Inspection on 08/05/06 for Glenmar

This inspection was carried out on 8th May 2006.

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 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

Glenmar 02/03/09

Glenmar 23/04/08

Glenmar 29/05/07

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 Alexis Reilly Key Unannounced Inspection 8th May 2006 1:00 Glenmar DS0000021113.V291904.R01.S.doc Version 5.1 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.V291904.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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.V291904.R01.S.doc Version 5.1 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.V291904.R01.S.doc Version 5.1 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 November 2005 Brief Description of the Service: Glenmar is registered to provide accommodation for up to 25 people suffering from mental health issues and admits people with low to medium dependency needs. The premise was originally two terraced properties situated in St Leonard’s with single and double rooms on the ground floor and two other floors (some of which are en suite, all having wash hand basins). Clients have the use of two separate lounge areas on the ground floor (one of which is nonsmoking) 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. The service charges £322.00 per week, and there are no additional costs. The current e mail address is glenmarjulia@aol.com. Glenmar DS0000021113.V291904.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection began at 1pm and lasted for two and half hours, further time was spent on preparing for the inspection and gaining the views of people who use the service. The following documents were examined on the inspection: Care Plans, Adult protection policy, complaints book, Menus, training programme, quality assurance forms and staff supervision records. Also records in relation to health and safety were also examined. No new staff had been recruited since the last inspection. The inspector spoke with two residents in detail during the inspection, one of which was recently admitted to the home. The inspector spoke to the two care staff on duty, the care manager and the registered manager. Clients were seen in the home and appeared happy, feed back was received from them in the form of questioners, the comments of which are included in the report. The remaining clients declined to meet with the inspector on the day of the inspection. What the service does well: What has improved since the last inspection? What they could do better: No requirements or recommendations have been made during the inspection, however the inspector has only inspected the core standards on this occasion. However the Registered Manager must continue to ensure that staff receive training in mental health which is applicable to the client group placed within Glenmar DS0000021113.V291904.R01.S.doc Version 5.1 Page 6 the service. This will ensure that the residents placed receive the best possible care, by suitably trained staff. Staff must ensure that residents are encouraged to become involved in the activities offered within the home. 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.V291904.R01.S.doc Version 5.1 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.V291904.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to this service. The service ensures it has gained the relevant background information for a resident prior to offering them a place in the service, and has assessed their individual needs. EVIDENCE: The service has had one resident admitted 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 inspector spoke with the resident on the day of the inspection they felt settled within the service and felt that the staff were helpful. The service carries out a Quality Audit of the experience of individuals moving into the service, this helps to address any concerns the resident may have. Glenmar DS0000021113.V291904.R01.S.doc Version 5.1 Page 9 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): 6,7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to this service. The service creates plans of care for residents, and carries out comprehensive assessments. Within this framework residents are supported to take risks as part of an independent lifestyle. EVIDENCE: One new resident has moved in since the last inspection. The Manager had the following documents in place for this resident: an assessment, a plan of care for the resident and a risk assessment, these documents were comprehensive and detailed. A lifestyle choice and preferences form was also completed, thus enabling staff to create a individual tailored care plan. An emotional well being and intellectual assessment was in place also which had been completed by the home. The file contained a completed questionnaire about their experience of moving into the service, a ‘service users feedback questionnaire on admission to the home’, this had positive feed back recorded in it. The Manager had detailed information about the persons needs both emotional and physical and was Glenmar DS0000021113.V291904.R01.S.doc Version 5.1 Page 10 aware of particular health needs. The Registered Manager and Care Manager demonstrated very clearly they respected the individual’s rights and choices. Care plans are reviewed every three months, and the service has a key worker system in place for residents. Individuals are issued with a contract when they move into the home, a copy of which is kept in the office. Glenmar DS0000021113.V291904.R01.S.doc Version 5.1 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): 12,13,14,15,16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to this service. Service users take part in appropriate leisure activities, and access the local community. Appropriate relationships are encouraged, and service users enjoy their meals. 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. 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 Glenmar DS0000021113.V291904.R01.S.doc Version 5.1 Page 12 in particular or if they would like any new activities offered. In addition to this a caravan has been purchased for the residents to use for either weekend stays independently or daily visits. Staff now ensure that any activities that residents are involved in are recorded on an individual and daily basis. Glenmar DS0000021113.V291904.R01.S.doc Version 5.1 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): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to this service. Residents physical and mental health needs are monitored within the service. Residents are supported to remain well both physically and emotionally. Residents are protected by the homes policies on administration of medication. EVIDENCE: The service has had no accidents since the last inspection. 