Inspection on 22/07/09 for Glen Lyn

This is the latest available inspection report for this service, carried out on 22nd July 2009.

CQC found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Glen Lyn 11/07/07

Extracts from inspection reports are licensed from CQC, this page was updated on 15/11/2009.

Key inspection report Care homes for older people Name: Address: Glen Lyn 16 Glen Road Sarisbury Green Southampton Hampshire SO31 7FD     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this full review a ‘key’ inspection. Lead inspector: Janette Everitt     Date: 2 2 0 7 2 0 0 9 This is a review of quality of outcomes that people experience in this care home. We believe high quality care should • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. The first part of the review gives the overall quality rating for the care home: • • • • 3 2 1 0 stars - excellent stars - good star - adequate star - poor There is also a bar chart that gives a quick way of seeing the quality of care that the home provides under key areas that matter to people. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. that people have said are important to them: They reflect the things This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Care Homes for Older People Page 2 of 35 We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care Homes for Older People can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report Care Quality Commission General public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Care Homes for Older People Page 3 of 35 Information about the care home Name of care home: Address: Glen Lyn 16 Glen Road Sarisbury Green Southampton Hampshire SO31 7FD 01489602222 Telephone number: Fax number: Email address: Provider web address: Name of registered provider(s): Type of registration: Number of places registered: joy.leach@saffronland.co.uk Mr Amin Lakhani t/a Saffronland Homes Group care home 43 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 dementia old age, not falling within any other category Additional conditions: The maximum number of service users to be accommodated is 43. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) Old age, not falling within any other category (OP). Date of last inspection Brief description of the care home Glen Lyn is a forty-three bedded home registered with the Care Quality Commission CQC to provide personal care to older people, some of whom may have dementia. Accommodation is provided in a two-storey building. There are nineteen single rooms and twelve shared rooms all with en-suite facilities. There is a well-maintained enclosed garden to the rear of the building with easy access for service users. Care Homes for Older People Page 4 of 35 Over 65 0 43 43 0 Brief description of the care home Glen Lyn is located on the outskirts of Park Gate village, which are the closest local amenities to the home. There is parking for visitors. The fees do not include hairdressing, chiropody, newspapers, toiletries and other personal items. Care Homes for Older People Page 5 of 35 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Health and personal care Daily life and social activities Complaints and protection Environment Staffing Management and administration peterchart Poor Adequate Good Excellent How we did our inspection: The site visit inspection to Glen Lyn, which was unannounced, took place over a one day period on the 22nd July 2009 and was attended by one inspector who was assisted throughout the visit by the registered manager Mrs. Joy Leach. For the purpose of this report the inspector is referred to throughout as we or us collectively, being a representative of CQC. The visit to Glen Lyn formed part of the process of the inspection of the service to measure the service against the key national minimum standards. The focus of this visit was to support the information gathered prior to the visit. The judgments made in this report were made from information gathered prior to the visit from the Annual Quality Assurance Assessment (AQAA) which was submitted to CQC by the manager, information from the previous inspection report, which took place on 22nd July 2008. The service history correspondence and any contacts relating Care Homes for Older People Page 6 of 35 to the service were also taken into consideration. Evidence for this report was also obtained from documents and records examined and talking to staff and observing their working practices. We also looked around the premises. There were a number of service users able to be involved with the inspection and those spoken to were generally complimentary about their home and the care they receive. Surveys had not been distributed to service users owing to their mental frailty but 15 surveys were sent by CQC to relatives, carers and advocates. 6 were returned, all of which were very complimentary about the care their relatives receive. Three (3) visiting professional surveys were sent out and three were returned. All three indicated that they consider a good level of care is provided by the staff and the service. Two (2) surveys were sent to care managers, these were not returned. 