Inspection on 17/08/06 for Glenthorne House

This inspection was carried out on 17th August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Glenthorne House 20/03/07

Glenthorne House 08/12/05

Glenthorne House 18/08/04

Glenthorne House 20/05/04

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

CARE HOMES FOR OLDER PEOPLE Glenthorne House Glenthorne House Dover Street Bilston Wolverhampton West Midlands WV14 6AL Lead Inspector Mr Ian Harris Key Unannounced Inspection 17th August 2006 08:00 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 Glenthorne House DS0000040718.V308132.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Glenthorne House DS0000040718.V308132.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glenthorne House Address Glenthorne House Dover Street Bilston Wolverhampton West Midlands WV14 6AL 01902 491633 01902 304094 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) Mr James Walter Dell Miss Evelyn Thomas Vacant Care Home 20 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (20) of places Glenthorne House DS0000040718.V308132.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Maximum of 3 (three) older people within the Dementia (DE) category. Older people with mild dementia only to be accommodated. Adequate level of staff and suitable dementia training for staff to be provided within one month of approval of this application. 8th December 2005 Date of last inspection Brief Description of the Service: The home is a large detached property, situated in a residential area of Bilston. The home is currently registered for twenty older people, of which three older people with mild dementia. It is in close proximity to all local amenities, which includes the Health Centre, library, shops and a market. The area is well serviced by buses and Metro. The home has 16 single bedrooms, three lounges/dining rooms, two bathrooms, two showers with WC’s, seven WC’s, a kitchen, a small staff room, the main office, car park is at the rear and garden and patio area. The laundry facilities are located in the basement area. The present Registered Providers - Mr James Walter Dell and Miss Evelyn Thomas have been operating this care home since March 2003. Glenthorne House DS0000040718.V308132.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced key inspection and took place over 5. hours commencing at 8 a.m. During the inspection a tour of the premises took place and staff and care records were inspected. Also staff rotas and general records regarding the maintenance of the home were checked. 4 members of staff and 6 residents were spoken to. It was noted that the fees range between, £336 to £394. On the day of inspection the atmosphere within the home was found to be warm, friendly and comfortable with contented residents. All the residents spoken to who could express themselves in a meaning full way expressed their satisfaction with the home and the care they receive. “ We are all very happy here we’ve got company” “ We have good food and the home is always nice and clean” “ The staff look after us very well ” were some of the comments made. What the service does well: The home makes every effort to provide individuals with a good standard of care to meet assessed needs following a care plan. The home has a good key worker and supervision system in place. The home is registered for 19 older people, of which five older people can have Dementia. The home makes every effort to provide individuals with a good standard of care to meet the assessed needs by following a care plan. The home communicates well with the families/friends and representatives of the residents. The visitors’ book indicated a lot of activity. The residents’ spoken with said that they are happy and content with living in a homely and caring home. Observations during the inspection saw very attentive staff providing for the individual needs of the residents and assisting them with choices. A number of residents confirmed that the care staff are very kind and caring. The home has a very good staff- training programme, which all staff are involved in, this ensures that they continue to improving their knowledge and skills. Glenthorne House DS0000040718.V308132.R01.S.doc Version 5.2 Page 6 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. Glenthorne House DS0000040718.V308132.R01.S.doc Version 5.2 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 Glenthorne House DS0000040718.V308132.R01.S.doc Version 5.2 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 The home has a satisfactory admissions procedure ensuring the individual needs of the residents are fully met. The home does not provide intermediate care they only provide short stay and introductory stays when the home has a vacancy. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: All the residents who are funded by the Local Authority undergo a full multidisciplinary assessment prior to admission. The residents’ who are self funding are assessed by the Care Manager, using the homes assessment forms. Copies of the assessment, Care Plan and Reviews are on the residents’ files. The Six care plans inspected contained pre admission assessments of the persons needs, both from assessments by the home’s staff and other relevant professionals. Glenthorne House DS0000040718.V308132.R01.S.doc Version 5.2 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 Each resident has a comprehensive, individual care plan that is reviewed on a monthly basis. The home has good contact with local G.P. s. local hospitals and paramedical services, which ensures that resident’s health needs are met. The systems for the administration of medication in not good and residents could be at risk. The quality outcome in this area is poor. This judgment has been made using available evidence including a visit to this service. EVIDENCE: Six residents case files were inspected and all contained a comprehensive Care Plan for