Inspection on 12/07/07 for Glen Lee

This inspection was carried out on 12th July 2007.

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

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

Other inspections for this house

Glen Lee 08/01/08

Glen Lee 13/02/07

Glen Lee 05/09/06

Glen Lee 14/10/05

Glen Lee 05/05/05

Glen Lee 18/10/04

Glen Lee 21/06/04

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

CARE HOMES FOR OLDER PEOPLE Glen Lee Wavell Road Bitterne Southampton Hampshire SO18 4SB Lead Inspector Christine Walsh Unannounced Inspection 12th July 2007 09:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Glen Lee DS0000039231.V341047.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. Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glen Lee Address Wavell Road Bitterne Southampton Hampshire SO18 4SB 023 80473696 023 80476734 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) Southampton City Council Mr David Robert Shepherd Care Home 34 Category(ies) of Dementia - over 65 years of age (34) registration, with number of places Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th February 2007 Brief Description of the Service: Glen Lee is a purpose built local authority home managed by Southampton City Council and is located in the residential area of Bitterne, a suburb to the east of Southampton city. The home is designed over two storeys, was built in 1964 and offers accommodation in 34 single bedrooms with a lift access to the first floor. Glen Lee provides care and support for people over the age of 65 years with dementia. A community day centre operates from an area of the home that also offers respite services and is run by Southampton Care Association. The building is detached in its own grounds and gardens with a housing estate surrounding the property. Garden furniture is placed in a covered patio area, which is used as the service users’ smoking area but can also enable service users to enjoy the grounds and gardens in finer weather. Fees at the home are currently for permanent residents is £447 02 per week and short stay £194.67. Service users are responsible for paying for their own toiletries, hairdressing, chiropody and items of a personal or luxury nature. Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit formed part of the key inspection process and was carried over one day by Mrs C Walsh, regulatory inspector. The manager completed an Annual Quality Assurance Assessment (AQAA) document, which was returned to the Commission for Social Care Inspection prior to the visit to the home. In addition “Have Your Say” resident and relatives comment cards were sent of which a small number have been received. The information obtained to inform this report was based on viewing the records of the people who use and work at the service, speaking with the residents, visitors and staff and observing care and support practices. A tour of the home took place and documents pertaining to health and safety were viewed. What the service does well: Glen Lee provides prospective residents and their families with information about the home before they move in this has been developed with the needs of people with dementia in mind. The home makes sure it can meet perspective residents’ needs by carrying out an assessment of their needs before they move in. Following an assessment and it agreed the home develops a personal plan providing vital information on how the residents wish to be supported. This helps staff to support the residents in the way they are used to. The manager and staff make sure residents health care needs are fully met and where possible will support the residents to maintain contact with their own doctor as well as making sure their mental health care needs are carefully monitored and reviewed. Glen Lee provides a variety of in house and social activites that stimulate and are greeted well by both residents and relatives. “A relative said” There is always something going on here and the residents seem to really enjoy themselves”. Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 6 A resident said. “I love the sing songs and sometimes I get up and have a jig too!” The home makes visitors welcome and provides them with up to date information about the health and well being of their family member. A relative said “I am always made to feel welcome, I turn up at anytime and there is always someone to greet me and tell me how dad is”. The home has a cook on site who is made aware of the different diets and likes and dislikes of the residents, catering for special diets and individual choices. Residents and relatives are provided with information on how to raise any concerns or complaints they may have and the resident’s complaints leaflet has been developed with the needs of people with dementia in mind. The home is spacious, airy and clean, it has been adapted to meet the needs of people with dementia such as coloured coded passageways and photographs on individual bedroom doors to assist the residents to get around. Staff attend a variety of training that supports them to meet the needs of the residents including how to protect residents from abuse, dementia, moving and handling to name but a few. They are also supported and encouraged to do a national vocational qualification (NVQ). Glen Lee has recently appointed a new manager who works well with the residents, relatives, staff and health care professionals and who has good ideas for improving the quality of care they provide at the home. The resident’s monies are safely handled by the home and lockable storage is available for any residents wishing to hold their own money or valuables. What has improved since the last inspection? The home was issued with six requirements following the last visit to the home in February 2007, three requirements have been met. Care plans now provide evidence that the residents’ daily care is being reviewed, which allows better communication and better monitoring of the residents health and wellbeing. Each resident now has lockable storage in their bedroom in case they wish to hold valuables and money safely. The three bedrooms situated in the day service are now only used to accommodate residents using the home for respite care and who access the Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 7 day service whilst residing in the home. Previously these rooms were used for permanent residents, which did not allow for them to access their rooms during the day. 