Inspection on 08/12/05 for Glenthorne House

This inspection was carried out on 8th December 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

Glenthorne House 20/03/07

Glenthorne House 17/08/06

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 Bhag Jassal Unannounced Inspection 10:00 8 December 2005 th 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.V270400.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. Glenthorne House DS0000040718.V270400.R01.S.doc Version 5.0 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 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.V270400.R01.S.doc Version 5.0 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. 28th June 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.V270400.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and conducted by the Regulation Inspector and the Regulation Manager – Mrs Teresa Wild and started at 10 00 am and lasted three hours and 15 minutes. The inspection included discussions with the acting care manager Ms Carrol Collins, Registered Provider Miss Evelyn Thomas, service users, the staff and visiting relatives. The daily routines were observed and service users and staff records, policies and procedures were examined. Inspection of premises both inside and outside was also undertaken. Discussion was held with the Registered Provider and the acting care manager with regard to the progress made by the home in implementing the requirements contained in the last inspection report dated 28 June 2005. It was noted that the Registered Providers have taken appropriate action to implement all of the requirements and recommendations from the last inspection. What the service does well: The care home registered for Dementia –over 65 (3) Old Age (20). 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 communicates well with families/friends and representatives. The visitors’ book indicated a lot of activities. The service users spoken with said that they are happy and enjoy living in a homely and caring place. The service users were in the lounges engaging in their daily routines and activities and they further commented that they were content and satisfied with the care provided by the care home. A service user’s relative expressed his satisfaction of the care being provided to his mother and generally felt the staff do a good job. The atmosphere within the home was observed to be relaxed, comfortable and friendly. The friendly rapport was also observed between service users and staff. Meals are varied, well balanced and presented to meet each individual’s choices, preferences and requirements. Glenthorne House DS0000040718.V270400.R01.S.doc Version 5.0 Page 6 The home provides a good standard of accommodation, which is being maintained safe, secure and to a good standard. What has improved since the last inspection? What they could do better: The home has made good progress in implementing the requirements from the last inspection report dated 28 June 2005. The Registered Providers must ensure that those members of staff, who as yet not received training in safe working practice topics and the NVQ Level 2, must do so as a matter of priority. There are a small numbers of requirements relating to the safe working systems and the environment, which must be addressed as a matter of priority. The Inspectors would like to acknowledge that the further improvements made by the Registered Providers, the new acting care manager and the staff in the home’s environment and also further enhancing the good quality of care for service users at Glenthorne House. It is also welcome move by the Registered Glenthorne House DS0000040718.V270400.R01.S.doc Version 5.0 Page 7 Providers’ proposal to extend and alter the premises, which will further improve the accommodation and facilities, both for service users and the staff. 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.V270400.R01.S.doc Version 5.0 Page 8 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.V270400.R01.S.doc Version 5.0 Page 9 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, 4 and 6 The home has a comprehensive needs assessment procedure providing an effective assessment, suitability, evaluation and its ability to meet the assessed care needs of both privately funded and those placed by the Local Authorities. EVIDENCE: A sample of three service users’ care plans and files were thoroughly examined at the inspection. All contained evidence that the service users receive the benefit of a comprehensive assessment prior to admission. The acting care manager also carryout assessments and these details are documented on care plans, which are drawn up by the senior staff with the assistance from the service users and their relatives and where appropriate other professionals. The home has a good admission procedure, which is made available to all prospective service users and their relatives and/or representatives. The service users and/or their relatives can visit the care home prior to admission. If they indicate to the care home that it is suitable to meet the needs of the Glenthorne House DS0000040718.V270400.R01.S.doc Version 5.0 Page 10 prospective service users, and then the home formally confirm in writing whether or not it can meet the needs of the prospective service users. Once this is agreed between the parties then the placements takes place on a 28 days trial period. The home does not offer an intermediate care service. Glenthorne House DS0000040718.V270400.R01.S.doc Version 5.0 Page 11 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 The staff within the home is aware and sensitive of the needs of each and all service users and meet their needs in a professional manner. There is clear and consistent care planning system in place, which provides the information the staff requires to meet the service users’ health and care needs. EVIDENCE: It was evidenced that all service users undergo a comprehensive assessment of their needs prior to admission to the home. A care plan is produced, which is based on the assessment of needs. The home operates a key worker system, which helps ensure that the recommendations