Inspection on 28/07/05 for Glenside Manor - Old Vicarage Wing

This inspection was carried out on 28th July 2005.

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

The inspector 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

Glenside Manor - Old Vicarage... 13/03/07

Glenside Manor - Old Vicarage... 04/10/05

Glenside Manor - Old Vicarage... 04/02/05

Glenside Manor - Old Vicarage... 04/10/04

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

CARE HOMES FOR OLDER PEOPLE GlensideManor - Old Vicarage Wing South Newton Salisbury Wiltshire SP2 0QD Lead Inspector Karen Mandle Unannounced 28th July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. GlensideManor - Old Vicarage Wing Version 1.40 D51_D01_GlensideOldVicarage_V203282_280705_Stage4.doc Page 3 SERVICE INFORMATION Name of service Glenside Manor - Old Vicarage Wing Address South Newton Salisbury Wiltshire SP2 0QD 01722 742066 01722 744443 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Glenside Manor Healthcare Service Ltd, Mr Andrew Norman Mrs Shelia Marion Pickering Care Home with Nursing 24 Category(ies) of DE Dementia (24) registration, with number DE(E) Dementia - over 65 (24) of places MD Mental Disorder (24) MD(E) Mental Disorder - over 65 (24) GlensideManor - Old Vicarage Wing Version 1.40 D51_D01_GlensideOldVicarage_V203282_280705_Stage4.doc Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of service users who may be accomodated at any one time is 24. 2. The staffing levels set out in theNnotice of Decision dated 11 October 2004 must be met at all times. Date of last inspection 4th February 2005 Brief Description of the Service: Glenside Manor- Old Vicarage wing is registered to provide nursing care for 24 people with mental health conditions relating to acquired brain injury or dementia. The accommodation is provided over two floors offering single rooms and several large communal rooms. The majority of bedrooms have recently been refurbished to a good standard. The Registered Manager for the home is Mrs Sheila Pickering. Glenside Manor- Old Vicarage Wing is one of six homes located on the campus which is situated in South Newton near Salisbury, Wiltshire. The group of homes is owned by Glenside Manor Health Care Services Ltd. GlensideManor - Old Vicarage Wing Version 1.40 D51_D01_GlensideOldVicarage_V203282_280705_Stage4.doc Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection commenced at 10.40am and was completed at 2.20pm. The Registered Manager Mrs S Pickering was not available but the inspector was, assisted by the Deputy Manager Mr Rory Lambert. Mr Lambert provided the inspector with a tour of the building and information regarding the service provided by the home. The inspector was able to freely visit with Service Users and review care records. What the service does well: What has improved since the last inspection? What they could do better: The care records should be reviewed monthly ensuring that all areas of care are closely monitored. The weights of Service Users should be monitored monthly to ensure that all nutritional needs are being fully met. The recording of daily activities should be recorded daily. GlensideManor - Old Vicarage Wing Version 1.40 D51_D01_GlensideOldVicarage_V203282_280705_Stage4.doc Page 6 The main sitting room should be redecorated to ensure a pleasant living room for Service Users to sue during the day. The home should employ enough domestic staff to maintain a clean environment for Service Users to live in. 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. GlensideManor - Old Vicarage Wing D51_D01_GlensideOldVicarage_V203282_280705_Stage4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection GlensideManor - Old Vicarage Wing D51_D01_GlensideOldVicarage_V203282_280705_Stage4.doc Version 1.40 Page 8 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 standard(s) 3 and 5 A clear admission procedure is in place and all nursing and social needs are fully assessed prior to admission, ensuring the home is able to meet the care needs of the individual Service User. Prospective Service Users can visit the home prior to admission. EVIDENCE: The Registered Manager was not available at the inspection. The Deputy Manager Mr Rory Lambert informed the inspector that Sheila Pickering was out of the home completing a pre admission assessment for a prospective Service Users. Due to the often complex mental health needs of the Service Users group a detailed and comprehensive pre admission assessment takes place ensuring the home is able to meet the nursing and social needs of the Service Users. Where possible the home encourages pre admission visits to the home enabling the Service User to visit with staff and other Service Users and provide an opportunity to view the accommodation provided. GlensideManor - Old Vicarage Wing D51_D01_GlensideOldVicarage_V203282_280705_Stage4.doc Version 1.40 Page 9 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 standard(s) 7, 8 and 10 Health care needs of Service Users are monitored and appropriate action taken when health care needs change. The care plans address all aspects of care but were not reviewed regularly. The privacy and dignity of Service Users is supported by the care team. EVIDENCE: Individual care plans are in place for each Service User, which are comprehensive and detailed. The plans provide a good social history for the care staff to use to help engage with Service Users suffering from mental health problems. Health care needs are clearly identified and addressed. The care records had not been reviewed monthly and not all Service Users had been weighed regularly ensuring that all dietary needs were being closely monitored. Information relating to daily activities was limited. All Service Users are registered with a GP. Many of the Service Users had limited communication skills therefore gaining the opinions of the Service Users regarding health needs being met was not possible. However through observing the care staff it was evident that the staff knew the Service Users very well and would be able to action any changes in health care needs appropriately. GlensideManor - Old Vicarage Wing D51_D01_GlensideOldVicarage_V203282_280705_Stage4.doc Version 1.40 Page 10 The care team are work within two teams, one team providing care for Service Users with mental health needs and the second team providing care for the older people suffering from dementia. All nursing care and personal care was observed being provided in the privacy of the Service Users’ bedroom or bathroom and staff were heard speaking to Service Users in a respectful manner. GlensideManor - Old Vicarage Wing D51_D01_GlensideOldVicarage_V203282_280705_Stage4.doc