Inspection on 29/05/07 for Glenmar

This inspection was carried out on 29th May 2007.

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 no outstanding requirements from the previous inspection report, but made 5 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 08/05/06

Glenmar 21/11/05

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 Helen Martin Key Unannounced Inspection 29th May 2007 1:15 Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 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.V337612.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 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.V337612.R01.S.doc Version 5.2 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.V337612.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of service users to be accommodated is twentyfive (25) Service users must be aged between eighteen (18) and sixty-five (65) years on admission Service users with a past or present mental illness only to be accommodated 8th May 2006 Date of last inspection Brief Description of the Service: Glenmar provides a service for up to twenty-five adults with or recovering from mental health issues. The home caters for people with low to medium dependency needs. Residents are provided with opportunities for personal, emotional and social development and are supported towards improving their living skills. The home, owned by Grovestead Limited, is located in a quiet residential street, close to the town centre of St. Leonard’s, within easy reach of the usual town amenities and public transport. The building was originally two terraced properties. All bedrooms are for single occupancy, with the exception of two. Some rooms contain ensuite facilities. As the accommodation is arranged over three floors and there is no passenger lift, the home is best suited to those with no mobility problems. Residents have the use of two separate lounge areas on the ground floor (one of which is currently non-smoking) and there are two dining rooms in the basement. The home has gardens to the rear with a seating and lawn area. In addition, Glenmar is situated opposite Gensing Gardens. Kerb side parking is available in the road to the front of the property. The home has an organisational structure, which includes the Manager, the Head of Care and support workers, who operating a roster, provide twentyfour-hour cover. Ancillary staff undertake catering, domestic and maintenance duties. Current fees for the home range between £335.30 and £348.00 per week. Full information about the fees payable, the service provided, the home’s Statement of Purpose and the latest inspection report by the CSCI are available from the Manager. Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced site visit took place on 29th May 2007. The visit included speaking with the Manager, the Head of Care, one Support Worker and eight people who live in the home. Some judgements about the quality of life within the home were taken from observation and conversation. Some records and documents were looked at. A tour of the house and garden was undertaken. The home has provided a completed Annual Quality Assurance Assessment. Postal surveys from two residents, one relative and one Care Manager have been received by the CSCI. All of the above have been used within the inspection process and some information has been included within this report where appropriate. Currently there are twenty-two residents accommodated. All rooms are for single occupancy, with the exception of two. Residents who share rooms have done so for some time and have made a positive choice to do so. Comments made by residents spoken with at the time of this visit included: ‘It’s a nice place’ ‘This is my home, I can have my room how I like it’ ‘I like my room and like being here’ ‘The home is clean’ ‘I like the food – there is a good choice and a good cook’ ‘I like the staff’ ‘I know my keyworker’ ‘I’ve got no complaints’ Comments received in postal surveys included: (Staff treat me) ‘With respect’ ‘Provides a safe and secure environment whilst still maintaining the privacy and dignity of each individual service user. Always being aware that everyone has choices.’ ‘Perfectly satisfied with the degree of care’ ‘At present Glenmar maintain a good service, always providing what the individual service user needs.’ ‘Glenmar is very well organised and gives the person I look after a homely, well looked after environment. The staff attend to (their) individual needs and demands excellently. I am extremely pleased with (their) placement.’ ‘Locking cupboards are provided for those (service users) who are able to self-administer their medications.’ ‘Majority of staff now have NVQ 2, some staff have over 20 years experience.’ Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 Page 7 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.V337612.R01.S.doc Version 5.2 Page 8 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Procedures are in place to support prospective residents to move into the home. They benefit from assessment prior to admission, to ensure their needs can be met, although this could be better reflected in records. Residents are given written information about the home and their terms and conditions of accommodation, although they would benefit from greater detail. EVIDENCE: A statement of purpose and service users guide are provided, which contain information about the home. Whilst most of the required information was included between both documents, the relevant qualifications and experience of the registered provider and registered manager and the organisational structure of the home were not. The qualifications and experience of the staff and the facilities of the home were not mentioned in detail. The documents do not for example mention that the home does not have a lift and is not best suited for residents with mobility problems. Each resident has a contract including the terms and conditions of accommodation with the