Care Home: Glenthorne House

What the care home does well The home makes every effort to provide people with good care to meet their assessed needs following a care plan. The home has a good key worker system and staff supervision system in place. The home communicates well with the families, friends and representatives of people who use the service and welcomes visitors. People who use the service say they are happy and content with living in a homely and caring place. The home provides a relaxed, comfortable and friendly atmosphere where people are treated with respect and in a dignified way. People who use the service are often vulnerable both physically and emotionally and the Registered Providers/Registered Manager ensure that staff recruited have the ability to carryout personal care services for people sensitively and tactfully. The recruitment of good caring staff is critical to the running of care homes and the Registered Provider and Registered Manager at Glenthorne House undertake this carefully. The home has a good staff training and development programme in place. A majority of staff have received mandatory training in safe working practice topics, safe handling of medication, Dementia care and NVQ Level 2. Thus this training will ensure that the staff have improved their knowledge and skills to meet the changing needs of people who use the service. The home provides good standard of accommodation and facilities for people using the service. What has improved since the last inspection? The management of medicines within the home has improved to the point where it was seen that the handling and administration of the medicines was being carried out safely. The home has implemented all the requirements from the previous inspection reports. The home now has a Registered Manager in post and she is embarking on gaining the required qualifications. Conversations with staff, people using the service and their visiting relatives, indicated that the Registered Manager is service user focused, leads and supports an enhanced staff team providing them with improved training and supervision. This style and approach to management aims to pursue future improvements in all aspects of service. One person who lives at the home stated "This place is a lot more peaceful and better organised now". The home has made good improvements in their record keeping and care planning. Care Plans seen for people who use the service were informative and gave some indication of how care is to be delivered for each of them. Medication practices have improved and more staff have received training in safe handling of medication. A majority of staff have received training in safe working practice topics and dementia care and that will enable them to expand their knowledge and skills and enhance the care they give to people using the service. It was noticeable that there have been many improvements made to the environment of the home. A rolling programme of redecoration has been implemented, and communal areas have been redecorated. The garden and patio areas at the side and rear have been improved and made accessible and secure. A suitable and safe sheltered space has been provided for people using the service who wish to smoke. What the care home could do better: The home should continue to improve further the detail and quality of daily care recordings. The menu needs should be revised in consultation with people who use the service. Activities enjoyed by the people who use the service should be incorporated into their individual care plans. Those members of staff who as yet have not received training in safe working practice topics, including Infection Control/COSHH, safe handling of medication, Dementia care, NVQ Level 2, Adult Protection and safeguarding issues must do so as a matter of priority. This training would enable staff to improve further their care practices and professionalism. Swift action to should be taken to ensure the regulation of water temperature, and design solutions to control the risks of Legionella. CARE HOMES FOR OLDER PEOPLE Glenthorne House Glenthorne House Dover Street Bilston Wolverhampton West Midlands WV14 6AL Lead Inspector Bhag Jassal Key Unannounced Inspection 4th December 2007 09:20 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glenthorne House Address Glenthorne House Dover Street Bilston Wolverhampton West Midlands WV14 6AL 01902 491633 01902 491633 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr James Walter Dell Miss Evelyn Thomas Carol Ann Marshall Care Home 20 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (20) of places Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care and accommodation for service users of both sexes whose primary care needs on admission to the home are within the following categories: - old age not falling within any other category (OP 20) - dementia over 65 years of age (DE(E) 3) The maximum number of service users to be accommodated is 20. 