Care Home: Glenfield House Nursing Home

What the care home does well What has improved since the last inspection? What the care home could do better: We observed clear indicators that the home`s main focus for improvement will continue to be the further development of staff skills, through training and supervision. In addition, commitment to on-going refurbishment to ensure continuation of improvements to the environment is evident. CARE HOMES FOR OLDER PEOPLE Glenfield House Nursing Home Middle Lane Wythall Birmingham West Midlands B38 0DL Lead Inspector Keith Salmon Key Unannounced Inspection 17th June 2008 09:30 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 Glenfield House Nursing Home DS0000004110.V366456.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. Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glenfield House Nursing Home Address Middle Lane Wythall Birmingham West Midlands B38 0DL 01564 823795 01564 822603 matron@glenfieldhouse.fsnet.co.uk 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 Cahal Joseph Grant Mr James Noel Walsh Mrs Barbara Hancock Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32), Physical disability (32) of places Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home with Nursing (Code N) to service users if the following gender Either Whose primary care needs on admission to the home are within the following categories: Old age not falling within any other category (OP) 32 Physical Disability over the age of 55 (PD) 32 The maximum number of service users to be accommodated is 32. 2. Date of last inspection 29th January 2007 Brief Description of the Service: Glenfield House is a purpose built nursing home, first registered in 1994, providing nursing care for up to 32 elderly residents. Situated in a semi-rural setting in the village of Wythall, south of Birmingham, accommodation is provided over three floors and comprises twenty-four single rooms - some with en-suite toilet facilities, and four shared rooms. There are three lounges including a spacious main lounge, an adjacent ‘quiet’ lounge, and the ‘Summer’ room, added as an extension during 2007. In addition, there is a large, separate dining room. Access to all floors is via a passenger lift, and handrails are fitted throughout to assist those with mobility difficulties. The home benefits from a large garden, with views to surrounding countryside, and a patio area accessed via the ‘Summer’ room. The garden is readily accessible to all residents, including wheelchair users, and offers seating, gazebo, and flower and shrub borders. Fees for care, which are published in the Service User Guide, range from £525.00 per week (shared room) to £650-£800 per week (single en-suite), are reviewed annually. Additional charges are made for hairdressing at the hairdresser’s rate, private chiropody at £12 per session, and newspapers at current prices. Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 5 The fee information given above applied at the time of the inspection; persons may wish to obtain more up to date information from the service. Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This Unannounced ‘Key’ Inspection of the service commenced at 9.30am, concluded at 4.30pm, and was conducted by Mr Keith Salmon, representing the Commission for Social Care Inspection (CSCI). Present, on behalf of the Home, was the Mrs. Barbara Hancock, registered manager. Unannounced ‘Key’ Inspections address all essential aspects of operating a care home and seek to establish evidence, which shows continued safety and positive outcomes for residents. Relevant information is gathered through observations made during a tour of the Home, a review of care related documentation, staff files and duty rotas, plus a range of other documents/records reflecting the general operation of the home. The report also utilises information submitted by the home to us, prior to the inspection, through the Annual Quality Assurance Assessment (AQAA). The content of this, which includes information relating to the Home’s policies, procedures, achievements, and plans for improvement, provide a useful framework for us to evaluate quality of service and progress made. We also received a small number of completed questionnaires (as provided by CSCI), amounting to five in total – three from residents, one from a relative, and one from a member of staff (all were anonymous). Individual discussions were held with four residents, three visitors, the manager, and several other members of staff. What the service does well: Professional nursing care is provided in a comfortable, homely environment, by staff who respond effectively to the assessed care needs, and preferences, of the residents. This is reflected in verbal comments made to us by residents and relatives, during the inspection visit, and through written comments gathered via the homes own ‘quality assurance’ questionnaires. Examples of comments included: • “This is my third care home and I have now found one I really like.” • “My (relative) has had excellent nursing care since day one” • “I would not hesitate in recommending the home to anyone.” Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 7 • • • “This is a caring, well run home. My (relative) is happy and well cared for by a first class team.” “I’m totally happy and comforted by the care they give to my (relative).” “I’m really happy my (relative is here) – the staff look after her very well – I have peace of mind. Analysis of the CSCI provided questionnaires evidenced all questionnaire respondents ticked the boxes predominantly to the left of centre, i.e. yes, always, usually (with a strong tendency towards always) with only one entry for ‘sometimes’. In addition, some ‘comments’ boxes had specific comments, which will be found in the relevant ‘outcome’ section within the body of this report. What has improved since the last inspection? • Access to information relating to the home has been improved, for prospective residents, by way of a thorough review and revision of the Service User Guide and the introduction of an internet web site. Improvements to the dining environment including new décor, crockery, and cutlery. Mandatory attendance by all staff at a two-day training course on ‘protecting vulnerable adults’. Addition of the sunroom extension. Establishment of the courtyard patio. Purchase of additional specialist beds and mattresses. • • • • • 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. The summary of this inspection report can be made available in other formats on request. Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 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 Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3, (6 - not applicable). Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People wishing to move into the home may readily access information about the home, which is easy to understand, accurate, and up to date. Prospective residents can be confident the home will be able to provide care which will meet their needs as assessed at the time of admission. EVIDENCE: People wishing to move into the home are provided with information to assist them in making an informed decision. Evidence supporting this view was observed in the Service User Guide. This document has recently been revised with copies now available to prospective residents. We also observed it has been made available, via distribution of copies within the home, to existing residents and relatives. Processes to ensure appropriate and thorough care needs assessment, prior to admission, are effectively applied, and subsequent findings are utilised to ensure appropriate placement and care provision. A detailed review of three Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 10 residents’ records/care plans provided evidence the manager, or another trained nurse, carries out a pre-admission assessment of each resident’s care needs, in order to judge whether the home can safely meet the resident’s care needs. If these needs can be met, and the person is admitted to the home, there was clear evidence this information is utilised as the basis for development of the resident’s written care plan. Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 &10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident their assessed care needs will be clearly stated in a written care plan, are reviewed regularly, and their needs effectively met through care, which is delivered considerately, and effectively, with residents’ privacy and dignity being respected. Residents can be confident the process of administering medicines will be completed in a safe and considerate manner. EVIDENCE: A detailed review of records/care plans, relating to three residents, demonstrated detailed content, including risk assessment, and relevant to assisting in ensuring provision of good quality care. Entries were clearly written with up to date entries relating to personal hygiene, mobility, nutrition, continence and pressure sores. Evidence was also observed confirming regular care needs review is undertaken, by the manager, Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 12 on at least a monthly basis, and of the signatures of the resident (or relative where appropriate) confirming their involvement in the development of the care plan. Specialist equipment, necessary to meet assessed care needs, was observed in use, e.g. specialist nursing beds (‘profiling’ beds), variable air pressure mattresses, cot-sides, and mobile hoists. The home maintains records of all health checks carried out by GPs, dentists, opticians, chiropodists and district nurses. It was also evidenced the home ensures that detailed nutritional screening is undertaken, including weight gain/loss records with appropriate action taken as required. As an adjunct to this, the home has commenced charting residents’ weight and ‘body mass index’. Throughout the tour of the home, and during our movement within the home (e.g. visiting residents who chose to remain in their bedrooms for private discussion), we noted staff were considerate and friendly, though not familiar, towards residents and visitors alike. Practical examples of this included staff knocking on doors before entering bedrooms, and ensuring privacy by closing bathroom doors. However, one CSCI questionnaire contained a comment by a resident, which was, …would prefer not to be called good lad.…A similar comment was made to us during discussion with a resident. We brought this to the attention of the manager, at the time of the inspection, who confirmed this might happen from time to time, and was a matter often discussed at supervision sessions, and staff meetings, with the purpose of ensuring residents are addressed as they would wish. Staff confirmed such discussions took place. The manager agreed of the need to reiterate the importance of residents being addressed appropriately. Residents and visitors commented to us how thoughtful and kind staff were towards them. Comments included - “The staff are polite, caring and professional in carrying out their work.” … “I know my (relative) receives kind and considerate care - even though not able to speak for herself.” These comments were reflected in responses within the CSCI questionnaire, e.g. They are all so caring.”