15 staff surveys were given to staff and 8 were returned. The outcome of the surveys and also speaking to staff on this visit, indicated that the staff feel well supported and consider they receive appropriate training that relates to their role and enhances their understanding of the service users needs. Comments and issues highlighted on the staff surveys are discussed in the main body of the report. There were thirty two residents living in the home at the time of this visit, all of which came from the same ethnic background. Care Homes for Older People Page 7 of 35 What the care home does well: What has improved since the last inspection? The home has had a good deal of redecoration which has taken place in the last year. New floor coverings have been put down and there is ongoing work to carry this through the upstairs of the home. The outside of the premises has vastly improved with new windows and doors installed and redecoration. Service users are living in a pleasant environment. Prescribed topical medicaiton is now stored appropriately in a locked environment. Chemicals used by the cleaning staff that are hazardous to health are not left unsupervised whilst cleaning is in progress. Care Homes for Older People Page 8 of 35 The care planning system in now computerised and being used by all staff. The privacy of service users in respected and a service users room is not now used as a consulting room for the GP. Service users see the doctor and other health professionals in the privacy of their own rooms. Hand washing facilities are now installed in the medication room. The records of monies held by the organisation for service users who wish their monies to be managed by the organisation, are kept in the home. All transactions are recorded and monies are stored separately within interest bearing accounts in the service users name. A quality assurance system for the service has been established and is being monitored appropriately by the management team. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line 0870 240 7535. Care Homes for Older People Page 9 of 35 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Older People Page 10 of 35 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them and the support they need. People who stay at the home only for intermediate care, have a clear assessment that includes a plan on what they hope for and want to achieve when they return home. People can decide whether the care home can meet their support and accommodation needs. This is because they, or people close to them, have been able to visit the home and have got full, clear, accurate and up to date information about the home. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between them and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has a system of assessing prospective service users to ensure that the home can meet their needs. Evidence: The AQAA stated that the home undertakes a pre-admission assessment for all service users who have been referred to the service. This assessment is undertaken by the manager or a senior member of staff who has been trained to this. The manager told us that she ensures that the home receives a copy of the care needs assessment from the social worker if they are involved with the potential service users admission. Information is also obtained from the clinical areas, if the person is in hospital, and also from other health professionals involved in the persons health care. The records and care plans are now being recorded electronically and there is also a hard copy of the assessment in individual files for staff to refer to. A sample of four Care Homes for Older People Page 11 of 35 Evidence: pre- admission assessments were viewed by us. The assessments cover all aspects of the persons activities of daily living and outlined the care and any risks involved in ensuring the persons needs are met. The home endeavours to involve families in the assessment and admission process and acknowledges the importance of sharing as much information as possible about the home with them and how that service users transition into living in residential care can be supported. The manager told us that due to the mental frailty of most service users it is difficult to give information about the home and gain a great deal of information from them about their lives unless their is some family involvement. The home give out Welcome Packs to all service users and their families and a staff member will go through this with the service user and the family and explain about daily life at the home. Pre-admission visits are welcomed if this is possible. Fifteen relatives surveys were distributed. Six surveys were returned to CQC, all of which indicated that they considered that they and the service user had received sufficient information about the home to help them make the decision about admission to the home. The home does not provide intermediate care. Care Homes for Older People Page 12 of 35 Health and personal care These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s health, personal and social care needs are met. The home has a plan of care that the person, or someone close to them, has been involved in making. If they take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it, in a safe way. People’s right to privacy is respected and the support they get from staff is given in a way that maintains their dignity. If people are approaching the end of their life, the care home will respect their choices and help them feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans provide care staff with information ensuring that service users needs are met. However, the electronic risk assessments do not identify the level of risk nor a care plan to manage any risk. Health care needs are documented with a range of services available to meet service users needs. Medication records are accurate to ensure the safety of service users. Staff treat service users in a respectful manner. Evidence: The AQAA stated that the home had now implemented a computerised documentation system for all care management and produces individual person centered care plans that demonstrate the homes commitment to meeting service users needs. A sample of four care plans were viewed on the electronic system. These demonstrated an assessment of the service users needs and the action taken to meet that need. In most cases the care plans described the action to take for specific needs, i.e. hygiene needs, which said the same for each service user and could be seen a Care Homes for Older People Page 13 of 35 Evidence: core plans