Inspection on 31/05/05 for Glentworth House Nursing Home

This inspection was carried out on 31st May 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Glentworth House Nursing Home 21/01/09

Glentworth House Nursing Home 25/07/08

Glentworth House Nursing Home 21/08/07

Glentworth House Nursing Home 19/06/06

Glentworth House Nursing Home 23/11/05

Glentworth House Nursing Home 14/01/05

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

CARE HOMES FOR OLDER PEOPLE Glentworth House Nursing Home 40-42 Pembroke Avenue Hove East Sussex BN3 5DB Lead Inspector Elizabeth Dudley Announced 31 May 2005 10:00 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. Glentworth House Nursing Home H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Glentworth House Address 40-42 Pembroke Avenue Hove East Sussex BN3 5DB 01273 720044 None None Whytecliffe Limited 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) Vacant Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (OP), Physical disability (PD), 33 of places Glentworth House Nursing Home H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users should be 65 years or over on admission 2. The service can provide up to (33) nursing places and (33) social care places 3. The maximum number of service users to be accommodated is (33) Date of last inspection 14 January 2005 Brief Description of the Service: Glentworth House nursing home consists of 6 double and 21 single rooms and comprises a detached house with a purpose built extension. It is situated in a residential area of Hove, close to local shops and public transport. Parking is on-road and in a restricted parking area. The home has a well maintained garden which is easily accessed from the ground floor lounge by service users, and all parts of the home are served by a shaft lift. It has recently changed ownership and the new providers are undertaking a refurbishment of the home which is of a high standard. Glentworth House Nursing Home H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place on the 31st May 2005 and is part of the annual inspection programme of the home. This inspection provided an overview of the home since having a new provider and more recently, a new manager. During the day twelve residents, six staff and three relatives were spoken with and extracts from their views are included in the report. The home provides nursing and therefore there is a registered nurse on duty 24 hours a day, care staff receive training in the care needed by the residents and both registered nurses and care staff receive ongoing training to ensure that they are competent in the care of the residents living in the home. What the service does well: What has improved since the last inspection? There has been a great deal of refurbishment taking place within the home and this has resulted in a new kitchen, redecoration to the lounge and hallway and all rooms will eventually be redecorated. It is estimated that this will be finished within two years. The owner and manager are now increasing the amount of training being given to staff and also some new staff have been recruited. There is a new manager in place and extra staff are going to be employed to increase the numbers on some shifts. New menus are in place, the standard of food has always been high, but residents stated that having new types of food included in the menu has made it ‘more interesting’. Care plans have been improved, making it much easier to see what care a resident requires. Glentworth House Nursing Home H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc Version 1.20 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Glentworth House Nursing Home H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc Version 1.20 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 Glentworth House Nursing Home H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc Version 1.20 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) 1,2,3,4,5, Glentworth house provides sufficient documentation to enable prospective residents to decide whether they wish to live there. However all residents must receive a guide to the home, in the form of the service users guide to use as a reference whilst they are living there. EVIDENCE: The home provides a Statement of Purpose which has been updated and reviewed to reflect the recent changes made within the home. Not all residents have a service users guide and this should be provided. The home is discussing whether to provide this in a format similar to that used in hotels, and also to provide this in a format which make it more ‘ user friendly’. There is evidence that residents are only admitted to the home following an assessment provided by the owner or manager, and that staff receive sufficient training to allow them to be confident in their care of the resident. All residents receive a statement of terms and conditions, which complies with this standard on their admission to the home. All residents and their relatives can visit the home prior to deciding whether they wish to make Glentworth House their home. Glentworth House Nursing Home H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc Version 1.20 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) 7,8,9,10 The home provides a good standard of health care to residents and the documentation is adequate ensure