arising from the care plans and monthly reviews are implemented. Three service users’ care plans were examined in detail and it was noted that the short-term and long-term goals and appropriate interventions required to put them into action to meet the individual service user’s needs are identified. It was also evidenced that the care plans are being reviewed on a monthly basis. The daily care recording formats were also examined and it was noted that the quality and detail of recording has steadily improved. The Registered Glenthorne House DS0000040718.V270400.R01.S.doc Version 5.0 Page 12 Provider stated that the staff would be closely supervised and supported to make further improvements in daily care, both day and night recording. The home also ensures that detailed nutritional screening is undertaken, including weight gain and loss records are maintained and appropriate action is taken if required. The home also maintained records of all health checks. Case tracking demonstrated an effective review process together with the home’s ability to met the changing needs as they occur. The service users health is closely monitored and appropriate medical care service s are sought as and when required. It was observed on the day of inspection that no personal interventions were taken in communal areas. In addition, consultations with health and social care professionals are carried out within the service users’ bedrooms. The Inspectors spoke to majority of service users, who were able to have meaningful conversation. Generally the service users appeared to be content, comfortable and happy. It was evidenced from the staff training records updated on 14 October 2005 and discussion with the Registered Provider and acting care manager that ten carers have received their training in safe handling of medication. The other care staff are undergoing this mode of training. Glenthorne House DS0000040718.V270400.R01.S.doc Version 5.0 Page 13 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, 14 and 15 Glenthorne House provides a good quality of care and promotes lifestyles for the service users in residence. The service users are positively helped to exercise choice and control over their lives as far as possible. Meals at Glenthorne House are of a good homely type offering both choice and variety and catering for special needs. EVIDENCE: It was evidenced that the home provides an activities programme in accordance with the service users’ choices, preferences and capacities in relation to – social and leisure activities and cultural interests. It was also noted that the home also organise entertainment delivered by external entertainers. The service users also keep contacts with the local community facilities – for example, church services, shops and park. The records of activities enjoyed by the service users are being appropriately maintained. The acting care manager stated that the service users are positively assisted and helped to exercise choice and control over their lives. A close liaison is maintained with the relatives and representatives where the service users are not able to make certain decisions. The service users and their relatives are Glenthorne House DS0000040718.V270400.R01.S.doc Version 5.0 Page 14 informed about the availability of the local Advocacy Service based at the local Age Concern office. It was evidenced that the home provided a varied, wholesome and nutritious diet. The meals provided during lunchtime on the day of inspection were well received by the service users. It was also observed that those service users, who needed assistance in feeding, the members of staff were available to assist these service users. The Registered Provider stated that the menu is changed on a regular basis and in consultation with the service users. Several service users told the Inspectors that the food was nice, tasty and well prepared. The kitchen is well equipped and kept clean and tidy. The Registered Provider stated that the requirements and recommendations contained in the Inspection Report dated 06 December 2005 of the Environmental Health Officer are being implemented appropriately and as a matter of priority. Glenthorne House DS0000040718.V270400.R01.S.doc Version 5.0 Page 15 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): Not assessed on this occasion EVIDENCE: Glenthorne House DS0000040718.V270400.R01.S.doc Version 5.0 Page 16 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, 25 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. 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. It was noted that a conservatory was being built next to lounge/dining room. The radiators throughout the home have been covered appropriately, and supply of hot water to all hot water outlets is being maintained at the required temperature level i.e. close to 43 Degrees C. The maintenance man carryout Glenthorne House DS0000040718.V270400.R01.S.doc Version 5.0 Page 17 tests on all hot water outlets once a month. The last recorded check was carried out on 24 October 2005. It was noted during the inspection of premises that there was inadequate hot water supply in the shower room on the first floor and this matter was drawn to the attention of the Registered Providers and the maintenance man rectified this problem immediately. The Registered Providers to ensure that all hot water outlets temperature tests are to be carried out once a week and appropriately recorded. 