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. Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Glen Lee does well in ensuring the people who are planning to use the service are issued with information about the home in a format that meets their needs. To ensure Glen Lee can meet the needs of prospective residents it undertakes an assessment of their needs prior to moving into the home, however the home must ensure all information is considered including information obtained from care managers. The home does not provide intermediate care. EVIDENCE: The annual quality assurance assessment (AQAA) tool stated under “What we do well” (In summary) residents are admitted only after they have had an individual needs assessment which follows a proecdure for obtaining Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 10 information on them which includes both permanent and residents seeking respite care. A relative confirmed that prior to her father moving into the home they were provided with information about the home and an assessment of his needs carried out. The relative said: “I found the information in the Statement of Purpose very useful and it gave me an insight into the service they would provide for my father” The relative went onto say: “The assessment process was very thorough and the “Look at me” document they use to obtain information about my fathers history and key dates in his life is very good”. Four residents assessment documents were viewed and on the whole provided valuable information to support staff to develop an understanding of the residents previous lifestyle, to assist in developing care plans and to provide a consistnecy of care, however not all assessment information had been fully completed and information provided from a care manager had not been used to risk assess the specific needs of a resident, placing this resident at potential risk of harm. Intermediate care is not provided in the home, however three beds are used for respite care and are situated in a separate area of the home, the service users receiving respite care can access the main area of the home and eat their evening meal with the residents if they wish. Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8,9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Glen Lee does well in ensuring each resident has a personal plan that identifies their strengths and needs, however the home must ensure it is safeguarding residents health, safety and well being by informing staff of how to minimise individualised risks. This is a repeated requirement. The people who use the service have their health care needs well met by various health care professionals. Glen Lee has made improvement to the administration of medication, however further improvements are required in the administration of “as required” medications (PRN). This is a repeated requirement. People who live at Glen Lee are treated with respect and their privacy upheld. EVIDENCE: Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 12 The home stated about themselves in the completed annual quality assurance assessment (AQAA) tool stated that they do well to, ensure individual person centred care plans are in place for every resident, which focuses on abilities and personal health care needs. That the residents are supported by skilled staff who receive a through induction and supported to achieve a NVQ to enable them to deliver a high standard of care and who have all received training in effective care planning. The home has good links with health care professionals and staff are trained in the administration of medication. This was tested by viewing four residents personal plans and other information relating to their care such as the accident book, viewing medication records, observing practice in the administration of medication, speaking with staff, reltives and where possible residents. Four residents personal plans were viewed and provided information on the strengths and the support the residents require in every aspect of their personal and daily living skills including providing a past history. In some cases the plans provide clear information on how the resident wishes to be supported however this is not consistent for all and some plans lack detail. This was discussed with the manager and senior staff who agreed to review the plans with care staff. An improvement has been made since the previous visit in the recording of monthly reviews and daily records providing information on the residents wellbeing. In addition to care plans risk assessments are also in place and includes moving and handling, nutritional assessment and in some cases specific risk assessments. However the home must ensure all residents are individually risked assessed and identified risks minimised as far as feasibly possible. The requirement issued following the last visit to the home will be repeated. Relatives spoken with at the time of the visit were complimentry and satisifed with the care being provided: A relative said: “My father would not receive the standard of care he gets here if he lived in some of the other care homes I looked at before he came here”. “He always looks clean and tidy” Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 13 The manager stated that the home has very good links with health care professionals such as GP’s, district nurses, continence advisors and pychogeriatrician. Residents personal plans provide evidnce of appointments and visits carried out by health care professionals providing information on the concern the treatment and the outcome. On the day of the visit concerns were raised regarding the