and not individualised. This was discussed with the manager who said that the care plans for each service users activities of daily living are written with the person at the centre of the plan and that there are folders in each persons room that inform carers on how that person wishes their activities of day to day living to be undertaken and supported. This system allows for continuity of care if the carers on duty who may not have access to the electronic system. Risk assessments are undertaken for all service users for the use of call bells, falls and mental health. It was observed that in some cases the risk assessments had been undertaken but not completed fully and therefore the system did not produce the level of risk with a score that would enable the staff member to write an appropriate care plan to manage the identified level of risk. The manager said that she would consult with the training manager about how the system would produce a score. Nutritional assessments are undertaken and the service users are weighed each month and this is recorded in their care plans. If there is a risk identified through the records the person is referred to the GP for further investigation. There was evidence that the care plans are reviewed monthly and relatives are invited to be involved in the review of care. The care plans are signed by the service user or relative if possible but the manager told us that there are not many relatives involved in the home and those that are will be involved with the care planning and do sign the care plans. Service users mental health assessments are undertaken and care plans for how to manage their dementia are recorded. Those viewed were very similar in what actions to take and did not specify what the service user responded to specifically. Observations throughout the day demonstrated that staff were familiar with service users and there specific ways in which they preferred to spend their days. The carers showed good interpersonal skills and interacted well with the service users and were familiar with what activities they enjoyed doing and how two service users preferred to just wander about the home freely. Another service user like to spend the afternoon sitting next to another service user going through the daily newspaper telling her what the news was. The manager told us that currently there are no service users with challenging behaviours and therefore there were no care plans documented for this. The manager told us that most of the staff have received training on the computer system and they are using it appropriately for documenting all records and that she is Care Homes for Older People Page 14 of 35 Evidence: monitoring the records as part of the quality assurance system. The daily notes are recorded electronically by the carers. The service users have access to a GP of their choice from the local area. The GP will visit the home on request and will only review medication when the home requests this. The home has access to the primary care team who will visit the home when requested to give advice on tissue viability and will access pressure relieving equipment for the home if the assessment identifies a risk. It was observed throughout the home that profile beds, pressure relieving mattresses and cushions were in use for a number of service users. The community matron will visit the home regularly to offer support and advice on any health care problem. The service users have access to the chiropodist, optician and dentist and any visits from the health professionals are documented in the daily records and care plans and any intervention or change in treatment is recorded in the care plans. The home is also visited by the community mental health team who will attend the home on request. A survey returned by them said that the home seek advice and act on it to meet peoples health care needs and improve their well-being commenting that the home raises their concerns about residents well being at the earliest opportunity rather than delaying matters. Surveys were returned from two other health professions who said I have found staff respectful to the service users and sometimes work in difficult situations with people with dementia. Another comment said It is always a pleasure to visit Glen Lyn, we are only with service users for a short time but residents always seem happy. The AQAA states staff have regular medication training in the management of medications, which is undertaken by the manager. The home have medication policies and staff understand their roles and responsibilities and recognise that medication records are the key to efficient management of medication.The home has polices and procedures that underpin the management of all aspects of medication administration, storage and disposal. The medication system was viewed. The home take delivery of a monitored dosage system (MDS) for each service user from the local pharmacy who visit the home annually to check medications and records. The manager and senior carer have the responsibility for the ordering to disposal of medication to ensure consistency and prevent over stocking of medications. The medication administration record (MAR) charts were examined and had been recorded appropriately. There was a list of Care Homes for Older People Page 15 of 35 Evidence: specimen signatures of all nurses who administer medication and this was kept in the MAR chart records. The MAR sheets are audited by the manager as part of the quality assurance for the home. Records were viewed for the disposal of unwanted medications and had been signed for by the receiving pharmacist. The cupboards and trolley were viewed. The shelves of the trolley were found to be sticky and untidy. The cupboards and room in general were untidy and there was a pile of paper work in the one cupboard waiting for filing or disposal. This was discussed