residents receive the care and the safe administration of prescribed medication for their assessed needs. EVIDENCE: All care plans have recently been reviewed and also reformatted. Prior to reformatting the last inspection identified all care plans had been reviewed monthly, but with the new care plans it was evident, in the sample examined that until the recent review they had not been reviewed since February. However the manager states that this will be re-continued. There was evidence of risk assessments and consent forms in place. Some care plans have not been signed by the resident or their representative. Care plans identify the physical, social and psychological needs of the residents, however in order to assure that all staff are providing person centred care, registered nurses other than the manager must be involved in setting and reviewing the care plan, the manager and owner are working towards this. This was a previous recommendation. Glentworth House Nursing Home H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc Version 1.20 Page 10 Pressure relieving equipment is provided, and the owner stated that they plan to purchase further mattresses following from an assessment of their equipment requested by them from the wound care nurse. Asking the wound care nurse to assess their pressure relieving aids, ensures that equipment that best serves the needs of the residents is used, and the home is to be commended for having taken this action. The manager has recently sought advice about continence care from a specialist manufacturer, and new supplies of this and accompanying training are being put in place. The home is trying to identify a GP practice which will provide GP services to the home, but this will not prevent residents retaining their own GP if this is what they prefer. It was seen that catheter stands are resting in bowls and bags are not covered. In order to preserve residents dignity it would be advantageous if some other method was found of protecting the floor and some covering was put over the bags so that the urine was not so obvious to visitors. One resident felt that she had to wait a long time to be taken to the toilet, although conversation with staff identified that they answer all bells as quickly as possible, and it is accepted that the time span involved in putting a resident into a hoist in order to take them to the toilet is unavoidable. The manager is asked to consider whether there is a quicker way of addressing this issue. No residents are responsible for their own medication, and all MAR charts had been signed following administration of medication. All medication apart from controlled drugs are kept in a locked cupboards within residents rooms. All medication examined was within its expiry date. The clinic room was clean and tidy and fridge temperatures were recorded daily. The home has two residents receiving feeds by PEG and it is recommended that a second suction machine is purchased and that these are kept within easy distance of these residents. Some staff have attended training days at the local hospice and residents that were seen to be very ill, appeared comfortable and well cared for. Glentworth House Nursing Home H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc Version 1.20 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) 12,13,14,15 There is evidence that the home is addressing the need for activities for the residents and this will improve the quality of life offered. There is concern that residents choices regarding the times of rising and retiring may be compromised. EVIDENCE: Some activities are now taking place within the home, including art therapy music and a fitness therapist. These at present occur monthly and the manager is intending to introduce activities ‘ in house’. Courses on providing suitable activities for residents in this age group are available it is recommended that some staff attend these. The provider states that there has been a noticeable improvement in residents since providing activities and one resident stated ‘ that it was nice to be doing something other than television’. Residents have always had a choice of their time of rising and retiring, however the provider now intends to commence a few residents getting up early, between 0600 and 0800, whilst this does ensure that all staff play a part the daily care of the resident, getting people up this early is not in keeping with good practice guidelines. Therefore the manager has a responsibility to ensure that staff do not feel they are under pressure to get people up, as this could result in residents who do not wish to rise early being forced to do so, and must monitor which residents are being got up early. Glentworth House Nursing Home H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc Version 1.20 Page 12 Preferred times of rising and retiring must be recorded in the care plan following consultation with the resident or their relative and should be signed accordingly. Wishes of residents must be upheld and this will be monitored by the CSCI. Residents can follow their religious beliefs and it was seen that a member of a church visited to administer communion to a resident. There is an open visiting programme and two visitors spoken with stated that they were made to feel welcome at any time by the staff, and are informed of any