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. Two 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. Staff support residents emotionally and are aware of individuals mental health needs, in discussion with the Registered Manager, Care Manager, and staff it is evident they are aware of how best to support individuals to maintain their emotional and mental health. Staff are aware of any decline in a residents Glenmar DS0000021113.V291904.R01.S.doc Version 5.1 Page 14 mental health and have good links with the Community Mental Health Team to ensure the resident gets the correct support. Glenmar DS0000021113.V291904.R01.S.doc Version 5.1 Page 15 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): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to this service. The service has an accessible complaints procedure in place. Residents are listened to and complaints are taken seriously. The service has an up to date Adult Protection Policy. EVIDENCE: The service has had two complaints since the last inspection. These were both in house complaints and were in relation to resident making a noise and disturbing one another at night. Residents are aware that if they make a complaint this is taken seriously and acted upon. The service records complaints and the actions taken to address the particular complaint are also recorded. The service has an Adult Protection Policy in place. Staff receive training on Adult Protection and are aware of the procedure, and what to do in the event of an allegation of abuse. Glenmar DS0000021113.V291904.R01.S.doc Version 5.1 Page 16 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to this service. Residents have bedrooms decorated to their choice and live in a safe environment. EVIDENCE: The inspector confirmed during the inspection that residents are able to personalise their rooms as they wish, this includes choosing the colour of the paint and soft furnishings. Communal areas in the home are maintained adequately, residents 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 a area of lawn for resident to enjoy. The service has an up to date electrical wiring certificate in place, tests for emergency lighting, and fire alarms are carried out on a regular basis. A hand rail has been fitted to both sides of the stairs for the lower basement floor. The service has addressed the requirements from the last inspection in relation to liquid soap in communal areas and paper towels. A bath mat and chair have also been replaced. Glenmar DS0000021113.V291904.R01.S.doc Version 5.1 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): The home was free from odour on the day of the inspection. Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to this service. Staff receive a variety of in house training in addition to the statutory training. Residents are protected by the homes recruitment procedures and staff supervision polices. EVIDENCE: Staff have job descriptions in place and terms and conditions of contract. The service employees 17 staff in total, 13 of these are involved in the care of residents. Out of these 3 have completed the NVQ level 2, 3 are working towards NVQ level2, and 1 is starting NVQ level 2 in September. 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 completed before staff can give out medication. Food health and hygiene training was carried out on the 9/2/06, and first aid training was completed by all staff on 30/3/2006. Medication management is scheduled to be taught on the 22/5/2006. Raising health and safety awareness in planned for June 2006, infection control is planned for July 2006, and Challenging behaviour is planned for August 2006. Glenmar DS0000021113.V291904.R01.S.doc Version 5.1 Page 18 No new staff have been employed since the last inspection, however historically on inspection recruitment files have been comprehensive and in order. Staff receive appraisals and supervision within the service, these supervisions are carried out by the Care Manager who has attended the relevant supervisory course. The inspector saw a written record of both supervisions and appraisals. Glenmar DS0000021113.V291904.R01.S.doc Version 5.1 Page 19 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): 37,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to this service. Resident’s views are taken into consideration within the home. EVIDENCE: The service has a Quality Assurance system in place, this gains the views of residents on admission and through the admission process, the registered Manager and Care Manager ensure that assessments are carried out in detail and comprehensive information is gained prior to offering a resident a place within the home. Separate Quality Assurance forms are used during the residents stay in the service. The Registered Manager ensures staff are supervised and receive appropriate training. Through the residents meetings and complaints procedure residents views are included in the self monitoring and development of the home. Residents have residents meetings which are recorded and are normally held the week prior to the staff meetings, this enables any issues which are brought up at the residents meeting to be discussed in the staff meeting the following week. Glenmar DS0000021113.V291904.R01.S.doc Version 5.1 Page 20 Feed back from residents spoken to on the day was positive and included comments ‘This is the best home I have ever been in’, ‘I like it here I come and go as I please, just let them know if I am going to be out at a party or whatever’, ‘Quite happy here, food is ok’ and ‘The staff looked after my health needs very professionally’. The following health and safety documents were examined and were in order. The service has an Electrical wiring certificate dated 5/12/05. Fire fighting units were tested in March 2006, the Last recorded emergency lighting tests were carried out on 3/5/2006, the fire alarms and emergency lighting test are carried out weekly by the maintenance person, and an external company comes each quarter to test them and the call system is tested at the same time. All three systems are serviced annually. The service has the following policies in place, Sexuality and Relationships, implemented January 2005 and reviewed in January 2006. Values of privacy, dignity choice, fulfilment, rights and independence, implemented July 2002 and reviewed December 2005. Racial harassment occurring between service users, between staff by staff or by service users on staff, implemented December 2002 and reviewed in December 2005. Cleaning substances are stored following the COSHH policies. Glenmar DS0000021113.V291904.R01.S.doc Version 5.1 Page 21 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 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 3 X 3 X 3 X X 3 X Glenmar DS0000021113.V291904.R01.S.doc Version 5.1 Page 22 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. Refer to Standard Good Practice Recommendations Glenmar DS0000021113.V291904.R01.S.doc Version 5.1 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. 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