… All I would like to say is that it is due only to the care of all at Glenfield that I still have my (relative) with me. A ‘Requirement from the previous inspection was: • Staff must adhere to the policy and procedures for the receipt, recording and administration of medication. We undertook a full review of the home’s practices in respect of the storage, reception, disposal, and record keeping, relating to medicines’ administration. We found them to be fully in accordance with accepted ‘good practice.’ Examples of evidence supporting this view included – up to date records of Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 13 medicine receipt and disposal, medicines administration records (MAR sheets) with up to date entries with no gaps, full records of medicines’ refrigerator temperatures, and a recently revised Medicines Policy. The above ‘Requirement’ is therefore met. Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Those residents, who are able, choose their life style, social activity and keep in contact with family and friends. Opportunities for contact with family/friends/community are established and encouraged. The Home provides a daily choice of attractive and nutritious meals based on residents’ preferences. EVIDENCE: Social/leisure activities provided appear generally pertinent to the needs of the client group. Leading this is a full time Activities Coordinator who provides a very ‘hands on’ approach. This staff member applies thoughtful, innovative and skilled input into the development and provision, of relevant and appropriate leisure/social activities, which are personalised to resident’s individual needs and abilities. Activities recorded include; quizzes, puzzles, arts and crafts, bingo, gardening and special events at Christmas, (e.g. staff in fancy dress), Easter, and Summer/Autumn fetes. Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 15 Photographic records of these events were observed, and residents and relatives mentioned them to us. On a Monday, Wednesday and Friday visitors from outside the home attend to provide entertainment such as music, musical movement, and exercises. All relatives/visitors spoken with were very complimentary regarding the quality of service provided and the caring approach of all staff. It was quite evident to us the routines of daily living are very flexible and based on a ‘person centred’ approach to care provision. Evidence was seen in records, and provided through conversation with residents and relatives, which demonstrated the home works actively to meet individual lifestyle preferences. Specific examples include – residents, in small groups or individually, are escorted to do personal shopping. The home has arranged for one resident to receive Sky television to enable access to favourite sports. Records reviewed (including the AQAA) indicated that residents belonged either to the Church of England or the Roman Catholic Church - no other faiths were recorded. In addition to visits by clergy from those denominations, people from the adjacent evangelical church provide a church service in the home, every two weeks. Residents are welcome to attend the church, with members of the church happy to collect residents wishing to attend. Residents’ meetings are held frequently, and residents confirmed they were encouraged to participate and express their views and opinions. Minutes are maintained. The home operates a four weekly menu, with choice available for residents who wish something different to that offered on the menu for the day. The evening meal operates on andopen choice’ basis, i.e. range of light cooked meals are always available from a long list. Drinks and snacks are available throughout the day. A ‘specialty of the house’ is the provision of a birthday cake, baked on the premises for each resident’s birthday. Residents commented to us how much they enjoyed the food, both the quality and quantity, as well as the choice. Also, those who wish may take meals in their bedrooms. The relative who returned one of our questionnaires commented - Lunch is excellent - home cooking, but also suggested the tea meal could be improved by offering a wider variety. Food hygiene is of a high standard evidenced by the fact the home is currently the possessor of the Bromsgrove Council’s four star award for food hygiene. Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives can be confident their views are listened to and acted upon, and that residents are safe and protected from abuse. EVIDENCE: The home has a well-organised, well-documented system for receiving and responding to complaints. Copies of the complaints procedure were available in the Service Users’ Guide. Copies were observed in bedrooms and the procedure was displayed on the notice board in the main entrance hallway. In addition, the home includes reference to ‘complaints’ and ‘complaints management’ within the quality assurance questionnaire format. Completed questionnaires received from residents stated staff listened to residents and acted on what they were told. Residents clearly knew who to speak to if they wished to make a complaint, and the “Matron” was always available.” In addition, the Manager operates an ‘open-door’ policy for relatives/visitors, who may wish to discuss their relative’s/friend’s care. Relatives informed us they took advantage of this arrangement, as and when necessary, and all felt they were well informed. Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 17 Review of the complaints register demonstrated complaints were responded to in a timely and effective way. This supported by an entry from a staff member in one of our questionnaires, which stated, …if a complaint has been made immediate action is taken to resolve the situation. Review of the Accidents/Incidents record book presented a picture of reported accidents, the nature and type of which caused us no concern. We interviewed four staff and all were able to describe the action they should take if they were in receipt of a complaint or observed abuse of a resident. Training records confirmed they had all received relevant ‘adult protection’ training. Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment in which residents live is pleasant, safe, and clean, with satisfactory standards of hygiene. EVIDENCE: A tour of the home, which included all communal rooms and corridors, laundry, kitchen, all toilets and bathrooms, and a random selection of bedrooms, showed the home provides a safe, pleasantly decorated, well-maintained environment in which to live. Most furnishings were in good order and presented a ‘domestic’ ambience, and clear evidence was seen of an effective, ongoing refurbishment and furnishings replacement programme. Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 19 During the previous twelve months residents have had the benefit of: • • • Improvements to the dining environment, including – new décor, crockery, and cutlery. The addition of the sunroom extension, which offers well-lit, comfortable ground floor accommodation with direct access to the courtyard garden. Establishment of the courtyard patio and attractive borders with shrubs and flowers. The Home has good provision of specialist equipment, consistent with meeting the assessed care needs of service users, and the demands of tasks carried out by Care Staff. During recent months the home has purchased additional specialist beds and mattresses. Records demonstrated maintenance and servicing of care related equipment, e.g. passenger lift, hoists, wheelchairs, call bells, is regularly undertaken, and appropriately documented. A ‘Requirement’ from the previous inspection was: • Suitable arrangements must be made to prevent the spread of infection through the home and safeguard residents. During that inspection it was seen that personal toiletries and prescribed skin creams had been left in two of the bathrooms. Also, a sluice room door was open, and a bin in one bathroom lacked a lid thus presenting potential health and safety hazards. At this inspection no personal toiletries or prescribed skin creams were seen in bathrooms, sluice doors were locked when not in use, and all waste bins for paper hand towels had lids. The above ‘Requirement’ is met. At this inspection it was noted that, whilst the laundry room does have a sink at which washing of hands is undertaken, the sink is a ‘general use’ stainless steel model with draining board, i.e. it is not a sink dedicated for washing of hands only. As this presents an infection control risk it is recommended a dedicated wash-hand basin be installed as soon as possible. Aside from this, the laundry is well run by dedicated laundry staff. Clothes are labelled for each resident, and the ‘return to owner’ system ensures laundered items are returned to the rightful owner. This was reflected in residents being dressed in well-fitted, clean clothes. We found the home to be clean and hygienic – a view supported by comments from our questionnaires, i.e. in answer to the question - ‘Is the home always clean and fresh?’ two responses were received – That (the cleanliness) is one of the many things that is wonderful about Glenfield, and Excellent. Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 20 Also comments on the day of inspection included – “My (Relative) has been in several other homes – this is the best – clean, no smells.” Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be confident staff numbers on duty, and skill-mix, are sufficient to meet their assessed care needs, and that recruitment and employment practices are consistent with safeguarding them from abuse The commitment of the Home in providing training for care staff is good, and in accordance with individual staff member’s learning needs. EVIDENCE: A review of recent duty rosters, and staff numbers, skill-mix and deployment at the time of the Inspection, demonstrated staffing to be sufficient to meet the assessed care needs of current residents. Furthermore, the Manager is usually supernumerary and there is good support from the activities coordinator, kitchen staff, domestic staff and the full-time maintenance man. The use of ‘Agency’ staff is minimal at Glenfield House, i.e. no use of ‘agency’ nursing staff for two years, with agency care staff used on only three occasions during the past twelve months. A review of files relating to the four most recently employed staff demonstrated recruitment practices to be satisfactory, with all elements required by Care Homes’ Regulations being completed, and evidence retained on file. Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 22 We had ‘one to one’ discussions with four staff members. All described the robust recruitment process they had gone through prior to appointment, and commencing work at the home. Evidence was seen in staff files, which showed references had been obtained and the Criminal Records Bureau (CRB) had made checks before new staff were appointed. All said they enjoyed working at the home and were able to give a detailed account of their initial orientation/induction and subsequent training. Staff records showed that all new staff now undertook the ‘Skills for Care’ Induction programme and maintained a progress log, which the manager confirmed. The picture presented was of a training programme, which is fundamentally supportive in enabling staff to successfully complete the ‘basics’ (e.g. lifting and handling, safe food handling, fire safety, infection prevention and control, health and safety, adult protection), as well as an opportunity to undertake National Vocational Qualifications (NVQ). A comment, in a CSCI questionnaire completed by a relative, suggested the skills of staff in relation to caring for people with dementia could be improved. It is noted that during discussion with us the manager stated staff are to be provided with additional training, aimed specifically at providing care, which meets the needs of residents with dementia. Review of staff training records showed the proportion of staff who have attained NVQ Level 2, or above, to be at good levels, i.e. from a complement of twenty-seven care staff, fourteen (52 ) have attained that standard. Of the remainder twelve staff are currently working towards Level 2. Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33,35, & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from effective management provided by an experienced manager, who ensures the main focus of care provision is in meeting individual residents’ care needs, and enabling realisation of their aspirations, wherever possible. Residents and their relatives can be confident their views on the provision of service quality will be sought and, where possible, acted upon. Residents and their relatives can be confident transactions involving expenditure of residents’ personal monies are safeguarded. Residents, relatives, other visitors to the home, and staff, can be confident their health, safety, and welfare are safeguarded. Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 24 EVIDENCE: The Manager, a well qualified and experienced person, works continuously to improve the service, and quality of life for residents. There is a strong focus on equality and diversity issues, reflected in our observations during inspection of many aspects of the home e.g. the views of people (residents, relatives, staff), care practices, record keeping, the general state of the environment. All presented a picture suggesting thorough, thoughtful and effective management. This is reflected in comments made by staff with whom we held discussions, and also in our questionnaire returned by a member of staff who provided very positive responses with all boxes ticked to the extreme left (rating good), plus written comments, i.e. “the manager is doing a wonderful job…always helpful and supportive. Its a wonderful nursing home to work in. The home has a structured approach for gaining the views of residents, relatives, friends, and others (e.g. visiting clinical, and social care professionals). This includes utilising ‘Senti’ questionnaires developed and operated by Derek Brown Associates. This process includes professional analysis and reporting as part of ‘quality analysis feedback’. We were informed of plans to expand service quality monitoring by introducing an ‘active listening’ component. This will involve one-to-one conversations with interested parties as an adjunct to the more formal questionnaire. The Home holds regular residents’ meetings, the minutes of which we were able to read. These supported the claim in the AQAA that recognition ‘equality and diversity’ needs are an important part of the provision of comprehensive care by the home (e.g. residents individual preferences and wishes with regard to religion, entertainment, meals, privacy). The Home manages cash for a number of residents and a review of arrangements for safeguarding the interests of residents was undertaken. We concluded that accounting practices were appropriate, thorough, and in accordance with safeguarding the personal monies of residents. A review of staff personal files, and related records, demonstrated Staff are subject to regular supervision. All systems such as fire alarms, emergency lighting, gas, and electricity are regularly maintained, checked as required, with certificates to evidence this. Accidents are reported appropriately and there are risk assessments in place for ensuring safe working practices. Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 25 Observation and review of relevant records provided evidence that Health and Safety Policies/Procedures/Practices are satisfactory, maintenance and servicing of equipment regularly undertaken, and appropriately documented, and all COSHH requirements met. Other ‘health and safety’ records examined related to fire risk management, lighting, nurse call bells, Legionellae, portable electric equipment, hoists were all found to be satisfactory. Records showing regular testing of hot water outlets accessible to residents were observed – these demonstrated temperatures to be in accordance with the Standard, i.e. ‘about 43o Celsius’. Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 26 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 X 3 X 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 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 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 3 X 3 X 3 X X 3 Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action 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 OP26 Good Practice Recommendations To ensure robust infection prevention and control practice it is recommended a dedicated wash-hand basin be installed in the laundry room, with a notice displayed to instruct washing of hands only. Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Glenfield House Nursing Home DS0000004110.V366456.R01.S.doc Version 5.2 Page 29 - 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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