Inspection on 04/10/05 for Glenside Manor - Old Vicarage Wing

This inspection was carried out on 4th October 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

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

Glenside Manor - Old Vicarage... 28/07/05

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 Glenside Manor - Old Vicarage Wing South Newton Salisbury Wiltshire SP2 0QD Lead Inspector Karen Mandle 4 TH Announced Inspection October 2005 11.15a 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 Glenside Manor - Old Vicarage Wing DS0000015910.V254716.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. Glenside Manor - Old Vicarage Wing DS0000015910.V254716.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Glenside Manor - Old Vicarage Wing Address South Newton Salisbury Wiltshire SP2 0QD 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) 01722 742066 01722 744443 Glenside Manor Healthcare Services Ltd Mrs Sheila Marion Pickering Care Home 24 Category(ies) of Dementia (24), Dementia - over 65 years of age registration, with number (24), Mental disorder, excluding learning of places disability or dementia (24), Mental Disorder, excluding learning disability or dementia - over 65 years of age (24) Glenside Manor - Old Vicarage Wing DS0000015910.V254716.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The maximum number of service users who may be accommodated at any one time is 24 The staffing levels set out in the Notice of Decision dated 11 October 2004 must be met at all times 28/07/05 Date of last inspection 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. The Old Vicarage Wing is one of six homes located on the Glenside Manor campus, which is situated in South Newton, 5 miles west of the city of Salisbury. All six homes are owned by Glenside Manor Health Care Services. Mr Andrew Norman is the nominated responsible individual. Glenside Manor - Old Vicarage Wing DS0000015910.V254716.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection commenced at 11.15am and was completed at 3.45pm. The registered manager assisted the inspector during the inspection. A tour of the home took place with all bedrooms being visited. Care records were reviewed and health and safety records. The medications were inspected by the pharmacy inspector Mary Collier. What the service does well: What has improved since the last inspection? What they could do better: Glenside Manor - Old Vicarage Wing DS0000015910.V254716.R01.S.doc Version 5.0 Page 6 The recruitment procedures should be more robust and further domestic support is recommended. 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. Glenside Manor - Old Vicarage Wing DS0000015910.V254716.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Glenside Manor - Old Vicarage Wing DS0000015910.V254716.R01.S.doc Version 5.0 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 the following standard(s): 3 and 5 A clear admission procedure is in place which is inclusive of a pre admission assessment. Prospective service users can visit the home prior to admission. EVIDENCE: All service users are fully assessed by the Registered Manager Sheila Pickering prior to admission to the Old Vicarage Wing ensuring that through the assessment process the home is able to meet the often complex mental health and social care needs of the service user. A recent pre admission assessment was seen which was detailed providing information relating to current health care needs and social needs. A record of the assessment is kept on the service user file. Where possible the home encourages pre admission visits to the home providing an opportunity for the service user and family to meet with staff and other service users and view the accommodation. Glenside Manor - Old Vicarage Wing DS0000015910.V254716.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9 and 10 Health care needs are closely monitored and appropriate action taken when physical or mental health needs change. The care plans fully address all aspects of care. The systems for the handling of medication are good and the needs of service users with a variety of different conditions are provided for. Service users are very much treated with respect. EVIDENCE: Each service user is provided with a detailed and comprehensive care plan. The care plans address current and long term health care needs with a detailed social history. Monthly reviews take place or when care needs of the service user change. A record of daily activities is also recorded within the care plan. Observation of changing care needs and action taken by the care team was evident in the care records. All service users are registered with a GP who visits the home weekly. Many of the service users had limited communication, however two service users were able to express their opinion. Both service users were complimentary of the care and support provided. Through observation it was evident that the care team fully supported service users with health and personal care needs, some of which have complex mental Glenside Manor - Old Vicarage Wing DS0000015910.V254716.R01.S.doc Version 5.0 Page 10 health care needs. Service users were observed as calm and were able to make their own choices and decisions throughout the day. The home has a comprehensive medication policy and up to date homely remedies list. All records are appropriately kept and medication stored securely in two separate areas. A disposal system for medication is in place, in line with current legislation. Nurses are knowledgeable about the different types of medication used in the home for the different conditions of the service users. The interaction between the staff and service users was good with service users being treated with much respect by the staff. Personal and nursing care was observed being provided behind closed doors. Glenside Manor - Old Vicarage Wing DS0000015910.V254716.R01.S.doc Version 5.0 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 the following standard(s): 12 and 15 The activities provided suit the social needs of the service users. The food provided by the home is enjoyed by service users and is supported by a varied and balanced menu. EVIDENCE: An activities programme is in place, which is provided by an activities coordinator who is shared with another home on site. Many service users have personal activities provided in their room such as music systems, television, DVD players. The Staff were also observed supporting service users with daily activities. A record of personal activities is recorded in the care records. Service users were observed during lunch. The older service users with dementia are supported with their meals in a separate communal area. The younger adults are