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 Registered Provider 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.V270400.R01.S.doc Version 5.0 Page 18 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 adequately staffed at all times, which ensures the quality of care provided, and ability of the home to home to meet the needs of the service users. The home continues to support staff to complete their training. The home has satisfactory staff recruitment policies and procedures. EVIDENCE: The information provided by the Registered Provider and the available staff rotas showed that the home is adequately staffed to care for 20 service users with varying levels of dependency and differing needs. It was evidenced that from the staff training records that were updated on 14 October 2005, that 12 members of staff have completed their NVQ Level 2 training and the remaining staff would also undertake this mode of training shortly. It was also noted that two member of staff also completed their NVQ Level 3 training. The Registered Provider stated that all new members of staff receive the TOPSS Induction and Foundation training. The home has a good training programme in place. The majority of staff has now received training in safe working practice topics, dementia care and bereavement. However, those members of staff, who as yet not received training in safe working practice topics must do so as a matter of priority. (See NMS OP38 below). Glenthorne House DS0000040718.V270400.R01.S.doc Version 5.0 Page 19 The Registered Providers should also consider providing specialist staff training in adult protection from abuse, disability awareness and management of challenging behaviours as a matter of good practice. Discussion with the Registered Provider and examination of the most recently recruited members of staff files demonstrated that thorough recruitment procedures had been followed in line with the home’s recruitment policy. Two written references and Enhanced CRB and POVA checks are being obtained before new members of staff are appointed. The Registered Provider stated that recently several members of staff have left Glenthorne House and now new staff has been appointed. Glenthorne House DS0000040718.V270400.R01.S.doc Version 5.0 Page 20 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, 35, 36 and 38 The home is managed satisfactorily. The vacant post of the Registered Manager has been filled by Ms Carrol Collins, who would act-up in this role until she is registered with the Commission for Social Care Inspection. The staff is clear of their roles and responsibilities. Money is well managed on behalf of the service users by the acting care manager. The staff is regularly supervised to enable them to carry out their work professionally. Health, safety and welfare of the service users and staff are promoted by safe working systems put in place by the Registered Providers. EVIDENCE: The Registered Manager resigned in August 2005 and now an acting care manager has been appointed. The acting care manager is well supported by the Registered Providers. An application to register the new manager would be submitted to the CSCI shortly. Glenthorne House DS0000040718.V270400.R01.S.doc Version 5.0 Page 21 The home has good financial procedures in place. The home assists several service users with their monies. There is a safe in the home for storage of money and valuables. A sample of three service users’ money was checked and found to be satisfactory. It was evidenced that all members of staff receive formal supervision at the required intervals. Records of supervision meetings were also examined during the inspection. The Registered Providers also held regular meetings with staff. Accidents that occurred in the home are being appropriately recorded in the accidents book, but the Registered Providers must ensure that the CSCI is notified as soon as possible of all the accidents in the care home in accordance with Regulation 37 of the Care Homes Regulations 2001. The fire safety records were checked and it was noted that last weekly check was recorded on 20 November 2005, and the emergency lighting system monthly check was last recorded on 6 September 2005. The last fire safety system maintenance was carried out on 10 September 2004, which is now overdue. All those members of staff who as yet not received their training in safe working practice topics must do so as a matter of priority. (See NMS OP30 above). Glenthorne House DS0000040718.V270400.R01.S.doc Version 5.0 Page 22 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 3 X N/A 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 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 2 X X X X X 2 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 X X 3 3 X 2 Glenthorne House DS0000040718.V270400.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP25 Regulation 13 & 17 Requirement The Registered Providers must ensure that the required level of hot water temperature i.e. close to 43 Degrees C is maintained in all water outlets at all times and hot water tests are carried out on a weekly basis and appropriate records maintained at all times. 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 Providers must ensure that the CSCI is notified as soon as possible of all the accidents that occurred in the care home. The registered Providers must ensure that all those members of staff who as yet not received their training in safe working practice topics must do so as a matter of priority. The Registered Providers must ensure that the fire alarm system is tested on a weekly DS0000040718.V270400.R01.S.doc Timescale for action 15/01/06 2 OP31 9 31/03/06 3 OP38 37 15/01/06 4 OP38 13, 18 &23 31/03/06 5 OP38 13 & 23 31/12/05 Glenthorne House Version 5.0 Page 24 6 OP19 23 basis and the emergency lighting system is tested on monthly basis and all records of these tests are appropriately recorded; and that the fire safety systems are serviced annually and appropriate certificates obtained and made available in the home and for inspection by the CSCI. The Registered Providers must ensure that the requirements and recommendations contained in the inspection report dated 06 December 2005 of the Environmental Health Officer are appropriately implemented as a matter of priority. 08/12/05 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 OP30 Good Practice Recommendations The Registered Providers should consider making provision for staff training in adult protection from abuse, disability awareness and management of challenging behaviours as a matter of good practice. Glenthorne House DS0000040718.V270400.R01.S.doc Version 5.0 Page 25 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.V270400.R01.S.doc Version 5.0 Page 26 - 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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