2. Date of last inspection 20th March 2007 Brief Description of the Service: Glenthorne House care home provides personal care and accommodation for 20 older people some of whom have mild dementia. The home is in close proximity to all local amenities, which includes the Health Centre, library, shops and a market. The area is well serviced by buses and Metro. Glenthorne House is a large detached property, situated in a residential area of Bilston. The home has 16 single bedrooms, two double bedrooms, three lounges/dining rooms, a conservatory, two bathrooms, two showers with WC’s, seven WC’s, a kitchen, medication room, the main office, car park is at the rear and garden and patio area. The laundry facilities are located in the basement area. The present Registered Providers - Mr James Walter Dell and Miss Evelyn Thomas have been operating this care home since March 2003. The Registered Manager - Ms Carrol Marshall was registered with the Commission for Social Care Inspection (CSCI) in June 2007. The Registered Providers – Mr Dell and Ms Thomas - make their services known to prospective service users in the Statement of Purpose and Service Users’ Guide. The Inspection Report is mentioned in the Statement of Purpose and how a copy can be obtained. The care home charges (fees) are reviewed annually and people who use the service are notified one month in advance. The only additional charges to people who use the service are for hairdressing, expensive toiletries, sweetshop, and chiropody. This is clearly laid out in the home’s terms and conditions. The current fees charged at Glenthorne House, as stated in the Service Users’ Guide, range from £349.00 to £399.00 per week. All people Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 5 using the service pay monthly. Up to date information about fees is obtainable from the Registered Manager. Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This report is on a Key Inspection, part of which included an unannounced visit undertaken on 4th December 2007. This unannounced visit started at 09:27 am and lasted 7 hours and 40 minutes. The home had 19 places occupied and one place vacancy. The judgements made within this report are based upon information supplied by the home, from interviews with staff, people who use the service and their relatives. During the course of inspection the assessment information and care plans were inspected for 6 people who use the service. The management of medication in the home was checked by the Pharmacy Inspector – Mr Ian Henderson. Staff records were seen to check staff rotas, recruitment procedures and training. Various documents were seen in order to check compliance with health and safety legislation. A tour of premises was also undertaken and observations of care practices and interaction between staff and people who use the service was completed. Discussions took place with 4 members of staff on duty, several people using the service and 4 relatives were spoken to throughout the day of inspection. Registered Provider, Mr James Dell, and the Registered Manager, Ms Carol Marshall, were present throughout the Inspection. Ms Evelyn Thomas was present during part of the inspection. All the information received from the care home, including the AQAA was considered and discussed with the Responsible Provider and the Registered Manager. The Inspectors wish to thank the and the Registered Manager, the staff, people using the service and their relatives for their assistance and cooperation on the day of inspection. What the service does well: The home makes every effort to provide people with good care to meet their assessed needs following a care plan. The home has a good key worker system and staff supervision system in place. The home communicates well with the families, friends and representatives of people who use the service and welcomes visitors. People who use the service say they are happy and content with living in a homely and caring place. The home provides a relaxed, comfortable and friendly atmosphere where people are treated with respect and in a dignified way. Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 7 People who use the service are often vulnerable both physically and emotionally and the Registered Providers/Registered Manager ensure that staff recruited have the ability to carryout personal care services for people sensitively and tactfully. The recruitment of good caring staff is critical to the running of care homes and the Registered Provider and Registered Manager at Glenthorne House undertake this carefully. The home has a good staff training and development programme in place. A majority of staff have received mandatory training in safe working practice topics, safe handling of medication, Dementia care and NVQ Level 2. Thus this training will ensure that the staff have improved their knowledge and skills to meet the changing needs of people who use the service. The home provides good standard of accommodation and facilities for people using the service. What has improved since the last inspection? The management of medicines within the home has improved to the point where it was seen that the handling and administration of the medicines was being carried out safely. The home has implemented all the requirements from the previous inspection reports. The home now has a Registered Manager in post and she is embarking on gaining the required qualifications. Conversations with staff, people using the service and their visiting relatives, indicated that the Registered Manager is service user focused, leads and supports an enhanced staff team providing them with improved training and supervision. This style and approach to management aims to pursue future improvements in all aspects of service. One person who lives at the home stated “This place is a lot more peaceful and better organised now”. The home has made good improvements in their record keeping and care planning. Care Plans seen for people who use the service were informative and gave some indication of how care is to be delivered for each of them. Medication practices have improved and more staff have received training in safe handling of medication. A majority of staff have received training in safe working practice topics and dementia care and that will enable them to expand their knowledge and skills and enhance the care they give to people using the service. It was noticeable that there have been many improvements made to the environment of the home. A rolling programme of redecoration has been implemented, and communal areas have been redecorated. The garden and patio areas at the side and rear have been improved and made accessible and Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 8 secure. A suitable and safe sheltered space has been provided for people using the service who wish to smoke. 