provided with a large dining area again the staff were observed fully supporting service users with their meals. Service Users appeared satisfied with the meal and two service users when asked were complimentary of the food provided. Glenside Manor - Old Vicarage Wing DS0000015910.V254716.R01.S.doc Version 5.0 Page 12 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 and 18 A complaints policy and procedure is in place. Service Users are protected from abuse, although recruitment practices need to improve. EVIDENCE: The homes complaints policy and procedure was displayed in the entrance hall to the home for service users and visitors to see. No complaints had been received by the CSCI for this service and the home had not received any formal complaints. A procedure is in place for dealing with any allegations of abuse. Staff also receives mandatory training in abuse awareness. Recruitment procedures need to be more robust with regard to obtaining CRB checks and references. Findings are detailed in the ‘Staffing’ section of this report. Glenside Manor - Old Vicarage Wing DS0000015910.V254716.R01.S.doc Version 5.0 Page 13 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): 19,24,26 Service users live in a safe and homely environment. The home was clean and infection control measures in place. EVIDENCE: The home provides two separate living areas, one area for the older people with dementia who are fully supervised and supported at all times by two members of staff. The larger communal space is for the service users with mental health needs with a smoking room provided. The home is generally well maintained throughout apart from one small bedroom on the ground floor and the sitting room which need to be decorated. The bedrooms are single, personalised and homely, many of which have been refurbished to a good standard. The home was clean throughout; however only one domestic is employed for the home with no support provided when that person is not available. Infection control measures were in place and clinical waste dealt with appropriately. Glenside Manor - Old Vicarage Wing DS0000015910.V254716.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, 29 and 30 The skills and experience of the staff support the complex needs of the service users. In some instances, recruitment procedures do not fully protect service users. EVIDENCE: The home operates to the agreed staffing notice. The staff are allocated to work either with the older people for the duration of the shift or the younger adults with mental health problems. This system appears to work well for both the service users and the staff. The staffing rotas provided evidence that a trained nurse is on duty at all times ensuring the nursing needs of the service users are being met. The staffing level provided was meeting the care needs of the service users. New staff are recruited via the Glenside human resources department and the registered managers do not always have the opportunity to undertake interviews, although they do meet candidates to show them around the individual units. Recruitment procedure appears non discriminatory. A selection of staff recruitment records for all of Glenside units was reviewed. In the main appropriate documentation was in place, however in one instance a CRB check had not been obtained for a staff member who had been employed for almost two years and in two other cases, references from previous employers, one of whom had been a care provider, had not been obtained. Should a person with a criminal record be employed, full details of any convictions should be on file. Glenside Manor - Old Vicarage Wing DS0000015910.V254716.R01.S.doc Version 5.0 Page 15 It is also desirable that written evidence of a risk assessment process, indicating their suitability for employment, be available. Training records indicated that staff received induction, foundation, and mandatory training. Further training in relevant subjects such as dementia care and cognitive rehabilitation therapy is also provided. NVQ training is provided and the training manager stated that ‘most units’ had up to 50 of staff with an NVQ. Glenside Manor - Old Vicarage Wing DS0000015910.V254716.R01.S.doc Version 5.0 Page 16 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 and 38 The home is well managed by an experienced manager. Health and safety issues are mainly addressed apart from the weekly testing of the fire alarm system. EVIDENCE: Mrs Sheila Pickering is a Registered Mental Health nurse who has much experience with caring for the needs of the service users living at the Old Vicarage. Mrs Pickering shows a good knowledge of each individual service users’ needs and medical problems. The home is generally well maintained throughout. Health and safety issues are addressed; apart from the weekly testing of the fire alarm system which had not always taken place. All accidents were clearly recorded and audited Glenside Manor - Old Vicarage Wing DS0000015910.V254716.R01.S.doc Version 5.0 Page 17 centrally. Electrical equipment is tested annually and regular servicing of hoist was taking place. Glenside Manor - Old Vicarage Wing DS0000015910.V254716.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X X X X 3 Glenside Manor - Old Vicarage Wing DS0000015910.V254716.R01.S.doc Version 5.0 Page 19 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 Standard OP19 Regulation 23 Requirement The registered person will provide plans to the commission regarding the refurbishment programme for the sitting/communal room. The registered person will ensure that decoration of room 4 takes place. The registered person is required to ensure that all staff have undertaken a Criminal Records Bureau check. The registered person is required to ensure that two written references, including, where applicable, a reference to the person’s last employer, be obtained for all new staff. The registered person will ensure the fire alarm system is tested weekly. The registered person is required to ensure that details of any criminal offences of which a staff member has been convicted are recorded. Timescale for action 01/01/06 2 3 OP19 OP29 23 19 15/12/05 03/10/05 4 OP29 19 03/10/05 5 6 OP38 OP29 23(4,c) 19 04/10/05 03/10/05 Glenside Manor - Old Vicarage Wing DS0000015910.V254716.R01.S.doc Version 5.0 Page 20 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 OP27 Good Practice Recommendations The registered person should consider employing further domestic support to ensure the home remains clean at all times. Glenside Manor - Old Vicarage Wing DS0000015910.V254716.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham 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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