Inspection on 13/02/07 for Glen Lee

This inspection was carried out on 13th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 12/07/07

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 Michael Gough Unannounced Inspection 13th February 2007 10:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Glen Lee DS0000039231.V327132.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.V327132.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 Position Vacant Care Home 34 Category(ies) of Dementia - over 65 years of age (34) registration, with number of places Glen Lee DS0000039231.V327132.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 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. Glen Lee is not designed as a secure provision for persons suffering from dementia or to care for persons assessed as having nursing needs. Fees at the home are currently £434 per week and service users are responsible for paying for their own toiletries, hairdressing, chiropody and items of a personal or luxury nature. Glen Lee DS0000039231.V327132.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the evaluation of the quality of the service provided at Glen Lee and takes into account the accumulated evidence of the activity at the home since the last inspection, which was carried out on 5 September 2006. The inspection took into account the homes pre inspection questionnaire; and comment cards received from 9 service users, 3 members of staff and 3 health care professionals. An unannounced site visit to the home took place on the 13 February 2007. During the site visit the inspector had the opportunity to tour the home, read and inspect records and also observe the interaction between staff and service users. It was not possible to gain the views of people living at the home on this occasion, however the inspector did have the opportunity to speak with 4 members of staff. The homes manager assisted the inspector throughout the visit. The home is registered to provide support for 34 service users but at the time of the inspection there were 31 service users living at the home. What the service does well: Staff at the home treat residents with dignity and respect and service users have access to a full range of healthcare support. Meals in the home are good and offer a choice at meal times and there is a varied diet, which includes vegetarian options at all meals. Visitors to the home are made welcome and there is a flexible visiting routine. There are a range of varied activities and staff offer support to enable service users to take part. The home was commended for supporting staff to obtain recognised qualifications and all of the staff employed by the home have either achieved or are working towards National Vocational Qualifications. They are committed to their role and work well together as a team. Glen Lee DS0000039231.V327132.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The inspection report will make 6 requirements to the home, which will help improve the service provided for residents. It is acknowledged that some of the issues that require improvement are in the process of being implemented, however until such times as they are fully in place, they will remain as requirements. However realistic timescales have been given for these to be fully completed. Care plans have been updated but review notes do not provide clear evaluation of how the care plan is working for the service user and these should give information on service users progress and also give information to indicate if there are any changes to the care plan. Risk assessments in care plans are not individualised, they contain risk assessments for some service users but the care plan does not indicate any risk exists, where risk assessments are in place they do not provide clear information for staff on how identified risks can be minimised. At present the home is waiting for the new up to date medication policy and procedure, therefore there are no clear guidelines in place and there is no clear information for staff with regard to administering any “when required” medication. Also medication administration records are not always clear and do not always state the actual dose of medication administered each time it is given. Glen Lee DS0000039231.V327132.R01.S.doc Version 5.2 Page 7 A major cause for concern is the situation regarding the 3 service users rooms that are situated in the day service area of the home, despite requirements being made at 3 previous inspections and also the serving of a statutory enforcement notice the problem has not been fully resolved. There is access to the rooms via a back staircase, but this is unacceptable, as this would present some problems to certain service users. Normal access is via a doorway on the ground floor and a keypad lock is used to restrict access to service users who may wander, however it also restricts those service users with rooms in this area from free access to their bedrooms during the day. It is understood that lockable bedside cabinets are currently on order and that these will be delivered shortly, however until such times that they are in place it will remain a requirement for lockable storage to be available in all service users rooms. A visit by a fire officer highlighted that emergency lighting should be provided at external fire exits and this has not yet been carried out. His report also stated that a new fire risk assessment was needed. This had not been carried out at the time of this inspection and the last fire risk assessment available in the home was dated 10 May 2004. 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.V327132.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.V327132.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): 2, 3 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each service user has a written contract and has the terms and conditions of the home and no service users move into the home without having their needs assessed. The home does not provide intermediate care. EVIDENCE: The inspector viewed contracts for service users and these contracts were clear and gave details of the room to be occupied, the fees payable and by whom and detailed the rights and obligations of the service user and the provider if there was a breach of contract. There was information stating the fees would increase annually and informed service users that they would be notified in advance of any changes to their fees. Contracts were signed by someone from the home and also by the service user concerned or a representative. Where contracts had not been signed there was information giving an explanation why this had not taken place. Glen Lee DS0000039231.V327132.R01.S.doc Version 5.2 Page 10 The home carries out an individual needs assessment prior to service users moving into the home and there is a clear admission process and assessments were on file at the home and were looked at for the 3 service users case tracked. Assessments were made using a needs assessment form and service users were visited before they moved into the home. Care management assessments were also on file. Intermediate care is not provided at the home. Glen Lee DS0000039231.V327132.