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. Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 10 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 and 6. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Everyone receives a full assessment prior to admission to the home to make sure that their needs can be met. EVIDENCE: Glenthorne House care home provides detailed and clear information, in the form of a Service Users’ Guide, to people who will be using the service and their families to enable them to make decisions about whether or not to live at the home. Copies of this Guide were seen in the people’s bedrooms. Admissions are not made to the care home until a full assessment has been undertaken. The home is then able to confirm that they can meet the needs of the individual through the service they deliver as detailed in the Statement of Purpose. For people who are self-funding and without a care management assessment, they always receive assessment by the Registered Manager. 6 files/care plans of people who use the service were inspected, which contained pre-assessments of their needs, both from assessments by the home’s senior staff and other relevant professionals. Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 11 Observations and discussions with people using the service, their visiting relatives, the Registered Providers, Registered Manager, and staff on duty indicated that the home continues to meet the needs of older people and those with dementia in a satisfactory and sensitive manner. It was noted from the staff training records that 12 members of staff have undertaken their training in Dementia care and 2 have commenced this training and those who as yet have not undertaken this mode of training will do so shortly. Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 12 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 and 10. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. People who use the service have individual pans of care, which ensures that their personal, healthcare and social needs can be met. Medication is administered and stored in a manner that safeguards everyone using the service. People who use the service are treated with respect and dignity and their right to privacy is understood and upheld. EVIDENCE: On the 4th December 2007 the Pharmacist Inspector visited the home to carry out a medication management inspection in relation to regulation 13(2) of the Care Homes Regulation 2001 as part of the key inspection undertaken by the Lead Inspector on the same day. We found that the receipt of medication into the home was being accurately recorded on to the Medicines Administration Record (MAR) charts. We also found that any medication that was being carried over from the previous month was now being included in the total for the new month. As a consequence the home had a good basis for the start of the audit trail of the medication found in the home. Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 13 We found overall that the administration records had again improved compared to the last inspection. As a result of these improvements, the audit process of the residents’ medication showed that on the whole the medication could be accounted for and people who use the service were receiving their medication as prescribed. We found that 10 members of staff had undertaken medication training on the 17th September, which had been carried out by J.S. Consultants. One member of staff had also completed the Safe Handling of Medicines course conducted by Walsall College. The Registered Manager was also carrying out formalised competency assessments on all of these staff on a bimonthly basis and the results of these assessments were being incorporated into the staff’s supervision time. The stock levels of the medication held in the excess stock cupboard upstairs had again been reduced and as a consequence the risks of residents receiving the wrong medication had been further reduced. We found that the maximum and minimum temperatures of the dedicated medication fridge were being maintained within the accepted temperature range. On observing the contents of the fridge it was seen that the home was still appropriately storing those medicines that required cold storage conditions. On the 16th August 2007 the Misuse of Drugs (Safe Custody) Regulation 1973 were amended to include care homes offering personal care requiring a Controlled Drugs cabinet. We found that there were no Controlled Drugs being held within the home. The requirements for obtaining a Controlled Drugs cabinet were discussed should the prescribing of Controlled drugs arise. People who use the service undergo an assessment of their needs prior to admission to the care home. A Care Plan is produced, which is based on the assessment of needs. The home operates a good key worker system, which helps to ensure that the recommendations arising from the care plan reviews are implemented. 6 Care Plans of people using the service were case tracked and examined in detail. There was evidence to show that the short-term goals and long-term goals, aims and objectives were clearly identified and appropriate interventions required to meet the individual needs of people who use the service were also identified. The quality and detail of daily care recordings have improved since the last inspection in March 2007. However, the Registered Manager should continue to make further improvements and staff should be supported and closely supervised in this endeavour. Discussion with people who use the service showed that the home has a good ethos of involving them in all aspects of their life. The care plans that were read were clearly written and included an element of risk assessment. Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 14 Information from the initial assessments had been written into plans of care. The care plans are reviewed on a monthly basis by staff. Care Plans demonstrated that the staff actively promoted the rights of people who use the service of access to the health services both within the home and the community. Appointments are planned or arrangements are made for professionals to visit frail people using the service. Whenever possible continuity of care for the service users’ declining state of health is assured. District Nurses are called upon to assist with clinical help, equipment and advice where necessary. The Registered Manager promotes the key worker system so that relationships between staff and individuals are enhanced. The Registered Manager stated that the key workers have commenced compiling the “This is my life” story books for all people who use the service. The relatives and friends of people using the service were also involved in this process. Information obtained through this process will enable care staff to increase their knowledge and understanding of the individual people who use the service and their particular needs. Visitors are able to meet people using the service in their bedrooms and in the lounges on the ground floor. It was observed that people who use the service wee being treated with respect and staff were working both professionally and sensitively in meeting individual needs. Inspector spoke at length with several people using the service and all of them commented positively about their care and felt they have everything that they need. Four people who use the service stated that “The carers are very good and kind and they look after us very well”. Two other people who use the service said “The carers are always there to help”. Generally people who use the service appeared to be content and comfortable. They were complimentary regarding the quality of their lives and care they were receiving at Glenthorne House. Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 15 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 and 15. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to exercise choice with regard to social and leisure activities at the home. Activities provided meet the needs of the people using the service. Relatives and friends are encouraged and assisted to maintain contact with the people who is using the service. The food at the home is of good quality and choices are always available. EVIDENCE: The home provides an activities programme in accordance with everyone using the service, their choices, preferences and capacities in relation to – social, leisure and cultural interests. People using the service, who were able to give opinion, were very complimentary about the activities provided, and particularly the external entertainers. People who use the service are enabled to enjoy a full and stimulating life style with a variety of options to choose from. A record of activities participated in is kept and photographs of major events displayed in the home. However, the activities enjoyed by the people who use the service need to be incorporated into their individual care plans. People using the service were seen sitting in the lounges chatting to staff and visitors and other communal areas within the home. Several people who use Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 16 the service stated that they preferred to sometimes sit quietly in their bedrooms and the staff respected this. Several people using the service spoken to stated that they were in regular contact with their family members and friends, and spoke about their visitors’ involvement and interest in their care matters. The visitors’ book kept in the home showed a considerable activity. People who use the service also keep contacts with the local community – for example, church services, pubs, shops and park. Four relatives told the Inspector that they are happy with the care and social activities offered by the care home. They further added “the home provides a good service and the staff are very caring and they are pleasant”. The home also provides a variety of indoor activities, including festive and birthday parties. The Registered Manager stated that the people who use the service were positively encouraged and helped to exercise their choices, and control over their lives and daily living, subject to risk assessments in terms of safety, security and capacity to make certain decisions. The Registered Manager also stated that a close liaison is maintained with the relatives and representatives, where the people using the service are not able to make certain decisions. The relatives of people using the service and their representatives are informed of the availability of Advocacy Service based at the local Age Concern. The information about the Advocacy Service is included in the home’s Statement of Purpose and Service Users’ Guide. Several people who use the service told the Inspector “The home is very good and its peace and quiet here”. “The food was very nice well cooked and tasty”. The consensus of people using the service was the range, quality and choice of food provided was very good and the home catered for those people using the service, who have individual preferences and medical needs. The Registered Manager stated that the menu will be changed shortly in consultation with the people who use the service. This is usually done in accordance with seasonal changes as well. The kitchen is well equipped and kept clean and tidy. The catering staff are trained in food safety and hygiene matters. Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 17 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 and 18. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. There is clear Complaints Procedure in place, a copy of which is made available to people who use the service and their relatives. This should ensure that any complaints made are listened to and acted upon. The home has an Adult Protection policy and procedure in place to protect people who use the service from all forms of abuse. EVIDENCE: The home has a good Complaints Procedure in place, which is referred to in the home’s Service Users’ Guide and in the Statement of purpose. There is a system of recording concerns and complaints. The Commission for Social Care Inspection (CSCI) has not received any complaints about the care home. The people, who use the service, when asked, were certain of how to formally make a complaint but they said they would quite happily talk to one of the staff or the manager. The home has had to report one adult protection matter in July 2007, concerning the administration of medication and this issue was appropriately dealt with through the Wolverhampton’s multi-agencies’ adult protection procedures. The home has good policies and procedures in place regarding restraint, dealing with aggressive behaviour and prevention of abuse, which includes whistle-blowing policy. The Registered Manager stated that adult protection issues are discussed during induction training and supervision meetings. The Registered Provider – Mr Dell - stated that all members of staff Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 18 will receive formal training in protection of vulnerable adults as a matter of priority. He also stated that trainers are being approached to set up a training day for all staff in early January 2008. Several people who use the service stated they are satisfied with the service provision, feel safe and well supported by staff that have their protection and safety as a priority. Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 19 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 and 26. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The general standard of the environment is good providing a homely, clean and secure place to live. EVIDENCE: The home offers a comfortable and well-maintained environment to all people who use the service. The home has ample communal space – three lounges and dining areas, and a conservatory. The home has a rolling programme of redecoration to maintain good standards. The garden and patio areas are also well-maintained. The home has provided suitable aids and adaptations in the home to meet the general and specific needs of all the people using the service. There is an adequate number of bathrooms and WCs in the home. It was noted that the bedrooms are “personalised” by the people using the service. During the day of inspection, the home was found to be clean, tidy and free from any unpleasant odour. The home has good policies and procedures in place regarding infection control/COSHH. However, it was noted from the staff Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 20 training records that 4 members of staff have undertaken training in infection control and another member of staff has commenced training in this area. The Registered Provider stated that the remaining members of staff will receive this mode of training shortly and as a matter of priority. It was noted that all new members of staff received induction training and they are made aware of the dangers of cross-infection. Glenthorne House DS0000040718.V352321.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 and 30. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Glenthorne House is adequately staffed by well-trained staff to meet the needs of people who use the service. There are robust recruitment procedures in place to protect people who use the service. There is a good training programme in place that ensures staff are competent to do their jobs. New members of receive structured induction training. EVIDENCE: Information provided by the home and available staff rotas for the month of November and first week in December 2007 indicated that the home is adequately staffed. There is one senior carer and three carers in the morning and one senior carer and two carers in the afternoon shift and two night carers on wakeful duty. There are adequate numbers of ancillary staff on duty to cover catering, cleaning and general maintenance work at the care home. The Registered Manager’s hours are supernumerary. In addition the Registered Providers also support the Registered Manager with the administrative and management tasks. The staff training records showed that 16 members of staff have completed their NVQ Level 2 qualification and two members of staff have commenced their NVQ Level 3 training. The remaining members of staff who as yet have not received this mode of training will also be nominated to undertake this mode of training. The home does not employ Agency staff. The staff team is a well-balanced group in terms of age, experience gender and ethnicity. Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 22 4 staff files were examined in detail in order to check compliance with the recruitment requirements. All four files contained copies of two written references, and a full employment history. There was evidence on staff files that all four had been subject to satisfactory Criminal Records Bureau (CRB) and POVA checks prior to being appointed. There was evidence on files that staff have received the statements of their terms and conditions of employment. There is a staff training and development programme in place. In addition to the mandatory training (see NMS OP38) staff also would benefit from training in adult protection/safeguarding issues, Mental Capacity Act 2005, equality and diversity. Staff confirmed that training is provided and there are many opportunities to improve themselves for the benefit of the care of people using the service. All new staff received their induction training in accordance with the Skills for Care standards and specifications. People who use the service commented that they feel safe with staff caring for them and they felt that the home employs people that are capable of carrying out their care duties. Glenthorne House DS0000040718.V352321.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 and 38. Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. People who use the service can be assured that the home is run in their interests. Financial interests of people using the service are safeguarded. The home promotes the health, safety and welfare of people who use the service. EVIDENCE: The Registered Manager – Ms Carol Marshall - was registered with the CSCI in June 2007. Ms Marshall is currently undertaking her Registered Managers’ Award, and she hoping to complete this course at the end of February 2008 and then to commence her NVQ Level 4 qualification. She appears to be managing the home well. There are clear lines of accountability within the home and the Registered Manager is well supported by the Registered Providers. The home has a formal staff supervision system in place, and Ms Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 24 Marshall has already begun to implement supervision of staff and meetings both with staff and people using the service. Observations made and discussions with people who use the service and their relatives and staff have indicated that the Registered Manager is very approachable and she operates an ‘open door’ policy. People who use the service, who could express themselves stated that they are happy to approach the manager and staff with any problems they might have and were confident that they would respond to them appropriately. It was noted that the home has a Quality Assurance monitoring system in place. Quality Assurance takes place throughout the service in both a formal and informal manner. Meetings and day-to-day contacts all provide records to show that satisfaction is at the heart of the service for people who use the service. Financial records and administrative procedures relating to the handling of the monies of people who use the service were looked at and were found to be well ordered and maintained. The home actively encourages people using the service, where able, to manage their own money. The home keeps records to show that health and safety of people who use the service is promoted and protected. However, it was noted that the hot water supply in nearly all the hot water outlets was inconsistent in terms of maximum temperature level being within the range of 34 Degrees C to 36 Degrees C. The Registered Provider stated that this matter will be addressed immediately. The home needs to ensure the arrangements for the regulation of hot water temperatures include design solutions to control the risk of Legionella. The Registered Provider stated that this matter will be pursed as a matter of priority. The staff training records showed that a majority of staff have received their mandatory training in safe working practice topics, e.g. moving and handling, food hygiene, first aid, health and safety and fire safety. The Registered Provider stated that all those members of staff who as yet have not received this mode of training will do so shortly. They will also receive training in Adult Protection, safe handling of medication, Infection Control, NVQ Level 2, and Dementia care. People who use the service spoken with were very complimentary about the Registered Manager and staff in the home. They knew who they were by name and looked at ease in their presence. Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X 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 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 26 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. 2. Refer to Standard OP12 OP30 Good Practice Recommendations Records of activities enjoyed by people who use the service should be incorporated into their individual care plans. A system should be in place to ensure that all care staff receive training in the protection of service users from abuse, dementia care, equality and diversity and the Mental Capacity Act 2005 in order to safeguard, and fully meet the needs of, people using the service. The detail and quality of daily care recording should be further improved. A system should be in place to ensure that all those staff, who as yet have not received mandatory training in safe working practice topics, including Infection Control/COSHH, can do so in order to ensure the safety of people using the service. The current menu should be revised in consultation with people who use the service. DS0000040718.V352321.R01.S.doc Version 5.2 Page 27 3. 4. OP7 OP38 5. OP15 Glenthorne House 6. OP38 Action should be taken to ensure a consistent supply of hot water at a high enough temperature for comfort but with safeguards in place against the risk of scalding and the spread of Legionella. Glenthorne House DS0000040718.V352321.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection 1st Floor Chapter House South Abbey Lawn Abbey Foregate Shrewsbury SY2 5DE 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 Glenthorne House DS0000040718.V352321.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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