each individual resident based on the initial assessment. The Care Plans are drawn up by the Care Staff in consultation with the resident and their family. There was evidence on the files to show the Care Plans are being carried out and reviewed on a monthly basis. The case tracking demonstrated an effective review process together with the home’s ability to meet the Glenthorne House DS0000040718.V308132.R01.S.doc Version 5.2 Page 10 changing needs as they occur. The service users’ health is closely monitored and appropriate medical care services are sought as and when required. The Inspector spoke to six service users, who were able to have meaningful conversation. Generally the service users appeared to be content, comfortable and happy. Medication is administered, by means of a monitored dosage system and the system appears to be working very well. All the Staff have been trained to use the system before they are allowed to administer medication. The home has very good policies and procedures, which are used as guidance and are an integral part of the care staff induction programme. No personal care interventions take place in communal areas. Observed practice on the day of inspection was appropriate and showed respect for the residents. Consultation with health care and social care professionals is carried out within the resident’s bedrooms. Visitors are able to meet residents in their bedrooms or the quiet lounge on the ground floor offers that privacy when not being used. Residents were being treated with respect and staff were working both professionally and sensitively in meeting individual needs. Those residents and visitors spoken to were complimentary regarding the quality of their lives at the home and visiting health professionals praise the management and care standards there. Glenthorne House DS0000040718.V308132.R01.S.doc Version 5.2 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, 13, 14, and 15 The home provides a good programme of social activities within the home, which are designed to meet the resident’s capabilities, which, the staff encourage residents to pursue. However it was note that there is very little take up by the residents and no outings have been provided this year. The Care Manager and staff encourage family and friends to maintain good contact with their relatives at the home. The meals in the home are good offering both choice and variety and also catering for special dietary needs. The quality outcome in this area is adequate. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The routines and activities within the home are flexible and are built around the needs of the residents. There was also evidence to show staff do consult with the residents regarding the choice of meals and activities within the home. The home has a staff member designated to organised social and leisure activities and who identified interests that the residents wish to pursue. It was also noted that the home organise entertainment delivered by external Glenthorne House DS0000040718.V308132.R01.S.doc Version 5.2 Page 12 entertainers. The records of activities enjoyed by the service users are being appropriately maintained. The residents also keep contacts with the local community facilities – for example, some are escorted to church services, local shops and the park. Special events are held to celebrate events such as Mothers- day, Birthdays and Christmas. Photograph seen during the inspection indicated that the events are very much enjoyed by residents and staff, with a great deal of effort taken over decorations and the creation of special cakes. All residents were very complimentary about the standard and choice of food provided. It was apparent that the menu is changed to incorporate seasonal changes. Several service users told the Inspector that the food was nice, tasty and well prepared. The kitchen is well equipped, kept clean and tidy and has been redecorated since the last inspection. The catering staff are trained in food safety and hygiene matters. Glenthorne House DS0000040718.V308132.R01.S.doc Version 5.2 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 the following standard(s): 16 and 18 The home has a satisfactory complaints system and there is evidence that residents’ and their families feel that their views are listened to and acted upon The home has good policies and procedures regarding protection from abuse, which includes a whistle blowing policy. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The home has a very good comprehensive complaints procedure. The residents and relatives are made aware of the procedure through the statement of their terms and conditions of residence, the service users guide and, which a copy is in every bedroom. Also a copy is placed in the reception hall. The home has a complaints book in which all complaints are recorded. It was noted that the home has not received any formal complaints since the last inspection all minor complaints are dealt with appropriately and quickly. The home has good policies and procedures regarding Restraint, dealing with Aggressive Behaviour and Prevention of Abuse, which, includes a WhistleBlowing policy. These issues are also covered in internal and N.V.Q. training, which all care Staff is undergoing. Glenthorne House DS0000040718.V308132.R01.S.doc Version 5.2 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 the following standard(s): 19 and 26 The general standard of environment is good providing service users with a homely place to live. The standard of cleanliness reflects the ongoing cleaning schedule maintains this standard of throughout the home. