score X X X X Standard No 37 38 39 40 41 42 43 Score X X 2 X 2 2 X DS0000021113.V265636.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA41YA14 Regulation 16(2)(m) Requirement The service must record the activities offered within the service (previous timescale of 01/08/05 not met) Contact the FO to confirm frequency of visual checks of fire extinguishers Contact the EHO to confirm requirement for stair hand rails Forward to CSCI a copy of the worksheet evidencing the repair of 6 emergency light units Address the isolated offensive odour and other areas highlighted to ensure the home is hygienic and promotes good infection control A certificate for an up to date electrical wiring is in place Store and handle cleaning products according to COSHH Timescale for action 19/12/05 2 3 4 5 YA24 YA42 YA24YA42 YA24YA42 YA30 23(4) c 13(4) 23(2) n 23(5) 23(4) b 16(2) j, k 19/12/05 19/12/05 19/12/05 19/12/05 6 7 YA42 YA42 23(4)(a) 13(4) 01/04/06 22/11/05 Glenmar DS0000021113.V265636.R01.S.doc Version 5.0 Page 22 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 YA39 Good Practice Recommendations Implement a formal QA system to seek the views of clients and other involved in the home to measure against the homes aims Glenmar DS0000021113.V265636.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection East Sussex Area Office 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 DS0000021113.V265636.R01.S.doc Version 5.0 Page 24 - 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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