Version 1.40 Page 11 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 standard(s) 13, 14 and 15 Service Users are supported by the home to retain links with family and friends. Freedom of choice for Service Users was well observed with appropriate support from the care staff. The food provided by the home is enjoyed by Service Users and is supported by a varied and balanced menu. EVIDENCE: Service Users can receive visits from family and friends at any time they wish in the privacy of the bedroom or in one of the communal areas. Two Service Users were able to confirm this. Service Users are also supported to participate in the community where possible and to go home for visits. Service Users were observed doing very much as they wished with appropriate support from the care staff. Good freedom of choice for Service Users was clearly seen which also enhanced the relaxed atmosphere of the home. The main hot meal of the day was observed, which was well presented with a daily choice available. The meal appeared to be enjoyed by the Service Users. The home provides two separate dining rooms, one for the Service Users suffering with Dementia and the other for the younger people. The staff were observed assisting Service Users to the dining areas and supporting them with their meal if needed on a one to one basis. The menus seen were varied and balanced and special diets well catered for. GlensideManor - Old Vicarage Wing D51_D01_GlensideOldVicarage_V203282_280705_Stage4.doc Version 1.40 Page 12 GlensideManor - Old Vicarage Wing D51_D01_GlensideOldVicarage_V203282_280705_Stage4.doc Version 1.40 Page 13 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 standard(s) 16 and 18 There is a complaints policy and procedure. A vulnerable adults procedure is in place and staff are fully aware of the local procedure and how to use it. EVIDENCE: A complaints policy and procedure is in place, which is available in the entrance hall to the home for Service Users and visitors to the home. No complaints had been received by the CSCI and no complaints were raised by Service Users during this inspection. A procedure is in place for dealing with any allegations of abuse and the staff had received training in the local vulnerable adults procedure. GlensideManor - Old Vicarage Wing D51_D01_GlensideOldVicarage_V203282_280705_Stage4.doc Version 1.40 Page 14 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 standard(s) 19, 24 and 26 The home is generally well maintained ensuring the safety of the Service Users. The décor and the floor covering of the sitting room did not enhance the living environment for Service Users. Infection control procedures were satisfactory. EVIDENCE: The Old Vicarage is generally well maintained through out providing a safe environment for Service Users to live in. The main sitting room will need to be refurbished. The sitting room carpet is stained and worn and the wall paper, appears old and discoloured. Service Users were seen using this room during the inspection for general daily activities. A Service User did comment to the inspector how he disliked the décor of this sitting room. However others parts of the home were in the process of being refurbished and many of the bedrooms had been refurbished to a good standard. The bedrooms were very personalised and homely. GlensideManor - Old Vicarage Wing D51_D01_GlensideOldVicarage_V203282_280705_Stage4.doc Version 1.40 Page 15 The general cleanliness of the home was just satisfactory however the care staff were responsible for the cleaning as a cleaner was not available. Cross infection procedures were in place. GlensideManor - Old Vicarage Wing D51_D01_GlensideOldVicarage_V203282_280705_Stage4.doc Version 1.40 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 The staff had the skills and knowledge to meet the care needs of the Service User group. The staff available did not meet the staffing notice. EVIDENCE: Staffing levels on the day were the Deputy Manager and three registered nurses and three carers, which did not meet the agreed staffing notice. However duty rotas indicated this was not common practice and the home did normally adhere to the agreed staffing notice. The care of Service Users had not been compromised, however the staff were observed as very busy throughout the inspection with the added duty of cleaning the home. The staff clearly had a good understanding of both client groups care needs both physically and mentally and interacted well with the Service Users. GlensideManor - Old Vicarage Wing D51_D01_GlensideOldVicarage_V203282_280705_Stage4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38 Health and Safety issues are addressed providing a safe environment for Service Users to live in. EVIDENCE: The home is well maintained throughout and Health and Safety issues addressed ensuring a safe environment for Service Users to live in. All accidents are clearly recorded and regularly audited. Electrical equipment is tested annually and servicing of hoists was taking place. The fire records indicated that all appropriate fire safety checks had been made and staff had received fire training. GlensideManor - Old Vicarage Wing D51_D01_GlensideOldVicarage_V203282_280705_Stage4.doc Version 1.40 Page 18 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x 3 x 2 STAFFING Standard No Score 27 2 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x x x x 3 GlensideManor - Old Vicarage Wing D51_D01_GlensideOldVicarage_V203282_280705_Stage4.doc Version 1.40 Page 19 no 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 OP7 Regulation 15(2,b) Requirement The Registered Person will ensure the care records are reviewed monthly for all Service Users. The Registered Person will ensure that all Service Users weights are monitored monthly to ensure that all nutritional needs are being met. The Registered Provider will ensure that the sitting room is refurbished. The Registered Person will ensure enough domestic staff are employed to maintain a clean environment for Service Users to live in. Timescale for action By October 1st 2005 By October 1st 2005 2. OP8 12(1,a) 3. 4. OP19 OP27 23 18(1,a) By November 15th 2005 By September 30th 2005 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 OP7 Good Practice Recommendations The Registered perosn should ensure activities provided are fully documented. GlensideManor - Old Vicarage Wing D51_D01_GlensideOldVicarage_V203282_280705_Stage4.doc Version 1.40 Page 20 Commission for Social Care Inspection Avonbridge House Bath Road Chippenham Wiltshire, SN15 2BB 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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