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The home offers a comfortable and well – maintained environment to all service users. The home has adequate communal space. The home is safe and is suitable for its stated purpose. The home has a rolling programme of redecoration to maintain good standard. The garden and grounds are also being well maintained. There are adequate toilets, bath/shower and washing facilities. However it was noted that the carpets in the corridors on the first floor need replacing. It was noted that a conservatory has now in use offering extra lounge/dining room. It was also noted that the ground floor corridors, front lounge, Glenthorne House DS0000040718.V308132.R01.S.doc Version 5.2 Page 15 bathroom, the kitchen and three bedrooms have been redecorated since the last inspection. The home is in compliance with the Fire Safety Officer’s requirements. During the inspection, the home was found to be clean, tidy and free from any unpleasant odour. The home has good policies and procedures in place regarding infection control. The Acting Care Manager stated that the majority of staff has received training in infection control and they are made aware of the dangers of cross-infection. Glenthorne House DS0000040718.V308132.R01.S.doc Version 5.2 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 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, 28, 29 and 30 The home is well staffed with adequate numbers and skill mix of staff to meet the needs of the residents. The staff have a very good understanding of the resident’s support needs. The home has good policies and procedures regarding the recruitment of staff. There is a good training programme in place that ensures staff are competent to do their job. The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: There has been an improvement in staffing since the last inspection and the inspection of staff rotas and discussions with staff indicated that the home is well staffed. There is a good balance within the staff group, which includes experience, mature and younger staff who are embarking on a new career. The home operates an acceptable recruitment procedure and has registered with the Social Care Association in order to complete the appropriate checks on staff. On inspecting 6 staff files, there was evidence within them that all the checks are being carried out. The Acting Care Manager and staff are committed to developing their knowledge and skill through training. The home has a very good induction programme and training programme. In addition to the N.V.Q. 2, training programme the Acting Care Manager has commenced the Registered Managers Award. Also care staff have attended training courses on the following subjects. Safe handling of medication, Risk assessment, Dementia Glenthorne House DS0000040718.V308132.R01.S.doc Version 5.2 Page 17 care, Manual Handling, First- Aid, Infection Control, Dementia Care and Fire Prevention and Health and Safety. Glenthorne House DS0000040718.V308132.R01.S.doc Version 5.2 Page 18 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, 33, 35 and 38 The home is a well managed, where service users interests and welfare is promoted. The home is operating a good system to assist residents with the safe handling and keeping of their personal finances and good records are being kept of all transactions made. All the general records that were inspected, were found to be well ordered and maintained. The home has good policies and procedures regarding Health and safety The quality outcome in this area is good. This judgment has been made using available evidence including a visit to this service. EVIDENCE: The home is without a Registered Manager however the Acting Care Manager has considerable experience in caring for older people in residential homes and has submitted an application for registration. There are clear lines of Glenthorne House DS0000040718.V308132.R01.S.doc Version 5.2 Page 19 accountability within the home and is very supportive of both staff and residents. Observations made and discussions with residents’, staff indicated that the Care Manager is very approachable and operates an open door policy. The staff and residnts who could express themselves stated that they are happy to approach the Care Manager and staff with any problems they might have and were confident that they would be responded to. There is no evidence that the home has a Quality Assurance system in place, where residents/ relatives’ views on the service provided is obtained. All the Financial records and administrative procedures within the home that were, inspected were found to be well ordered and maintained. The home has a good heath and safety policy and all staff are aware of their responsibilities regarding these issues and a number of staff have received training on these issues. All safety equipment is check and well maintained. Glenthorne House DS0000040718.V308132.R01.S.doc Version 5.2 Page 20 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 X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Glenthorne House DS0000040718.V308132.R01.S.doc Version 5.2 Page 21 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 OP31 Regulation 9 Requirement The Registered Providers must ensure that an application for registration of the newly appointed acting care manager is brought forward as a matter of priority. The registered person must ensure that a Quality Assurance system is in place, where residents/ relatives’ views on the service provided is obtained and acted upon. The registered person must ensure that the carpets in the first floor corridors are replaced. Timescale for action 31/10/06 2 OP33 24 (1) 01/11/06 3 OP19 23 01/12/06 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. OP19 Glenthorne House Refer to Standard Good Practice Recommendations That the two double rooms become single rooms fitted with en-suite DS0000040718.V308132.R01.S.doc Version 5.2 Page 22 Glenthorne House DS0000040718.V308132.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Glenthorne House DS0000040718.V308132.R01.S.doc Version 5.2 Page 24 - 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. 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