Inspection on 14/11/05 for Glenmuir House

This inspection was carried out on 14th 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Glenmuir House 11/09/08

Glenmuir House 12/09/06

Glenmuir House 17/05/05

Glenmuir House 09/11/04

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

CARE HOMES FOR OLDER PEOPLE Glenmuir House 4 Branksome Road St Leonards On Sea East Sussex TN38 0UA Lead Inspector James Houston Unannounced Inspection 14th November 2005 9:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Glenmuir House DS0000061434.V261992.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Glenmuir House DS0000061434.V261992.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Glenmuir House Address 4 Branksome Road St Leonards On Sea East Sussex TN38 0UA 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) 01424 430203 Angel Healthcare Limited Vacant Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Glenmuir House DS0000061434.V261992.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users should be aged 65 years or over on admission. The maximum number of service users to be accommodated is 20. Only older people who have been assessed as requiring residential care are to be accommodated. 17th May 2005 Date of last inspection Brief Description of the Service: Glenmuir House provides residential and personal care to up to twenty older people. The property is a large detached building situated in a quiet residential area of St Leonards. Accommodation is provided on three floors, having a passenger lift that provides level access to all rooms. Glenmuir House has been registered as a care home since 1978 and is owned by Angel Healthcare Limited. The gardens, surrounding the home, are well kept and readily accessible to the service users. The home is approximately one mile from the town centre and sea front. A bus service runs near to the home. Glenmuir House DS0000061434.V261992.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and afternoon of the fourteenth of November 2005. Before the inspection papers held by the Commission for Social Care Inspection were read and those standards to be assessed read. The inspection in the home took 5.75 hours. A tour was made of the premises. A variety of records including four care plans and policies and procedures were read. The inspector met nine residents, two visitors, two staff, the assistant manager and the acting manager. There were seventeen residents accommodated in the home on the day of the inspection. 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. Glenmuir House DS0000061434.V261992.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glenmuir House DS0000061434.V261992.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,4 and 6. The home gives full information to prospective residents and their representatives and encourages visits to the home by them prior to admission to assist with the decision whether or not to the decision to enter the home. EVIDENCE: The home’s statement of purpose and service users’ guide give the required information. Necessary changes identified at the inspection have been made. Residents said that they had already known the home prior to admission, or that they and/or their family visited it as part of the decision as to whether or not to come in. The home offers respite or short term care when rooms are available. The home does not offer intermediate care. Glenmuir House DS0000061434.V261992.R01.S.doc Version 5.0 Page 8 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 11. Plans of care and medication records need attention. The healthcare needs of residents are given careful attention. The needs of dying residents are well met. EVIDENCE: The home has a good system of care planning, but one record inspected at random did not have a care plan. This must be rectified. Care plans are reviewed regularly, but not monthly. Daily updates are written. Those sampled were well written and up to date. Care plans are kept in residents’ rooms and residents have access to them at all times. Residents said that their healthcare needs are well met, and records inspected and observation of arrangements being made during the inspection confirmed this. The record of drugs administered was inspected and found to be not fully kept. Glenmuir House DS0000061434.V261992.R01.S.doc Version 5.0 Page 9 The home has suitable policies for the care to be given to dying residents, and staff confirmed that they are familiar with these. Records are held in care plans to ensure that residents’ wishes regarding arrangements to be made after their death are met. Glenmuir House DS0000061434.V261992.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 13. Social activities are well managed and provide variation and interest for people living in the home. Visitors are made welcome. EVIDENCE: A member of staff has lead responsibility for arranging activities. Residents said that they feel free to participate or not in the activities arranged. Activities enjoyed include Tai Chi, Motivation therapy, bingo and crosswords. Staff take residents out for walks. A diary of activities is kept. Some residents go out to church and a church service is held regularly in the home for those who wish to attend. Residents said that the routines of daily living in the home, such as times of getting up or going to bed and where meals are taken are flexible. Many residents said that they have regular visitors, and that their visitors are made most welcome. Staff said that receiving visitors and offering hospitality is an important part of their role. Glenmuir House DS0000061434.V261992.R01.S.doc Version 5.0 Page 11 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home has suitable arrangements to deal with complaints made to it. EVIDENCE: The home has a suitable complaints procedure. A necessary modification was made during the inspection. Residents said that they are aware of the procedure. The home has a suitable log in which to record any complaints made about it and action taken. This was inspected. There have been no complaints recorded in the home, or referred to the Commission of Social Care Inspection since the last inspection. Glenmuir House DS0000061434.V261992.R01.S.doc Version 5.0 Page 12 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,21,22,23 and 26. The home provides a good environment that is accessible, safe and well maintained. EVIDENCE: The home provides spacious and elegant accommodation for residents on three floors. It is a detached property in its own