CARE HOMES FOR OLDER PEOPLE
Gleneagles Nursing Home Pexton Road Sheffield South Yorkshire S4 7DA Lead Inspector
Janice Griffin Unannounced Inspection 20th September 2005 09:00 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 Gleneagles Nursing Home DS0000021780.V251014.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. Gleneagles Nursing Home DS0000021780.V251014.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Gleneagles Nursing Home Address Pexton Road Sheffield South Yorkshire S4 7DA 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) 0114 244 1223 0114 244 1224 Gleneagles (Yorkshire) Limited Mrs Maureen Parr Care Home 56 Category(ies) of Old age, not falling within any other category registration, with number (38), Physical disability (18) of places Gleneagles Nursing Home DS0000021780.V251014.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 21st April 2005 Brief Description of the Service: Gleneagles is a purpose built home providing accommodation on three floors, all floors are serviced by a lift. The home is sited in a residential area in the North of Sheffield, close to local shops and a bus route to the city centre. Parking is located at the front of the building. The garden which has level access is attractive, well maintained and is situated to the rear of the building. Gleneagles Nursing Home DS0000021780.V251014.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place from 9:0 am to 2:15 pm. As part of the inspection process six-service users, and two staff, including the manager on duty, were spoken to. A number of records were examined and several areas of the building were inspected. The inspector was pleased to note that throughout the inspection staff interacted positively and sensitively with each service user. The inspector would like to thank service users, the manager and staff for their commitment to the inspection process What the service does well: What has improved since the last inspection?
Some areas around the home have been redecorated and new floor coverings fitted, providing a more pleasant environment for the service users. Some new equipment has been purchased to allow service users to make tea and snacks for themselves; this service still needs to be implemented by the staff. The menus have been reviewed and the cook has attended training courses to improve his understanding of the nutritional needs of service users. Medication containers were clearly marked. The Environmental Health Department have been consulted regarding the storage of food and all the bins were fitted with suitable lids. Gleneagles Nursing Home DS0000021780.V251014.R01.S.doc Version 5.0 Page 6 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. Gleneagles Nursing Home DS0000021780.V251014.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Gleneagles Nursing Home DS0000021780.V251014.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,4,5 and 6. The home had a detailed service user guide and statement of purpose that clearly provided service users with the necessary information regarding the services and facilities provided by the home. Service users individual needs had been fully assessed prior to their admission, and they had moved into the home once it had been agreed that the home could meet their needs. Service users were able to have informal introductory visits to the home and at the time of their admission and had been provided with a contract containing most of the relevant information. The number of the room occupied by the service user was not included in the contract. Intermediate care is provided in a dedicated area of the building, some refurbishment has commenced to provide specialist facilities to promote activities of daily living. Gleneagles Nursing Home DS0000021780.V251014.R01.S.doc Version 5.0 Page 9 EVIDENCE: The statement of purpose and service user guide contained all of the required information. Copies were available and the manager confirmed that they would be available in alternative formats should the service users request this. The manager confirmed that service users were only admitted to the home once they were sure that they could meet their needs. Service users were able to visit the home for informal visits prior to their admission if they wished. Service users confirmed that this helped them to get to know everyone at the home and made them feel less anxious. Records checked confirmed that service users families had been involved in decisions regarding the arrangements. An up to date contract/statement of terms and conditions was kept at the home. These clearly detailed the fees, including any extra charges, and the services and facilities provided by the home, the number of the room occupied by the service user was not included in the contract of care. The staff said the home had more equipment to enable service users with disabilities to take part in stimulating activities but the two hours a day activities coordinators time was not adequate, this view was strongly expressed by the service users. The qualified nurses said that they were trained to use techniques for rehabilitation including treatment and recovery programmes. The care assistants interviewed said that they had not yet received any specialist training. Gleneagles Nursing Home DS0000021780.V251014.R01.S.doc Version 5.0 Page 10 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): 7,8,9,10,and 11. Service users had their needs set out in an individual plan of care and their health care needs were in the