health of a resident and a senior was observed taking immediate action to call a GP and request a visit, with a clear description of the concern and clearly recording in the residents notes. Another resident has been referred to the GP for a review of medication as the staff are concerned that side affects are having an adverse effect of the residents wellbeing. This demonstrates good skills and awareness of staff. However the manager is advised to seek advice and support from the appropriate health care professional to asssess residents requiring support to sit leisurely and to sit comfortably whilst eating their meals. Staff are responsible for the administration of medication receiving training to ensure procedures are carried out correctly. Improvments in this area have been noted over the last couple of visits to the home, however further improvments are required and the previous requirement to provide clear “As required” plans has not been met and therefore will be repeated. The home must also be certain when residents have taken the responsibility to administer their own insulin that they have taken appropriate steps to ensure the resident is doing this correctly. Through observation and speaking with relatives and staff it was established that residents are treated with respect and their privacy and dignity upheld. However staff must consider the feelings of the residents who were left in wheelchairs rather than moved to a comfortable chair when moved to the lounge and the seating positions and arrangements for residents with poor posture to ensure they are comfortable and can easily view the television as identifed in a care plan for one resident who was noted to be sitting slouched in an armchair and feet not resting comfortably on the floor. Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Glen Lee is a lively active place to live where the people who use the service are stimulated daily with a variety of activites, encouraged to maintain contact with family and friends, encouraged to exercise choice and control over their lives and are provided with wholesome well balanced meals. EVIDENCE: The annual quality assurance assessment (AQAA) tool stated under “What we do well” We provide a variety of social activities which promotes independence and well being for all service users. Staff are aware of the importance of providing stimulation for service users and so enhance well-being, we recognise the important of supporting our service users with all daily activites and maintaining their independence. We encourage social, relaxed, unhurried and independent dining, with a choice of menus and where special diets are catered. Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 15 Family and friends are made welcome by staff and their support encouraged. This was tested by observing interaction between staff and residents and day to day working practice, speaking with residents, staff, visitors and the cook and viewing planned events. The activities programme is displayed on the notice board and these normally take place in the afternoons. Activities include: arts and crafts, board games, skittles, cake making, memory games, gardening in the summer months, and musical movement and bingo. One of the care staff at the home is responsible for organising activities and there are visiting entertainers who come to the home on a regular basis. A member of staff also brings in her 2 pet rabbits, and residents enjoy stroking and being with the animals. In the summer months there are trips out organised. There are trips to the pub on a monthly basis and families and friends as well as off duty staff members volunteer to support the residents to participate. The manager spoke of the homes efforts to raise money to buy a mini bus, which would allow for more spontaneous trips out into the community, although recent trips have been organised which, included residents visiting local parks and seaside resorts for tea and ice cream. The manager was very aware of the importance of activity to stimulate and to encourage residents to maintain independence. The manager shared ideas she hopes to implement to assist with reminiscence, such as furnishing unused areas of the home, for example a workbench, childcare area, dressing room, styled and furnished with dated furnishings and equipment. To assist residents to comprehend what activity is taking place picture prompt cards are in place. Relatives spoke highly of the level and variety of activity that takes place in and outside of the home and they are encouraged to participate and support their family member. “I often go to the pub with some of the residents, they look forward to it and appear to enjoy it as do I!” The residents were observed istening to and singing along to music and the staff were observed jigging to the music and sharing a joke and a laugh with the residents providing a friendly and relaxed feel to the home. The home has a clear visitors policy and there are no set times, a number of visitors were spoken with at the time of the visit and confirmed that they are Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 16 always made welcome and do not always notify staff when they are going to visit. A visitor said: “ I am always made welcome, I visit when I can and mum is always clean and tidy”. Residents were observed to be free to choose where and how they spent their time and there were no restrictions imposed upon them, this was assisted by the use of picture prompt cards that offer the residents choice through an alternative way of communication but also informs the resident of what is about to happen. Picture menu cards also assist the residents to make choices. The staff with whom were spoken with were aware of the importance of respecting residents choices and encouraging them to maintain their independence. Following a number of visits where the home was required to solve the concern of residents residing in bedrooms in the day service area which access was denied during the day has been resolved. The three bedrooms are now only used for respite care of which these service users will access the day service during the day. Amendments have been made to the Statement of Purpose and Service User Guide to reflect this change. The home operates a five-week rolling menu and residents appeared happy with the choice and food provided by the home. A resident said: “The food is very good” And another said: “I can always have something else if I don’t want what is on the menu”. There is choice of menu at each sitting including a vegetarian option. Residents are supported to make choices with the use of picture card menus, which are displayed on the residents’ notice board. These are still in the making to cover all meals provided by the service and could be the reason why what was displayed on the board was not on the menu for the day but for the day before. To avoid confusion the staff must be mindful to change the menu daily. Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 17 Residents’ mealtimes were unhurried and staff provided suitable support for those residents who required it. However the home must consider the compatibility of residents when planning where residents sit at mealtimes to avoid conflict and bad feeling. The cook appeared knowledgeable of the needs and specific likes and dislikes of individual residents including diabetes. Although the cook was aware diabetics should not have sugar in their diet she felt she would benefit from training in diabetes and other conditions related to diet such as celiac disease. Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 18 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. Glen Lee does well in ensuring the people who use the service feel that their views and concerns are listened to and acted upon. The homes adult protection policies and procedures and training of staff protect the people who use the service from potential risk of abuse. EVIDENCE: The annual quality assurance assessment (AQAA) tool stated under “What we do well” To have a clear pictorial complaints procedure which is given to every service user, we record complaints and actioned them within 28 days of receiving the complaint. We also promote an open culture which is stimulating and relaxing which encourages the service users to speak out. This was trested by vieiwng the complaints procedure, speaking where possible with residents to establish if they know how to make a complaint and who to, and by speaking with relatives and staff. The home has a pictorial and coloured complaints procedure, of which a copy Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 19 is kept in the residents bedrooms. In addition to this the home has produced pictorial prompt cards to assit the residents to communicate their emotions and feelings. Residents who were able to express their feelings said they were happy living in the home. Visitng relatives were spoken with and said they were very happy with the service provided in the home, but were aware of the complaints procedure and who to speak to if they were unhappy. A relative said: “The staff here are very good, they keep us informed of whats going on and how dad is, when I have raised concerns they have been quick to respond and resolve them” The home keeps a record of all complaints, which includes the nature of the complaint, when it was made, who by and what action was taken to resolve it. This provides evidence of the nature of complaints received and is a tool for measuring the quality of the service. All staff receive training in adult protection during their induction period and attend annual updates. The staff spoken with demonstrated that they understood their roles and responsibilities for providing a safe environment for the residents to live and reporting any incidents of concern or bad practice. This was evidenced at the time of the visit when a senior was observed to intervene to calm a resident who had become anxious by the actions of an agency member of staff. This was reported to the manager who in turn was to raise her concerns with the contracting agency. Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 20 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, 23 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Glen Lee does well in ensuring the people who use the service are provided with a homely, clean and comfortable environment to live in. The people who use the service each have a room of their own which promotes their individuality and suits their needs. Glen Lee is a large home, but despite this it does well in ensuring a good standard of hygiene, however attention to tidiness in some areas is required. EVIDENCE: The annual quality assurance assessment (AQAA) tool stated under “What we do well” We do well to provide a spacious and suitable environment for our Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 21 service users needs, it permits them to walk freely around the living areas. This is an important priority to a person who has dementia, i.e. not to be closed into small spaces. The garden is large with free access to a sensory wood which has a pathway and handrails. There is a large laundry with specialist laundry machines used to meet disinfection standards and we have a dedicated team of housekeepers who work hard to ensure the home is clean, homely and free of odours. Southampton City Council Property Services Department support the home in managing repairs. This was tested by touring the home with the manager and speaking with residents and relatives about the homes environment. The manager demonstrated that she has a good awareness of the needs of people with dementia and the importance of having an environment that is planned and decorated to assist the residents to maintain their independence and move around their home as freely as possible, specific colours, textures and notices supports this. The manager has further ideas for improving the environment to stimulate residents’ awareness and wellbeing, such as utilising specific and unused areas of the home for reminiscence therapy. The manager is