with the manager who told us she would delegate the cleaning of the trolley and tidying of the room and cupboards to the night staff to undertake on a regular basis. A controlled drugs cupboard was attached to the wall. At the time of this visit there were no controlled drugs being administered. The drugs register evidenced a record of the night sedations being administered and was being recorded appropriately as good practice. The manager sees the prescription before they are sent to the pharmacist for dispensing. This is good practice and prevents unwanted medications being delivered, which can result in over stocking of medication that are used as needed (PRN). If a medication that is prescribed as PRN is administered, the reasons for administration are described on the back of the MAR sheet. This was discussed with the manager as to the residents who were unable to verbally communicate their need for PRN medication and how did staff know when to administer this. A staff member, who was administering medication was asked how she would know if a person needed a PRN medication. She described how she would know and what signs and behaviours would determine whether to give the medication or not. This should be described in a care plan to ensure consistency from one carer to another. Part of the medication round at lunchtime was observed. It was being administered as set down in procedure and safe practice was observed. The AQAA states that the home respects the rights of the service users in the area of health care and medication and work with the decision made by individuals regarding any refusal to take medication within the confines of risk assessment and their mental capacity. There were no residents choosing to self-medicate at the time of this visit and residents were observed to be taking their medication, some needing just prompting to do so. Care Homes for Older People Page 16 of 35 Evidence: Staff were observed to be very familiar with the service users needs whilst respecting their wishes. The requirement identified last year with regards to a service users room being used for the GP consultation, this has now ceased and each service user is seen in their own room should they need to consult with a doctor. This was confirmed when talking to a member of staff. The six surveys returned to us by relatives were very complimentary about the home comments made said. I thing Glen Lyn does its best to meet and look after the residents in their care. My brother always looks well and is well care for and staff do ring me if he is not well I have no complaints to make. My father is always clean and well fed. The home engages relatives on a personal basis and are always available if you need to chat or have concerns. I think Glen Lyn is well run and always have the residents needs at heart. The staff are always kind and considerate to my sister who has been a resident for ten years. They give the best care possible under very difficult circumstances. They make is home from home as much as possible. The home look after all of my mums needs. Care Homes for Older People Page 17 of 35 Daily life and social activities These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives. They are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. People have nutritious and attractive meals and snacks, at a time and place to suit them. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a range of social activities to meet service users needs. Service users are able to exercise choice and make decisions about their lives. Visitors are made welcome to the home and they can see service users in private. A varied menu is available and good quality food is served to service users, giving them choices. Evidence: The AQAA says that the home provides activities that encompass leisure, cultural and social activities and actively promote service users to develop and maintain their life skills. The home encourages visitors from the local community as well as families and friends. The home does not employ a person to organise the activities for the service users. One member of staff told us that she is about to go on an activities training course to enable her to provide appropriate activities for people with dementia. The home has introduced a booklet titled This is your Life . It is a booklet that contains information about the persons previous social and recreational life and states likes and dislikes and what they enjoy doing. This information helps staff interact with the service users and is used as a reminiscence tool that helps stimulate memory. We viewed a number Care Homes for Older People Page 18 of 35 Evidence: of these booklets and these gave a general outline of the persons social history and their likes and dislikes. The manager told us it is not possible to always gain much information from the service users depending on their mental frailty and that if there is no family involvement the information can be minimal. The home does not have an organised activities programme on display. The carers have produced a large colourful activities board in the lounge area which identifies in pictorial format what activities and games are available each day. Service users can identify and point to the games they wish to participate in on a daily basis. Carers told us that, whatever activities take place on a day to day basis and what activity is decided on is dependant on the service users moods, how service users are responding and the level of their participation in whatever group activity is taking place, there are, therefore no set days of the week for specific activities. Carers told us that activities do take place every day and they try to do arts and crafts with those who wish to participate. The home was busy throughout the day and some service users were wandering about the home and this is possible through the geography