large and well-maintained grounds. The home’s own maintenance staff, employed by the group to whom the home belongs, were working in the home during the inspection. They adjusted two fire doors that did not close onto their stops. The home has a maintenance book for items identified as needing attention. The fire safety officer visited recently and the home is addressing all the items identified as needing attention. Minor physical items identified during the inspection as needing attention were pointed out to the acting manager. Glenmuir House DS0000061434.V261992.R01.S.doc Version 5.0 Page 13 All private bedrooms have en-suite facilities. There are two assisted bathrooms and a walk-in shower. All residents’ rooms and communal rooms have a call bell system, and residents said that staff always respond to these. A passenger lift gives access to all floors. There is a sloped walkway to the gardens. Handrails, grab-rails and other equipment are provided as necessary. The acting manager said that if it was needed to ensure that the needs of any resident could be met, a specialist assessment by a suitably qualified health professional would be commissioned. All rooms either meet or are above the national minimum size standard. The acting manager said that the home’s three double rooms are currently all let for single occupancy. The home has a suitably equipped laundry, and residents said that the laundry service was well organised with clothes being returned very quickly and in good condition. The home was clean and tidy throughout. The home has suitable infection control policies of which staff said that they are aware. Glenmuir House DS0000061434.V261992.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 29. EVIDENCE: The home has a staff rota that was inspected. The home has sufficient staff on duty to meet the needs of residents. Residents said that staff were helpful and friendly and that there are enough staff give assistance when it was needed. There has been considerable recent staff turnover. Staff said that other staff doing extra shifts had covered this and agency staff had not been used. The acting manager said that she has now appointed to all vacant posts. The acting manager said that she has worked long hours. The home now has in postappointed some weeks ago- an assistant manager who knows the home well and who will now share the on call duties. Recruitment records inspected showed that two recent recruits files did not contain all the necessary paperwork. A requirement has been made. Staff said that they have job descriptions and contracts of employment. Glenmuir House DS0000061434.V261992.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37 and 38. An application for registered manager is required. The home has an open and positive atmosphere. Quality assurance processes are suitable. Administrative systems are appropriate. Staff supervision and provision of training for staff in safe working practices need attention. EVIDENCE: The acting manager has been in post about four months. She has extensive relevant experience. She has undertaken training to update her skills, and has almost completed NVQ 3 in care. She intends to commence study for the qualification for registered manager early in 2006. An application in respect of a suitably qualified and experienced manager is required. The home has an open atmosphere. Residents and staff said that the manager is friendly and approachable. Staff meetings were held in the past and the acting manager plans to resume them. A residents’ meeting is to be held shortly. Glenmuir House DS0000061434.V261992.R01.S.doc Version 5.0 Page 16 The home has suitable quality assurance processes. Residents said that they and their relatives have used the process-completion of satisfaction questionnaires- to give feedback on how the home achieves outcomes for residents. The acting manager said that the responses have been used to inform practice in the home. The home is part of a larger group, and the acting manager said that she receives support from the group and her line manager. The home has adequate insurance cover, and a current certificate of insurance was on display in the home. The acting manager said that the home does not currently hold any monies or valuables on behalf of residents, but the facility to do so exists, should the need arise. The home has not given formal recorded supervision to staff for some time and this should restart. The group has this in hand and the acting manager said that she has received relevant training. Records inspected were found to be generally well kept, except where mentioned elsewhere in this report. An inventory of furniture brought into their rooms by residents should be kept. The acting manager said that the requirement made at the last inspection that a programme of training in safe working practices is delivered to all care staff has been partly addressed, but was not completed by the timescale set. The requirement has therefore been repeated. Glenmuir House DS0000061434.V261992.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 3 3 3 X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 3 3 1 2 2 Glenmuir House DS0000061434.V261992.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 3 4 5 6 Standard OP7 OP9 OP29 OP31 OP36 OP38 Regulation 15 17(1)(a)& Sch(3)(i) 19(1)(b) 8&9 18(2) 18(1)(c,i) Requirement Prepare a care plan for an existing resident. Record fully medication administered to residents. Obtain all the required papers on newly recruited staff. Submit an application for a suitably qualified and experienced manager. Provide formal recorded supervision for staff. That a programme of training in safe working practices is delivered to all care staff. (Timescale from previous inspection of 1/11/05 unmet) Timescale for action 18/11/05 14/11/05 30/11/05 28/02/06 31/12/05 30/04/06 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 2 Refer to Standard OP7 OP19 Good Practice Recommendations Review care plans monthly. Review minor physical items identified at inspection. DS0000061434.V261992.R01.S.doc Version 5.0 Page 19 Glenmuir House 3 4 OP36 OP37 Give care staff formal supervision at least six times a year. Hold an inventory of furniture brought into the home by residents. Glenmuir House DS0000061434.V261992.R01.S.doc Version 5.0 Page 20 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 Glenmuir House DS0000061434.V261992.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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