main met. One-service users had not had his nutritional needs assessed at the time of his admission to the home. The care plans were untidy and need to be reorganised. Where appropriate service users were able to administer their own medication. The procedures in place to ensure the safe management of medication need to be improved. Service users said they were treated with respect, but their right to privacy was not always upheld. The home did not have a policy on death and dying. EVIDENCE: Service users said they were consulted about their care plans and they knew that the home kept records, which they were able to look at if they wished. Staff said that care plans were reviewed regularly. Some bedroom doors were not fitted with suitable door locks and lockable facilities were not provided in all the bedrooms, this does not respect the service users privacy. Gleneagles Nursing Home DS0000021780.V251014.R01.S.doc Version 5.0 Page 11 Systems were in place to ensure the safe administration and recording of medication, however it was noted that several MAR sheets had not been signed on several occasions to show whether medication had been given or not. Gleneagles Nursing Home DS0000021780.V251014.R01.S.doc Version 5.0 Page 12 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, and 15. Service users said that two hours a day activities were provided but the activities coordinator could not provide adequate stimulation for all service users in the two hours as they were two many of them. They said that they were bored and had nothing to do but sleep for long periods. The service users with physical disabilities were not involved in any special activities that would promote independence, however some equipment had been purchased for this. The service users said the quality of the food provided had improved. EVIDENCE: All of the service users interviewed were very critical of the social and leisure activities provided at the home. Very little specialist equipment was provided for those service users with disabilities, this did not allow them to get involved in adequate stimulating activities. Service users confirmed that staff helped them to maintain contact with their family/friends and that they could choose who to see and who not to see. Service users spoken to said the food served was now much better and hot food was served hot and that there was a good choice of food, which they enjoyed. They confirmed they could have drinks and snacks when they wanted and that three full meals a day were offered. This promotes the health and wellbeing of service users.
Gleneagles Nursing Home DS0000021780.V251014.R01.S.doc Version 5.0 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): 17. The service users legal rights were protected. EVIDENCE: The manager said that one service user had a solicitor who protected her legal rights. She also said that if any service users requested access to advocacy services then she would facilitate the service for them, if requested. Gleneagles Nursing Home DS0000021780.V251014.R01.S.doc Version 5.0 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): 19,20,22,23,24,25 and 26. On the day of the inspection the home was clean but some areas had damaged/stained decoration. The bedroom doors were not fitted with locks. All the service users said their rooms and the home in general were well maintained and kept clean. More attention needs to be paid to the hygiene standards at the home. EVIDENCE: Some bedroom doors were not fitted with suitable door locks and lockable facilities were not provided in all the bedrooms, this does not respect the service users privacy. The home had an appropriate amount of sitting, recreational and dining space and there were sufficient rooms for a variety of activities to take place, creating a comfortable environment. Service users could see visitors in private. The dining areas were large enough to cater for all service uses. Gleneagles Nursing Home DS0000021780.V251014.R01.S.doc Version 5.0 Page 15 There were smoke free sitting rooms offering choice to non- smokers. Outdoor space and all areas of the home were accessible to people in wheelchairs. Some areas had stained decoration. Equipment was noted to be stored in the bathrooms this could be a trip hazard for staff and service users. The home provides intermediate care but there were very little specialist facilities provided to promote activities of daily living, restricting choice and independence. The string light cords were noted to be very dirty in the bathrooms and toilets, placing the staff and service users at risk from cross infection. Gleneagles Nursing Home DS0000021780.V251014.R01.S.doc Version 5.0 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): 28,and 30. Service users spoken to said that staff were kind and helpful. The home had a staff training and development plan but this had been on hold for over six months due to the training officers being off sick. EVIDENCE: The homes induction programme met required standard and staff spoken to said it covered such things as safe working practices, the organisation and workers role and the needs of the service user group. This ensures that the service users are in safe hands at all times. Training needs of care staff were identified via supervision and appraisal sessions but these have not been held for over six months. Some staff had completed NVQ training about care and this had ensured that several of the staff team were qualified to level 2. Staff said that they had