of the building and the very pleasant garden which is accessible through the french windows. We sat and observed the routine of the day. There was excellent interaction between the carers and the service users. There was a great deal of one to one activities going on. One carer was playing soft ball with several services calling their names to catch the ball. Another carer was playing scrabble with a service user. One service user was reading the daily paper to another service user, and another choosing to sit quietly in the small lounge. Six residents have newspapers delivered for them A hairdresser attends the home weekly. Musical entertainers attend the home every other week to sing and play music for the service users. All activities the service users take part in are recorded in their individual files. The home has had a sensory room installed. Currently it is not being used to its full potential as the manager told us that there is only one carer who has been trained in how to use this with service users. The May staff meeting minutes identified that no procedural guidelines have been written as yet and these, together with staff training need to be in place to ensure safe use of the equipment. The home did have the use of the outings bus once a week but this has stopped temporarily as the manager reported the driver of the bus is no longer employed with the organisation and they are in the process of organising another person to be able Care Homes for Older People Page 19 of 35 Evidence: to drive the buses for Glen Lyn. Comments on relative and staff surveys confirmed this and said. The home could do better if we could have the mini-bus trips as the clients enjoy this. The home should try and reinstate the minibus trips. A service user spoken with said she enjoyed the outings in the bus and wished she could go out more. The home has an open visiting policy and visitors are offered drinks and there is a quiet area for them to see their relatives. The visitors book demonstrated that the home is visited regularly by the same relatives, but the manager told us that there are a number of residents who do not get many visitors.The manager told us that she has invited families to afternoon tea and arranged a relatives meeting but the response was very poor with no relatives attending. The manager told us that whilst the mini-bus is off the road service users are dependant on their relatives to take them out into the community unless they have outpatients appointments. The assessments and care plans record the service users likes and dislikes and how they prefer to go about their daily routines. On looking around the home there was evidence that residents can bring with them items of personal belongings and furniture. Most rooms had been personalised, however there was evidence of some rooms being very impersonal and the manager said that the home does endeavour to make the rooms as homely as possible. The kitchen staff are familiar with the residents food likes and dislikes and the cook and the manager plan the five-week cyclical menu around these. The menus viewed were varied and nutritious. We observed the lunchtime meal being served. This was enjoyed by most of the residents and little waste was noted. There was a choice of two main courses on the menu. Diabetic diets and pureed diets are provided for and the cook told us she is familiar with the different needs of various diets. Most of the residents spoken to at the time of this meal told us that they had thoroughly enjoyed it and liked the food, another told us the food is alright but can be boring. Service users birthdays are acknowledged with a celebratory tea to which family and friends are invited. A comment from a relative said The staff make it a home from home and my brother recently had his birthday and there was a lovely birthday tea provided but we are always offered a tray of tea. Care Homes for Older People Page 20 of 35 Evidence: Care assistants were observed to be assisting those who needed prompting to eat, in a kind and encouraging manner. They sat with them talking and encouraging them to eat their meals. Dietary diaries are maintained for clients who may have an identified problem with their nutritional intake. A sample of these records were shown to us. Service users weights are monitored and recorded monthly and these records are maintained in the care plans. Care Homes for Older People Page 21 of 35 Complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them know how to complain. Any concern is looked into and action taken to put things right. The care home safeguards people from abuse and neglect and takes action to follow up any allegations. People’s legal rights are protected, including being able to vote in elections. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home had a clear complaints procedure to address the concerns of residents and relatives or their representatives. People who use the service are safeguarded by staff who have been appropriately recruited and trained. Evidence: The AQAA stated that the home have a complaints policy and procedure in place. This was seen to be displayed and a copy is issued to all service users and their family or representative. Assistance is given to all residents to register for voting at local and general elections. We have zero tolerance of any kind of abuse towards residents. All staff have training in abuse awareness. The home have close liaison with Social Services and have the No Secrets document in place along with the local authorities policy on abuse awareness. The home will act as advocates as necessary and will assist a resident in obtaining an outside advocate. All complaints are dealt with in a timely fashion as per our policy and protocol. The complaints procedure was displayed on the reception area wall. The complaints log was viewed and these recorded two