advised to tidy and clean current unused areas and avoid using them for storage of old and unwanted furniture. Some areas of the home have been newly decorated and new furniture purchased for bedrooms, providing a fresh and homely feel. Each resident has a room of his or her own that is personalised and reflects their individuality. At the time of touring the home unpleasant odours were detected and some areas of the home such as bedrooms had not been cleaned, a later visit to these areas demonstrated that the homes domestic staff work efficiently to maintain a clean and fresh environment. The home has a large separate industrial laundry managed by staff specifically employed to launder clothing and bedding, equipment used by the staff efficiently meets the needs and demands of the service. The home has good procedures in place for the prevention of cross infection and visitors are asked to use antibacterial hand gel prior to and when leaving the building. The staff are issued with uniforms and in addition wear disposable gloves and aprons when supporting residents with their personal care. Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 22 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 adequate. This judgement has been made using available evidence including a visit to this service. Glen Lee supports the people who use the service with skilled and competent staff, however staff vacancies and the use of agency are placing demands on the provision and standard of care the residents receive. The home uses corporate recruitment polices and procedures to safeguard the people who use the service from potential risk of harm, however better recording of required checks must be undertaken to demonstrate that staff are safe to work with vulnerable people. EVIDENCE: The annual quality assurance assessment (AQAA) tool stated under “What we do well” We do well to have 90 of staff with a national vocational qualification (NVQ) and who are provided with appropriate training including in house and Skills for Care induction training. We do well to have a staff team who are regularly commented upon for their dedication, and to ensure all staff are recruited using Southampton City Concils recruitment procedures which Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 23 includes promoting equal opportunities and only confirming new staff in post once CRB and POVA checks have been made. This was tested by observing staff practice, speaking with staff and the manager, veiwing staff recruitment and training records. It was established by speaking with the manager that the home currently has six care staff vacancies but that a recruitment drive is planned for September 2007 when it is hoped these vacancies will be filled. Until such time the home is using bank and agency staff. On the day of the visit the home had two care staff, two care coordinators and two agency staff in the morning and a similar ratio of staff in the evening. In addition to care staff the home has ancillary staff to carry out cleaning, laundry and cooking duties. Staff were observed working hard and demonstrating curtesy and respect for the residents. Despite evidence of staff being stretched they took time to engage with the residents and always had a smile for them. However the lack of competent agency staff places an extra burden on regular staff, especiaily when they are unable to engage appropriately with the residents and attend to basic needs. The manager must ensure agency staff are competent and skilled to carry out the responsiblities of the role they have been contracted to do. The manager stated in the AQAA that the home could do better: To recruit to fill vacancies to improve continuity of care for service users. This will be monitored during the next review of the service. The visit was undertaken partly with two senior carers who demonstrated confidnece and knowledge of the people they support as well as taking on the responsiblities of managing the shift, tending to the needs of the residents, answering queiries and managing staff. Both carers spoke of how they enjoyed their job, although hard at times and the satisfaction they get when the residents are comfortable and happy. Both carers have obtained a national voactional qualification (NVQ) level 3, one senior was also undertaking NVQ level 4, whilst having received mandatory traininig, supervisory management training and specific training to meet the needs of the residents. Four new staff training and recruitment files were viewed and demonstrated that staff undergo a comprehensive induction programme which includes mandatory training such as, fire safety and moving and handling and specifc Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 24 training such as dementia care. However the staff would benefit from specific training such as diabetes and Parkinsons. Glen Lee as with all Southampton City Council services has a human resource department that holds all original recruitment documentation centrally, however the manager must provide evidence that all staff have had the appropriate recruitment checks undertaken on them prior to commencing working in the home, such as criminal record bureau (CRB) and protection of vulnerable adult (POVA) checks. The files of four staff new to the home were viewed; poor completion of documentation (the annexe four form) in two files did not provide enough evidence that the staff had been recruited using the appropriate procedures. The manager was informed she must ensure that all records are up to date and ensure new staff have had all relevant checks before commencing in the home to safeguard the residents from potential risk of harm. Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 25 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 adequate. This judgement has been made using available evidence including a visit to this service. The people who use the service have their views and expectations considered when developing the home and in the main the home protects their health, welfare and safety. However the home must consider the risk it is placing the people who use the service and its staff at by not carrying out a thorough risk assessment of the premises and complying with requirements made by the Fire and Rescue Service. Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 26 EVIDENCE: The annual quality assurance assessment (AQAA) tool stated under “What we do well” we do well to have a manager qualified in NVQ3, NVQ4 care and 10 years experience in dementia care. A manager who is aware of Southampton City Councils polices and procedures and responsibilities, who is committed to improving services using a person centred approach including equality and diversity. The AQAA also states that it does well to hold regular service users meetings and providing them and professionals with questionnaires to review the quality of the service. To have good systems for managing service users finances and planning health and safety. This was tested by speaking with the manager observing practice, speaking with residents, staff and relatives and by viewing finance, quality questionnaires, health and safety and fire records. Two days prior to the visit to the home the manager was interviewed by the Commission for Social Care Inspection registration team to become the registered manager for Glen Lee. Through discussion and observation the manager appeared dedicated and keen to improve and build on the quality of care provided to the residents. A good rapport with residents and staff was observed and the manager was aware of what was happening in the home. Staff and relatives spoke highly of the manager and her contribution to the running of the home. A relative said: “The manager is lovely and very approachable”. A member if staff said: “The manager is very supportive and aware of what’s going on”. Some residents were aware of who the manager was and one jokingly called her “the boss”. The home undertakes quality reviews of the service to seek the views of the residents, relatives, staff and health care professionals. A recent quality review demonstrated that on the whole people are happy with the service, however the manager must review the information to establish and celebrate good work and develop a plan to action areas in need of improvement. Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 27 The home is visited monthly unannounced by a senior manager for Southampton City Council, (Regulation 26 visit), this is also to review the quality of care provided the residents. Residents spoken with at the time of the visit and those who could comprehend what was being asked of them appeared happy with the care they are receiving. Two sets of relatives spoken with at the time of the visit said they were very happy with the service. A relative said: “This is a very good home they cater for my dads needs very well” The home has very good systems for supporting residents with their finances, each resident has an individual account set up by Southampton City Council (SCC) where a very good audit trail of monies received and paid is kept. This is the responsibility of the homes administrator overseen by the homes manager. The home can demonstrate that all care staff have received training in health and safety, including first aid, moving and handling and fire safety. The senior responsible for fire safety keeps good records of staff training, weekly and monthly checks on fire safety equipment and topics covered in training sessions. However the home has again failed to meet the requirement made in 2005 by the Fire and Rescue Service to fit emergency lighting to external fire exits and carry out a fire risk assessment on the building. The failure to comply with these requirements potentially places residents at risk; therefore a requirement will be issued requiring the manager to request another visit from the Fire and Rescue service to carry out another review of the service. Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X X X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 29 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement The people who use the service must have their needs fully assessed and clearly documented to inform the staff and the care plans. All risk assessments in care plans must be reviewed to ensure that they identify any individual risk to the service user and must provide clear information for staff on how identified risks can be minimised. This is a repeated requirement from the last inspection dated 13th February 2007. 3 OP9 13(2) The people who use the service and who need “as required” medications must have clear and specific care plans in place to inform staff when the medication must be given. This is a repeated requirement from the last inspection dated 13th Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 30 Timescale for action 31/08/07 2 OP7 13(4)(a) (b) & (c) 31/08/07 31/08/07 February 2007. 4 OP34 19 To safeguard the people who use the service from the potential risk of harm the home must demonstrate that appropriate checks have been undertaken on staff prior commencing working in the home. To safeguard the people who use the service from the potential risk of fire the home must contact the Hampshire Fire and rescue service in respect of external emergency lighting. To safeguard the people who use the service from the potential risk of fire the home must contact the Hampshire Fire and rescue service to carry out and assessment of the building. 31/08/07 5 OP38 23(4) 31/08/07 6 OP38 23(4) 31/08/07 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 OP19 Good Practice Recommendations The manager is advised keep unused areas of the home clean and free from unwanted and unused furniture. It is recommended that the manager requests to know the qualification and skills of agency staff she is contracting for vacant shifts to ensure the needs of the people who use the service are appropriately and confidently met. OP27 Glen Lee DS0000039231.V341047.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. 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