changes relating to their relative. The provider has installed a new kitchen which was clean. Fridge and freezer temperatures are recorded regularly and there was a good supply of fresh, frozen and dried food. Menus have recently been updated with food such as Spaghetti Bolognese being introduced. Residents spoken with stated that they enjoyed these new additions to the menu. The majority of cakes and puddings are home made and the standard and presentation of food appeared good. Staff were seen to be feeding residents with care and in an unhurried manner. Sufficient tables should be available for all residents who take their meals in the lounge. There is no separate dining room, but residents can have their meals in the lounge or their rooms. The cook visits the residents each day to determine what they would like to eat and records are kept of those who have different food from the main menu. Consideration should be given to displaying the day’s menu in the dining room to enable residents to recall what is on the menu that day.The menu on this day was Chicken or Spaghetti Bolognese for lunch and cauliflower cheese or soup or sandwiches for supper . It is recommended that nutritious finger foods are supplied for one resident who appears to take the main part of her daily nutrition by eating throughout the day rather than at meal times. She visits the kitchen door very regularly and is provided with biscuits, sweets or cake on a constant basis and staff are to be commended on their willingness to meet her wishes. It is recommended that the manager contacts the dietician for ideas on types of finger foods that are nutritionally suitable for people with this condition. Food hygiene and food handlers courses are in progress for those staff that are in need of these. Glentworth House Nursing Home H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc Version 1.20 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) 16,18 The home listens and acts upon residents concerns, and staff have an awareness of their role in protecting the residents. EVIDENCE: There have been two complaints since the present provider undertook ownership of the home and these were dealt with sensitively and acted upon by the home. One concern was made known to the CSCI on the day of the visit, and this was regarding time taken to respond to requests to be taken to the toilet. The manager will try to address this. The majority of staff have undertaken adult protection training and appeared aware of their responsibilities in this matter. Training around the whistle blowing policy must be reinforced. Glentworth House Nursing Home H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc Version 1.20 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) 19,20,21,22,23,24,25,26 Once the refurbishment is complete the home will be a safe, pleasant and comfortable enviroment for residents. Maintenance issues should be continued to be addressed in order that residents live in comfortable, well maintained surroundings, whilst work is completed. EVIDENCE: The home is at present being refurbished, and this is anticipated to be ongoing for the next two years. To date, a new kitchen has been provided, the lounge has been redecorated including new carpets and curtains, some rooms have been refurbished and the hallway and stairs redecorated and re-carpeted. This has all been undertaken to a high standard. The garden is small, but well maintained and pleasant, and is easily accessible to all residents. Visitors spoken with stated that they were pleased that attention was being paid to the décor within the home and that they were impressed with the high standard of refurbishment. Glentworth House Nursing Home H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc Version 1.20 Page 15 However it was noted that some ongoing maintenance matters are not taking place and these must be continued whilst the refurbishment takes place. Some curtains were coming off their hooks and a carpet in room 29 needs restretching until it is replaced. The majority of rooms now have a lockable facility and all rooms will eventually have one of these, all doors have locks and keys are issued within the auspices of a risk assessment. Residents are encouraged to bring in their own possessions to make their rooms more homely, all rooms are comfortable and clean, bed linen being fit for purpose. The home must be assessed by an occupational therapist or similarly qualified person, although it is evident that there is sufficient equipment and aids for residents needs. All water temperatures have been tested and recorded regularly and are within recommended parameters. Cleanliness in some bathrooms need attention and staff must ensure that the seats of the bath hoists are kept clean. Staff identified that there were some problems regarding the laundry insomuch that clothes are often not labelled and that laundry gets put in the wrong rooms. Previous complaints received over the years by CSCI have identified that this is an ongoing problem. Staff have ideas on addressing this and the provider should consider these. Block soap should not be used in communal toilets and bathrooms and this must be replaced with liquid soap. Urine bottles in the sluice room were seen to contain dried sediment and be discoloured. New urine bottles must be purchased and staff