complaints being made since the last inspection. The log recorded the complaint, the investigation and outcome of the complaints which were resolved appropriately and within the stated timescales, which demonstrated that the home does deal with complaints appropriately. Care Homes for Older People Page 22 of 35 Evidence: 6 relatives surveys returned to us indicated that they all knew how to make a complaint and that the service has responded appropriately to any concerns raised. One relative saying the staff are available to you if you have any concerns, another saying I have no complaints. There have been no safeguarding referrals since the last inspection. Staff have received training in the safeguarding process and policies and there was evidence in the training files of this taking place this year.This training is also part of the induction programme for newly recruited staff. Staff are also made aware of the Whistle Blowing policy and the organisation has produced leaflets that have been distributed to all staff giving them guidelines on how to report abuse or poor practice, to ensure the best interests and safety of the service users is maintained. All staff are POVA and CRB checked before commencing duties. Risk assessments were evidenced in the care plan for service users who had been assessed as needing to use bed rails for their safety. Discussion and permission had been sought from the families of service users who were unable to consent to their use, owing to their mental frailty. Bumpers were in place for bed rails in use. Care Homes for Older People Page 23 of 35 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home ensures that the premises, decor and furnishings are maintained and a programme of ongoing refurbishment and replacement is in place. The home is clean and homely and staff training, policies and procedures protect service users from infection. Evidence: The AQAA identified that the home has a maintenance programme of ongoing redecoration of the home and there has been a considerable amount of redecoration in the home in the last twelve months.The lounges have been decorated and new flooring put down throughout the ground floor of the building. The manager told us that this flooring is also being put down in the upstairs corridors now that they have been painted. A comment from a relatives on a survey said The recent refurbishments have brought the home up to date and made a great difference on the approach and entering the premises. We looked in most areas of the home. The was clean and there was only one bedroom that an odour could be detected and this was acknowledged by the manager who told us that the flooring is being replaced in this room. The home employs an agency to supply staff for cleaning duties seven days a week and therefore care staff do not get involved with cleaning duties. Care Homes for Older People Page 24 of 35 Evidence: The home has two bathrooms and two shower rooms. One bathroom has a Parker bath installed, the other bathroom has an assisted bath hoist. The manager said the wet room is well used. The home has a programme of replacing all divan beds with metal-framed beds or profile beds. The back garden is well maintained and very pleasant with seating around the patio area. The home has a gardener who attends to this. Service users enjoy using the garden in the better weather and were observed to be going out into the garden throughout the day. The bedrooms were pleasantly decorated and new furniture had been purchased in some rooms. The bedrooms were individual and service users had made their rooms personal with their own belongings or some personal furniture. The outside of the home has been extensively upgraded. New windows and doors have been fitted and the outside of the building has been redecorated. The home has hand-washing facilities of soap dispensers and paper hand towels in all bathrooms and toilets and has now been installed in the treatment room where the medication trolleys are kept. The training matrix identified that staff have received training on the principles of infection control. Staff spoken to confirm that they had had this training. Protective clothing is supplied for staff. The policy of the safe handling and correct storage of all COSHH chemicals was in place and being observed by cleaning staff, who did not leave cleaning chemicals unattended whilst the home was in the process of being cleaned. The maintenance team respond to requests to correct any problems within the home that occur, the manager saying they were very good. At the time of this visit they were in the process of fitting new thermostat valves to all the radiators to enable individual room temperatures to be maintained. The manager told us that she and the director of the organisation plan together the improvements for the home for the coming year. Staff spoken to told us that they did not have a specific staff room to be able to have Care Homes for Older People Page 25 of 35 Evidence: their breaks or lunch. This was discussed in the surveys returned by staff. This was discussed with the manager who told us that there is facilities with lockers for the staff and they are able to use the small sensory room upstairs if they wish to remove themselves from service users for breaks and this issue had been discussed at other times. Care Homes for Older People Page 26 of 35 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable to care for them. Their needs are met and they are cared for by staff who get the relevant training and support from their managers. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Service users needs are met by sufficient numbers of staff that are trained and competent to do their jobs. Service users are in safe hands and are protected by the policies and practices of the recruitment of staff. Evidence: At the time of this visit there were 32 service users in residence. The staff rotas evidenced that 5 cares were on duty from 07.30 until 14;00 and 4 carers on duty from 14:00 until 20:00 when three waking night staff came on duty until 07:30 in the morning. The home employs separate domestic staff, the receptionist, a cook and kitchen staff and a person who undertakes all the laundry.The manager is on duty five days a week and is part of the work force if necessary but has protected management days. The nature of the service users needs and care, through mental frailty, means that the dependancy of this group of residents is high. The staffing levels were discussed with the manager as comments received from the 8 staff surveys returned said Have more staff on duty. We need more staff on duty so we can have more time with our residents.Have more staff on duty to help meet every need of every individual. More time is needed to be with residents and less paper work but understand it has to be done. The manager told us that the home is not at present fully occupied and the Care Homes for Older People Page 27 of 35 Evidence: staffing levels are in line with the number of residents. Dependacy levels were discussed and the manager agreed that if the occupancy of the home increases more staff hours will be allocated to accommodate this. From observations of the day, the home was very busy but carers were still observed to spend some quality time with service users on activities and talking to them in the early afternoon. Most of the service users are unable to use the call bell system and there are care plans in place to ensure their safety. The training matrix and the AQAA identified that nine of the fourteen care staff have achieved the NVQ level 2 or 3, thus achieving over 50 of care staff being qualified to this level. New staff undertake a thirteen-week induction programme and is based on the Skills for Care induction standards. Feedback from staff surveys indicated that the induction is good and covered everything they need to know to do the job. Evidence of a completed induction programme was seen in the staff file of a more recently employed carer. The AQAA states that the improvement over the last year is that the home have recruited more local staff. A sample of two staff personnel files was viewed of the most recently employed staff members. The records demonstrated that all appropriate checks such as CRB, POVA and two written references had been requested and received by the home. The home employs a mixed gender and multi-cultural staff group. The home also had evidence that all agency staff that attend the home have had the appropriate recruitment checks and training. The AQAA said and the manager confirmed that agency staff are invited to join in the in-house training the organisation provides. The manager has a training matrix that is stored on the computer. This was accessed and demonstrated to us by the administrator and evidenced that staff do receive a variety of appropriate training such as dementia awareness and challenging behaviours and most staff have done the dementia awareness training and the manager encourages all staff to undertake this. 6 of the 8 staff surveys returned and 4 staff spoken to told us that they consider they are well supported and training is made available to them. One stff member told us she enjoys her job and is supported by a good team. Conversely 2 staff surveys said that they consider the home could do better by providing more training. There was evidence on the matrix and in the personal files that mandatory training is provided appropriately. Care Homes for Older People Page 28 of 35 Evidence: The manager has undertaken training in the Mental Capacity Act and Deprivation of Liberty. This was discussed with her and she is in the process of sharing this information with the staff and what effect this will have on the service users lives and the decisions that are made for them. The organisation has produced a leaflet with information about the mental health act, which has been handed out to all staff to give them an awareness of this. The records seen also demonstrated that the manager regularly supervises and undertakes an annual appraisal for staff from which training needs are identified. The manager has received training in supervision and appraisal of staff. The organisation has applied for investors in people award and the aim is to achieve this by August 2009. The home has a staff handbook that is handed out to all staff which gives guidance on good care practice and the expectations of the organisation as to standards and the code of practice. Care Homes for Older People Page 29 of 35 Management and administration These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is led and managed appropriately. People control their own money and choose how they spend it. If they or someone close to them cannot manage their money, it is managed by the care home in their best interests. The environment is safe for people and staff because appropriate health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately with an open approach that makes them feel valued and respected. The people staying at the home are safeguarded because it follows clear financial and accounting procedures, keeps records appropriately and ensures their staff understand the way things should be done. They get the right care because the staff are supervised and supported by their managers. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The registered manager is qualified, competent and experienced to run the home. The home has an quality assurance system in place. The health and safety of the service user and staff are promoted. Evidence: The AQAA tells us that the registered manager has been in post for over nine years and has the qualified registered managers award.The manager is well supported by the General Manager, who the manager told us, is always available to give advice. The manager told us that she is able to demonstrate good knowledge of budgetary matters and considers the home provides a service that is value for money. The manager is a qualified moving and handling trainer and undertakes all training in the home to ensure the staff are competent in moving and handling skills and also ensure that these are maintained by regular training updates. The AQAA states that the home promotes equal opportunities and quality is measured Care Homes for Older People Page 30 of 35 Evidence: by use of the new quality assurance tools and surveys which are given to service users, relatives and visitors and the home is generally monitored by the general manager on the monthly visits. The home has introduced a quality assurance system which includes both day and night issues. The quality assurance consists of the environment being monitored to include the laundry, kitchen, water temperatures and the general cleanliness of the home. Care plans, risk assessments, medication records, supervision records and fir log records are also monitored by the manager. Also the general manager visits the home monthly and writes a monthly report on her findings. These records are maintained in the home and were viewed by us.The manager told us that she or the general manager will visit the home at night to ensure the night staff feel inclusive in the running of the home. Questionnaires have been distributed to families and friends and six were returned and indicated that generally they are very pleased with the service. The manager did plan a relatives meeting but no one attended and has not arrange a further one. The manager has an open door policy and will talk to relatives when they visit the home. Staff meeting are held regularly and the minutes of the last meeting were seen by us. Of the 8 surveys returned from staff, 3 say they regularly meet with their manager, 3 say sometimes and 2 say often. The AQAA tells us that the policies and procedures of the home have been reviewed in the past year and they are made available to all staff. The AQAA tells us that some clients ask that we keep safe their personal allowance to enable them to be able to pay for such things as hairdressing, toiletries or sweets that they may wish to purchase themselves. This is kept locked in the safe and the full records are kept by the manager in a safe and secure environment. Due to the mental health problems experienced by our clients we ensure that any large amounts of money is sent to head office where it is placed in a named bank account for that client. All records are updated on a regular basis and the client or family, as appropriate are able to access the information at any time. The manager holds all financial information locked away and this remains confidential at all times. The finances manager regularly audits all accounts and all findings are documented. At the time of this visit the manager was storing in a secure environment, 4 service Care Homes for Older People Page 31 of 35 Evidence: users monies for their personal use. The monies were being stored in individual containers. Two were examined and the records and receipts were in place and the amount being stored balanced with records. There were no large amounts being held. For those service users who the home manage their monies. These are kept in separate interest bearing bank accounts and a monthly print out of the accounts are sent to the home for each individual service user. If the service user wishes to know how much money they have, this information is now available in the home. We viewed the statements issued and these were being stored in a locked environment. The finance manager regularly audits the accounts and records the findings. The AQAA tells us that the home has a clear health and safety policy and the manager monitors all the servicing of relevant equipment and that staff are trained appropriately in all health and safety subjects. A sample of servicing certificates for equipment and systems such as gas boiler, hoist, lift, clinical waste contract, bacterial water testing and fire equipment servicing, was viewed. The five year electrical wiring certificate evidenced that this had been checked in June 2009. These demonstrated that servicing of equipment had taken place within the last year. The fire log was examined and that evidenced that all appropriate checks of the system and equipment had been undertaken at the recommended intervals. The training matrix demonstrated that all staff had attended a fire training lecture at least once in the past year and complete questionnaires in between. The organisation has employed a fire specialist person to undertake the fire risk assessment for the home which is to be done imminently. The manager having undertaken this in the past. The accident records were viewed. These are stored appropriately and the manager keeps a copy of the accident form. She periodically analyses these and identifies if there is a resident who is falling regularly, she will then refer them to the falls clinic. The falls clinic will visit the home to give advise and risk assess the person. Currently the falls clinic cannot provide any equipment owing to a lack of funding. Care Homes for Older People Page 32 of 35 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. No. Standard Regulation Requirement Timescale for action Care Homes for Older People Page 33 of 35 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No Refer to Standard Good Practice Recommendations 1 7 It is recommended that any risk assessments undertaken have a resulting level of risk identified, to enable a care plan to be produced to manage any risk. Care Homes for Older People Page 34 of 35 Helpline: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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