home. A blank format was seen, and although this included much of the necessary detail, the format does not allow for the room Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 Page 9 to be occupied and more personalised aspects of the agreement, including a copy of the care plan and arrangements for reviewing this or elements of a Care Management care plan where applicable. In addition the reference to the home being registered with Sussex County Council needs to be updated to the CSCI. Residents benefit from assessment before they move into the home, to ensure that their needs can be met. It was indicated that social services and specialist professionals provide information. Assessments are also undertaken by the home and these are recorded, although not in detail. Prior to admission prospective residents can visit the home to look around; these visits are gradually built up to overnight stays, then two nights to a week before moving in. After someone moves in there is a trial period of three months to ensure the home is suitable. Glenmar carries out a Quality Audit of the experience of individuals moving into the home, this helps to address any concerns the resident may have. Residents spoken with said that they were happy living in the home. The manager demonstrated an understanding of the range of needs that the home could and could not meet. Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are able to make their own choices and decisions about their lives and participate in aspects of life in the home. Residents’ changing needs could be better reflected in care plans and risk assessments. EVIDENCE: Care plans contain a range of issues regarding residents’ health and welfare. Although reviews are regular and ongoing, care plans are not recorded in detail. Hand written notes are recorded, although these are not undertaken on a daily basis. Residents’ activities have been recorded but only up to August 2006, individuals admitted to the home after this, are not included. The residents who share these rooms have made a positive choice to do so, although this is not recorded. One shared room has no privacy screening. The manager explained that mobile screening is available, but that the individuals concerned do not want this; they have been sharing a room for some time. This arrangement is not recorded. Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 Page 11 Residents are supported to take risks as part of maximising their independence. Discussion around this issue indicated that people living in the home are given the freedom to make decisions about their lives considering risk management and group living. They are provided with assistance to support their individual choices. Regular residents’ meetings are held. Although risk assessments are recorded for a range of issues, these are not undertaken in detail and not all contain staff guidelines. Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy individual lifestyles and are supported to develop their life skills. They have the opportunity to experience a variety of social and recreational activities. Residents are offered a varied diet and are able to choose what they eat. EVIDENCE: Residents benefit from opportunities for personal, emotional and social development and are supported towards improving their living skills, tailored to their abilities. They are treated as individuals and have different interests, aspirations and abilities. 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 Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 Page 13 spoken with described enjoying the garden and the park; going out often for coffee and time outside the home; going to the pub and the shops. Two residents will only access the community with support from staff. One staff member spoken with said that trips and events are organised for these individuals. Various trips are organised for residents, these include, trips to Raystede, Paradise Park and Rye. Transport is provided. Many residents are looking forward to the forthcoming trip to Brighton Sea World centre and lunch out. During residents meetings individuals are asked if they wish to go anywhere in particular or if they would like any new activities offered. The manager said that religious ministers used to come into the home but they have left the area; they are now are looking to get this again. Residents have friends that visit them at the home and families are also invited. They are able to see their family and friends as often as they wish. Residents also spend time in the home relaxing or undertaking activities that interest them. At the time of this visit some were listening to music, some watching TV whilst others enjoyed the communal lounge and gardens. The home has a pet rabbit. Table tennis and table football are available. Residents particularly enjoy regular Karaoke, bingo and board games. They enjoy privacy in their rooms and staff respect this. Staff talk to residents in a friendly and polite way. Residents enjoy a variety of meals and their choices are recorded; those spoken with said that they liked the food provided. Residents are involved in planning and choosing the meals. Menus are written in advance and developed in discussion with residents. Meals are in accordance with agreed menus, individual choices and nutritional needs or preferences. Special diets are catered for, such as vegetarian, soft and diabetic. Two residents are prescribed dietary supplements. There are two dining rooms and a choice of times for meals. Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from personal support which meets their individual needs. Their privacy and dignity is respected. Residents’ protection could be improved by improvements to the procedures for the administration of medication. EVIDENCE: Residents are given the personal support they need to maximise their independence, while respecting their dignity and privacy. They are able to exercise choice regarding this. Staff demonstrated an understanding of the preferred routines and varying requirements of each individual. Residents have access to health and social care professionals, including mental health specialists such as a Psychiatrist or Community Psychiatric Nurse. A chiropodist, District Nurses and Care Managers are also available. Residents are supported with any appointments and/or interventions and these are recorded. Diet and weight are monitored in residents’ care plans where necessary and food consumed is recorded. Two residents are prescribed dietary supplements. The needs of one resident regarding meal times were Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 Page 15 discussed; the head of care undertook to contact a speech and language therapist regarding a swallowing assessment. The manager said that one resident has been assessed as able to selfadminister their own medication, although this has not been confirmed in writing by a health care professional or recorded as a risk assessment. It was said that lockable facilities were provided. Staff manage all other medication for residents’; an easily monitored system is used. Medication is stored in a locked metal cabinet within a locked room, although this is not a facility specifically designed to store medication. Drugs that require refrigeration are stored in an unlocked domestic fridge within a locked room. The head of care stated that the fridge temperature was monitored and recorded. Medication records are completed appropriately with the exception of some hand written administration entries. The head of care said that in future they would ensure that a second member of staff would countersign these as accurate and keep written confirmation from the prescribing GP. Currently there are no controlled drugs within the home and reference material is available. Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ views and concerns are listened to and receive appropriate consideration. Systems are in place, which aim to protect residents from potential abuse, although improvement to the staff recruitment procedure would enhance their protection. EVIDENCE: Residents are at ease with staff who listen to their views and concerns. A regular meeting is held to discuss these. Residents receive continuity of care by having individual key workers. The home provides a written complaints procedure. The manager confirmed that no complaints had been received since the last inspection. Those recorded had been received some time ago; not all the investigations were documented and the manner in which records were held compromised data protection. The manager undertook to address this in future should any further complaints be received. Staff have access to an adult protection policy and training. The manager said that all residents look after their own money. It was mentioned that the home held small amounts of cash for some residents, although they did not make any purchases on their behalf. All money is stored securely and individually and records are maintained. Cash checked tallied with accounts seen. All cash given to residents is signed for. Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 Page 17 Discussion took place with the manager, head of care and a member of staff regarding two previous serious incidents. It was stated that the home had followed the correct procedures. Further information was awaited regarding one and the manager assured the inspector that this would be forwarded to the CSCI when available. Issues regarding staff recruitment have been mentioned elsewhere within this report. Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a comfortable and homely environment, which suits their needs and lifestyle. Continued refurbishment would enhance their quality of life. Residents may benefit from a review of the procedures in place for infection control, shared rooms and specialist equipment. EVIDENCE: The building fits in with the local community and has a style and atmosphere that meets individuals’ needs. Residents benefit from living in clean and comfortable accommodation. They have access to attractive gardens with a seating and lawn area. The manager stated that the maintenance and refurbishment of the home was undertaken on an ongoing basis. Some areas of the home have been refurbished and redecorated. The manager said that since the last inspection new wood panelling has been fitted downstairs, both houses have been rewired Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 Page 19 and one basement area has been re-decorated; in addition two bedrooms have been redecorated and fitted with new carpet. One ground floor toilet has been totally stripped and retiled to eradicate an offensive odour. A new washer and drier have been installed in the laundry room, the manager said that there were plans to retile the room and provide new flooring; currently one bedroom is in the process of being refurbished and re-plastered. Discussion took place regarding the environment; the manager said that more redecoration and refurbishment was planned. A maintenance person undertakes repairs on a daily basis. Adequate recreational, dining, toilet, bathing and individual accommodation are available to residents. The home provides two lounges, currently one smoking and one non-smoking and two dining rooms. All bedrooms are for single occupancy with the exception of two. The residents who share these rooms have made a positive choice to do so, although this is not recorded. One shared room has fixed privacy screening and one does not have any. The manager explained that mobile screening is available, but that the individuals concerned do not want this; they have been sharing a room for some time. This arrangement is not recorded. Bedrooms seen were highly personalised with residents’ possessions. Some contain ensuite facilities. Bedrooms are comfortable, furnished and decorated according to individual taste and reflect the interests of the occupant. Many residents spoken with said that they liked their room and the house. The manager, head of care and a member of staff spoken with all assured the inspector that no residents needed help with their mobility; it was stated that a passenger lift, specialist equipment and moving and handling training for staff were unnecessary. It was noted from the home’s Annual Quality Assurance Assessment that six residents were over the age of sixty-five, ranging in age between sixty-six and seventy-nine. The home has a staff call system throughout. It was noted that three toilets did not contain a hand-washing sink, soap or towels, although a dispenser was in place. The manager said that this provided an anti-bacterial agent. It was indicated that the reason for the lack of handwashing sinks in these toilets was because of limitations to the plumbing system. Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents benefit from a sufficient number of staff on duty to meet their needs. They would be better protected by improvements to the staff recruitment procedure. Residents may benefit from a review of the systems in place for staff supervision and moving and handling training. EVIDENCE: At the time of the site visit, there were sufficient numbers of staff on duty to support people within the home. It was noted that the staffing roster included planned shifts only; the manager assured the inspector that electronic records contained the actual hours worked, the full names of all staff employed and their role and allocation. The home’s Annual Quality Assurance Assessment together with discussion with the manager indicated that since the last inspection staff had been provided with training in Medication, Health & Safety, Infection Control, Stress, the Protection of Vulnerable Adults, First Aid, Food Hygiene and Care Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 Page 21 Planning. It was said that regular fire drills and appropriate fire training was undertaken. The head of care stated that they were planning to update Mental Health training for staff. Training certificates and individual training records are maintained. The manager, head of care and a member of staff spoken with all assured the inspector that no residents needed help with their mobility; it was stated that a passenger lift, specialist equipment and moving and handling training for staff were unnecessary. It was noted from the home’s Annual Quality Assurance Assessment that six residents were over the age of sixty-five, ranging in age between sixty-six and seventy-nine. The home’s Annual Quality Assurance Assessment stated that eight out of fourteen staff had obtained an NVQ qualification with a further three working towards this. Staff files seen did not all contain evidence of all the necessary preemployment checks. One staff file, although containing two written references, did not include evidence of proof of identity, including a recent photograph, a written explanation of gaps in employment history, a health statement or a criminal records bureau (CRB) check. Another staff file contained a criminal records bureau check undertaken by a previous employer and not by the home. . The manager stated that all staff receive an annual appraisal. It was said that staff receive one-to-one supervision when they are recently recruited and when they are in the process of an NVQ qualification; longstanding members of staff not in either of these situations do not receive regular recorded one-toone supervision. The head of care explained that they undertook performance reviews on a regular basis, although this did not include one-to-one sessions with staff. It was stated that regular staff meetings are held. Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents enjoy living in an open and friendly atmosphere. The home aims to promote their best interests, although residents would benefit from some improvements to the systems for quality assurance, record keeping and incident reporting. EVIDENCE: The manager has relevant experience of service provision for people with mental health difficulties. They have been at the home since 1981. There is an open and inclusive atmosphere in the home. Regular meetings for residents are held followed by staff meetings to address any issues. There is a suggestions box available. A Quality Assurance questionnaire is used to gain the views of residents on admission and throughout the admission process. Although residents are provided with the opportunity to air their views and Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 Page 23 participate in decisions made, there is no ongoing formal quality assurance system. The home has recorded policies and procedures that are available for staff. It was said that these were reviewed annually. Accidents and incidents records seen were completed appropriately. However, it was evident that not all events included in care plan notes were recorded as an accident or incident. Some but not all significant events had been notified to the CSCI. Discussion took place with the manager, head of care and a member of staff regarding two previous serious incidents. It was stated that the home had followed the correct procedures and notified the CSCI. Further information was awaited and the manager assured the inspector that this would be forwarded to the CSCI when available. Records seen indicated the regular testing and maintenance of systems and equipment within the home, including fire prevention and detection equipment and fridge and freezer temperatures. The manager stated that cleaning chemicals are stored securely and restrictors are provided for ‘tilt and turn’ windows. Discussion took place around the monitoring of hot water temperatures. The manager and the head of care explained that many residents had requested water at a hotter temperature than that recommended and that risk assessments had been undertaken and recorded. In order to evidence consistency of care for residents, a number of records have been looked at as part of the inspection process. Some of these have been mentioned throughout this report where necessary. Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 Standard No Score 1 2 2 2 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 2 26 3 27 3 28 3 29 2 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 2 3 2 3 X Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 Page 25 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. 1 Standard YA23 YA34 YA41 Regulation 19(1)(b) Requirement The registered person shall not employ a person to work at the care home unless…(they have) obtained…the information and documents specified in…Schedule 2. In that, in order to evidence a robust staff recruitment procedure, the home must be able to show that all the necessary pre-employment checks detailed in Schedule 2 have been undertaken. These include proof of identity, including a recent photograph, a criminal records bureau check undertaken by the home, a satisfactory written explanation of gaps in employment and a statement by the person as to their mental and physical health. 2 YA30 23(5) The registered person shall undertake appropriate consultation with the authority responsible for environmental health for the area in which the care home is situated. DS0000021113.V337612.R01.S.doc Timescale for action 06/07/07 06/07/07 Glenmar Version 5.2 Page 26 In that, the home must consult the environmental health authority regarding the current provision of anti-bacterial agent dispensers in place of hand washing sinks, soap and towels in three toilets. This is to ensure that the appropriate systems are in place for the maintenance of infection control. 3 YA41 37 The registered person shall give notice to the Commission without delay of the occurrence of the death of any service user…the outbreak…of any infectious disease…any serious injury to…(or) serious illness of a service user, any event…which adversely affects the well-being or safety of any service user, any theft, burglary or accident…any allegation of misconduct… In that, the home must notify the Commission of all significant events, including serious illness or injury and those adversely affecting the well-being or safety of residents. 30/05/07 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 YA1 Good Practice Recommendations It is strongly recommended that a review should be undertaken to ensure that the homes statement of purpose and service users’ guide provides detailed information about the home to prospective residents. This DS0000021113.V337612.R01.S.doc Version 5.2 Page 27 Glenmar should include: 1 The relevant qualifications and experience of the registered provider and registered manager 2 The organisational structure of the home 3 The qualifications and experience of the staff 4 The facilities of the home 5 The home does not have a lift and is not best suited for residents with mobility problems. 2 YA2 YA41 It is recommended that a review should be undertaken to ensure that the home’s recorded pre-admission assessments are completed with sufficient detail on which to base a plan of care. It is recommended that a review should be undertaken to ensure that residents terms and conditions of accommodation have the facility to include the following: 1 The room to be occupied 2 More personalised aspects of the agreement, including a copy of the care plan and arrangements for reviewing this or elements of a Care Management care plan where applicable. In addition the reference to the home being registered with Sussex County Council should be updated to the CSCI. 4 YA6 YA41 It is strongly recommended that a review should be undertaken to ensure that residents’ care plans are up to date, completed with sufficient detail to reflect residents’ changing needs and provide adequate guidelines for staff. It is strongly recommended that, in order to evidence residents’ positive choice, their agreement to sharing rooms and refusal of privacy screening should be recorded. 3 YA5 5 YA6 YA25 YA41 6 YA9 YA41 It is strongly recommended that a review should be undertaken to ensure that residents’ risk assessments are completed with sufficient detail to reflect residents’ DS0000021113.V337612.R01.S.doc Version 5.2 Page 28 Glenmar changing needs and provide adequate guidelines for staff. 7 YA20 It is strongly recommended that, with regard to medication: 1 The ability of self-administrating residents to do so should be evidenced in writing by a health care professional and the risk assessment should be recorded. 2 Drugs should be stored in a cabinet specifically designed to store medication. 3 Drugs requiring refrigeration should be stored in a fridge specifically designed to store medication. 4 Hand written MAR chart entries should evidence the procedures in place for reducing the risk of errors, such as a countersignature from a second member of staff and written confirmation from the prescribing GP. 8 YA24 It is strongly recommended that the manager should complete their stated intention to re-decorate and rerefurbish areas of the home that need this. It is strongly recommended that a review should be undertaken for all residents to include the recording of the home’s risk assessment that specialist moving and handling staff training and equipment is unnecessary. It is recommended that all staff should receive regular, recorded supervision at least six times per year. It is strongly recommended that, in order to ensure the promotion of residents’ best interests, the home should develop their quality assurance measures into a formal ongoing system. It is strongly recommended that all accidents and incidents should be recorded on designated forms in addition to hand written notes, in order to give a clear picture and audit trail. 9 YA29 YA35 YA41 10 11 YA36 YA39 12 YA41 Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Glenmar DS0000021113.V337612.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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