must ensure these are always put in the sluice for washing. No odours were apparent in the home and staff were seen to be wearing gloves and aprons when giving care and protective clothing when entering the kitchen. Kitchen staff must refrain from storing equipment underneath the workbenches as cleaning will be hampered and dried goods in the basement area must be kept in containers. Glentworth House Nursing Home H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc Version 1.20 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) 27,28,29,30.The manager is aware of the need to increase staff levels to meet the assessed needs of the residents. Staff are encouraged to attend training sessions to enable them to be familiar with all conditions and care requirements of residents within the home. EVIDENCE: The manager states that they are recruiting more staff as both she and the provider recognise that the needs of the residents indicate that more staff need to be on duty on individual shifts. The needs of the residents within this home are very heavy and the manager must try to balance this out more when assessing residents for future admission. The balance of trained staff to carers appears appropriate at present, although registered nurses identified that they find it difficult to fulfil all their duties especially on afternoon shifts. Staff stated that there was no formal break given to them on the night shift, but the provider thought that this was dictated by the person in charge on the shift. She is formalising this. The provider encourages all staff to attend relevant training and some training sessions are held in the home by various nurse specialists. Few staff have NVQ 2 at present and this must be addressed. All staff receive an induction course which meets NTO guidelines and the majority of staff spoken with confirmed that they had undertaken this. A selection of personnel files were examined and these identified that the majority of staff have all documentation, as required by legislation, in place. No staff now commence duties without a current CRB and POVA check and all have two written references prior to commencement of employment. Glentworth House Nursing Home H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc Version 1.20 Page 17 The provider was concerned that only photocopies of CRB’s were available for staff that have had ongoing employment at Glentworth, and is replacing these. However this is not necessary as the only data that should be kept is the number of the CRB check and that the date it was received. Printouts of emails relating to POVA checks should be kept. It is emphasised that any clinical or care training within the home should be undertaken by a registered nurse, this should ensure that only ‘best practice’ underpinned by researched knowledge takes place. The home must ensure that its registered nurses are aware of their responsibility and accountability in researching best practice and they must ensure that the care that they give relates to this. Glentworth House Nursing Home H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc Version 1.20 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 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) 31,32,33,34,35,36,37,38. The home provides a good ethos and atmosphere for residents staff and visitors. However some areas of resident safety are not being adequately met at present. EVIDENCE: The provider, Mrs Anita Redwood is an RGN who manages and owns another home in Brighton, she is experienced in the care of the elderly and at present is involved helping the new manager of Glentworth House, Mrs Donna Hardy, in running the home. Mrs Hardy is an RGN who was previously the senior sister at a nursing home in Brighton. She has been in post for 3 weeks and intends to undertake the NVQ4 or Registered Managers award. Staff identified that they found both the provider and manager very approachable and that the ethos within the home is good, this was also reinforced by visitors and residents within the home. Accounts and business planning for the home where seen prior to the new registration of the owners and were in order. Glentworth House Nursing Home H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc Version 1.20 Page 19 A limited quality monitoring system is in place and this should be increased to regularly identify residents and visitors views of the home and should include the manager and provider checking cleanliness and maintenance within the home and action plans to address any problems. A poster advertising the inspection was in place, but few ‘comment cards’ were received by the CSCI from residents or visitors. Registered providers’ reports have not been received by the CSCI and formal supervision of staff is not taking place. The manager must familiarise herself with the form that supervision must take. Previous requirements are not always addressed within the timescales given and in some cases have not been addressed at all. The CSCI will be taking further monitoring visits to ensure that these are addressed and this may result in further action been taken. A staff meeting took place within the last week and it is intended to repeat this on a three monthly basis. The home is also considering a newsletter to staff and residents. Care plans have been restructured to enable