not had any training on caring for people with physical disabilities. This does not allow the staff to ensure they meet the individual assessed needs of service users. Gleneagles Nursing Home DS0000021780.V251014.R01.S.doc Version 5.0 Page 17 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 31,33,35,36 and 38. The manager is currently undertaking NVQ level 4 in management. The responsible individual visits the home most days and produces a two monthly report. Records were in the main up to date but not very well organised. The service users financial interests were not safeguarded from abuse. Staff were not receiving regular supervision. A safe environment was not provided in all parts of the home and some health and safety issues need to be checked out. EVIDENCE: The manager had a job description that clearly defined her roles and responsibilities and staff were aware of her role. Service users confirmed that they could see the manager when they wished and they said that she was very approachable and supportive. Gleneagles Nursing Home DS0000021780.V251014.R01.S.doc Version 5.0 Page 18 Records were securely stored as required and up to date but in poor order. The manager handles money on behalf of some service users, account sheets were kept, but receipts were not available for all transactions made on behalf of the service users, one account sheet was incorrect and transactions were not being witnessed by a second individual. An independent auditor had never audited these accounts. This does not safeguard the service users from abuse. The responsible individual was visiting the home on a regular basis and talking to service users, a report was written two monthly following the visit. Staff said that they had not received individual supervision for over six months. No fire exits were blocked but hazardous substances were noted to be insecurely stored and one upper floor window was noted to be opening too wide. This does not maintain the service users safety. Gleneagles Nursing Home DS0000021780.V251014.R01.S.doc Version 5.0 Page 19 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 3 2 X 3 3 1 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X 2 3 X 1 3 1 3 2 STAFFING Standard No Score 27 X 28 3 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 1 1 X 1 Gleneagles Nursing Home DS0000021780.V251014.R01.S.doc Version 5.0 Page 20 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 OP2 Regulation 14 Requirement The service users contract of care must detail the number of the room to be occupied by the service user. Rehabilitation facilities must be provided for those service users with physical disabilities, and include equipment for therapy and treatment, as well as equipment to promote activities of daily living and mobility.This as been outstanding since 2004. Care plans must be tidy so information can easily be retrieved.This as been outstanding since 2004. Nutritional screening must be undertaken for service users on admission and subsequently on a periodic basis, the records must include nutrition, including weight gain or loss and appropriate action taken. Medication administeration sheets must always be signed to show whether medication has been given or not. Timescale for action 01/12/05 2 OP6 16 01/12/05 3 OP7 15 01/12/05 4 OP8 12 20/09/05 5 OP9 13 20/09/05 Gleneagles Nursing Home DS0000021780.V251014.R01.S.doc Version 5.0 Page 21 6 OP24OP10 23 Locks on their bedroom doors and a lockable facility must be provided.This as been outstanding since 2004. The manager must produce a policy on death and dying. Service users must be given the opportunity for stimulation through leisure and recreational activities in and outside of the home which suits their needs, preferences and capacities.This as been outstanding since 2004. Areas around the home with stained/damaged decoration must be redecorated.This as been outstanding since 2004. Suitable provision must be made for the storage of aids and equipment.This as been outstanding since 2004. The string light cords must be cleaned or replaced. Staff must be provided with training on caring for younger people with physical disabilities. The responsible individual must write a monthly report following his visits to the home. A copy of the report must be forwarded to the local office of the CSCI. Receipts must be available for all transactions made on behalf of service users. Money held must tally with the amount shown on the account sheet. Two people must witness financial transactions. An independent auditor must audit service users accounts. Care staff must receive formal supervision at least six times a year. Upper floor windows must be fitted with restrainers that stop the windows from opening too wide.
DS0000021780.V251014.R01.S.doc 01/12/05 7 8 OP11 OP12 12 16 01/12/05 01/12/05 9 OP19 16 01/12/05 10 OP22 16 01/03/06 11 12 13 OP26 OP30 OP33 12 10 26 01/12/05 01/12/05 01/12/05 14 OP35 20 20/09/05 15 16 17 OP35 OP36 OP38 20 10 13 01/12/05 01/12/05 20/09/05 Gleneagles Nursing Home Version 5.0 Page 22 18 OP38 13 Hazardous substances must be kept in a secure place at all times.This as been outstanding since 2004. 20/09/05 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 2 Refer to Standard OP28 OP31 Good Practice Recommendations At least 50 of the staff must be trained to NVQ level 2. The manager must be trained to NVQ level 4. Gleneagles Nursing Home DS0000021780.V251014.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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