the care to be given to be easily identified, and these are kept within the nursing office. Personnel files are kept in a locked drawer within the main office and have now been re-filed and contain all information relating to the individual’s training plan and recruitment details. Much improvement in both care plans and personnel files is seen. All certificates relating the servicing of utilities and equipment were in place and up to date and there was evidence that mandatory training for staff was in place or about to take place. Doors must not be propped open, and the provider must ensure the safety of residents in the case of fire. The Fire officers letter relating to what is an acceptable method of closure of residents doors must be referred to. Residents also need to have information on what they should do in case of a fire. The kitchen entrance has a difference in level from the corridor to the kitchen and this must be identified to prevent people tripping over this. It is recognised that this is temporary due to the refurbishment but must still be made safe. Toiletries and liquids must not be left in bathrooms. Likewise there is some concern regarding the free availability of alchohol based cleansing gel and whether there is a risk of residents ingesting this. This must be risk assessed. Glentworth House Nursing Home H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION 2 3 3 1 2 3 3 2 STAFFING Standard No Score 27 2 28 1 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 3 1 3 3 1 2 1 Glentworth House Nursing Home H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc Version 1.20 Page 21 yes 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 OP1 Regulation Reg 5 Requirement Timescale for action June 30th 2005 2. OP7 3. 4. OP7 OP12 5. OP22 6. OP33 7. OP36 That the service users guide is produced in a format suitable for service users, contains the inclusions as in NMS 1 and all service users, new and existing, are in possession of a copy of this Reg That all care plans are signed by 15(2)(b)(c the service user or their ) representative or indication given that this was not possible. (This has been a previous requirement Jan 14th 2005) Reg That care plans are continued to 15(2)(b) be reviewed on a monthly basis. Reg 12(2) That choices of service users regarding times of rising and retiring are recorded and followed. Reg 23(1) That the home is assessed by a suitably qualified person. (This was a previous requirement on four past inspections Last to be required by June 1st 2005) Reg 24 That the quality monitoring programme is reviewed and expanded.( This was a previous requirement April 1st 2005) Reg 18 That all staff receive regular (2) supervision at a minimum of 6 times a year. ( This was a H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc 30th June 2005 Immediate Immediate August 30th 2005 August 30th 2005 August 30th 2005 Page 22 Glentworth House Nursing Home Version 1.20 8. OP36 Reg 26 9. 10. OP12 OP38 Reg 16(m)(n) Reg 25 (4) Reg 25(4) Reg 13(4) Regf 23 (d) Reg 13(3) Reg 13(4) 11. 12. 13. OP38 OP38 OP26 14. OP38 15. OP28 Reg 18 (c ) previous requirement on three inspections.Jan 14th 2005) That the registered person makes reports to the CSCi on a monthly basis on those matters identified in Reg 26.(This was a previous requirement March 1st 2005) That a programme of activities is in place following consultation with service users. That measures are taken to ensure protection in the case of fire for service users who wish their doors to be kept open. That service users and visitors to the home are made aware of what to do in case of fire. That the difference in levels from corridor to kitchen is identifiable That the bathrooms are kept in a clean condition and that urine bottles are cleaned properly after use. That toiletries are not left in bathrooms and that alchohol gel is risk assessed and service users are not at risk of accidental ingestion of this. That provider encourages staff to undertake study for NVQ 2 July 1st 2005 July 1st 2005 Immediate Immediate Immediate Immediate Immediate July 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. 2. 3. Refer to Standard OP 7 OP10 OP15 Good Practice Recommendations That all registered nurses take part in the formation of, and the regular care plan reviewing. As registered nurses they are accountable for the care that they give. That service users using catheter bags have their privacy and dignity protected, by using a method to conceal the bags, and a discreet method of carpet protection used. That the manager approaches the community dietician for H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc Version 1.20 Page 23 Glentworth House Nursing Home 4. OP18 ideas for nutritious finger foods for the service user who prefers to take her daily diet in this manner. That staff training in the use of the whistle blowing policy is reinforced. Glentworth House Nursing Home H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc Version 1.20 Page 24 Commission for Social Care Inspection Ivy House, 3 Ivy Terrace Eastbourne East Sussex BN21 4QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Glentworth House Nursing Home H59-H10 S62476 Glentworth House V222752 310505 Stage 4.doc Version 1.20 Page 25 - 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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