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users health, personal and social care needs are set out in a plan of care and staff have the information they need to provide the support that service users need and in the way they prefer. Regular reviews are undertaken but review notes do not provide clear evaluation of how the care plan is working for the service user. Risk assessments in care plans are not individualised and do not provide clear information for staff on how identified risks can be minimised. Medication procedures require some amendments and at present there is no up to date policy and procedure in place and there is no clear information for staff with regard to administering any “when required” medication and medication administration records are not always clear. The health care needs of service users are met and service users at the home are treated with dignity and respect. EVIDENCE: Care plans were inspected for 4 service users and these had recently been updated and it was clear that a lot of work had been undertaken to update all of the care plans in the home. Care plans were simple and easy to follow and Glen Lee DS0000039231.V327132.R01.S.doc Version 5.2 Page 12 gave staff clear guidance on how care should be delivered. Care plans were regularly reviewed however, review notes did not provide any information on how the care plans were working for the service user and they require more information and evaluation and they should provide information on any progress of lack of it as the case may be. There were some risk assessments in place but these were not geared to the individual. Some care plans had risk assessments in place when the care plan clearly stated that there was no risk identified. The issues of risk assessment were discussed with the manager and the home needs to review all of its risk assessments for service users and ensure that they provide clear information on any identified risk and that they must also give clear information on how staff can minimise any risk identified. Service users at the home are registered with a number of different GP surgeries and they may keep their own GP if possible. The district nurse services are provided by one of the surgeries and other health care professionals are arranged through GP’s & district nurse referrals. A specialist from a local hospital visits once per month to assess service users health and to review medication. Dental care is arranged through a local health centre and a visiting optician calls once per year. The home also has a visiting chiropodist who calls on a regular basis. Service users who completed questionnaires all stated that they were well cared for and that staff were aware of their needs. Medication procedures at the home have been reviewed and all staff who are authorised to administer medication receive appropriate training. The home is waiting for an updated policy to be approved and sent to the home. The inspector informed the manager that she would need to have an “in house policy” which gave details of the actual procedures carried out in the home and this could be used in conjunction with the organisations policy. The home uses a monitored dose system provided by a local pharmacist and there are clear routines in place for the receipt storage and disposal of medication, however the home does not have a protocol for administering “when required” medication and this must be put in place. Medication administration recording was inspected and these were generally sound, although where instruction on the medication administration record sheet stated 1 or 2 tablets to be given there was no information recorded on how many tablets had been given each time they were administered. Staff were observed interacting with service users appropriately and they were seen to treat service users with dignity and respect. Staff were heard to use service users preferred form of address when talking to service users and staff were seen to knock on service users doors before entering. Glen Lee DS0000039231.V327132.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is Adequate. This judgement has been made using available evidence including a visit to this service. The home provides a range of activities for service users, which meet their expectations and the religious and recreational interests of service users at the home are provided for. Service users are able to maintain contact with family and friends and visitors are welcome at any time. Generally service users are supported to exercise choice and control over their lives as much as possible, however the situation regarding free access to service users accommodated in the 3 bedrooms in the day service area of the home has not been fully resolved. Service users are provided with a balanced diet in pleasant surroundings at time convenient to them. EVIDENCE: 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, 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 service users 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 Glen Lee DS0000039231.V327132.R01.S.doc Version 5.2 Page 14 support service users to participate. The manager is hoping to raise money to buy a mini bus, which would allow for more spontaneous trips out into the community. Comments cards seen by the inspector from service users and information from previous inspections indicated that service users are happy with the activities provided at the home. The home has a clear visitors policy and there are no set times, visitors sign in at the home and the visitors book is kept in the hallway, the inspector checked the visitors book and there is a regular stream of visitors to the home. Residents were observed to be free to choose where and how they spent their time and there were no restrictions imposed upon them, however two previous reports have highlighted that there are three bedrooms that are not accessible to service users during the day because they are in the same area as the day centre, which is locked off from the main home. This issue was discussed with the homes manager and the situation has not been satisfactorily resolved, there is access to the rooms via a back staircase, however this is not acceptable, as this would present problems to certain service users who have dementia. Normal access is via a doorway on the ground floor and this is controlled by a keypad lock. This is to stop some of the service users who may wander from entering the day service, however it also restricts those service users with rooms in this area from free access to their bedrooms and also all of the other facilities in the home. The door is kept secured between the hours of 0930 – 1600; outside these hours there is free access to this area. The inspector observed staff supporting service users and it was clear that service users were able to make informed choices and are able to control their own lives as much as possible. A number of service users had brought some of their own possessions into the home and some bedrooms had been personalised. The home operates a five-week rolling menu and it appeared that service users were very happy with the food provided by the home. They have previously stated that the food was plentiful and good. Service users are offered a choice at meal times and there is also a vegetarian option at all meals. Service users are encouraged to eat their meals in the dining room but may eat elsewhere if they prefer. The inspector observed lunch being taken in the dining room and meals were unhurried and staff provided suitable support for service users if needed. Glen Lee DS0000039231.V327132.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a simple, clear and accessible complaints procedure, which includes timescales for the process and any complaints are logged and responded to appropriately. The homes policies and procedures protect service users from any form of abuse. EVIDENCE: The home has a clear complaints procedure, which contains all of the required information and there is a complains log where any complaints made to the home are recorded, together with the actions taken to investigate and the homes response. Service users spoken with at previous inspection and comment cards received indicated that they were confident about raising any concerns they may have. Staff members spoken to were aware of the complaints procedure and said that they would support any service user to make a complaint if they wished to do so. Staff have received training on adult protection and the home has a whistle blowing policy and also a copy of the Hampshire Adult Protection procedure. Staff spoken to were aware of their responsibilities in this area and knew what to do should they suspect any form of abuse had taken place. Glen Lee DS0000039231.V327132.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally service users live in a safe and well-maintained environment and have access to comfortable indoor and outdoor facilities. Service users are provided with the specialist equipment they require and generally bedrooms are safe and comfortable, however further improvements are necessary to comply with the National Minimum Standards. The home was clean, pleasant and hygienic and free from offensive odours. EVIDENCE: The inspector toured the building and this included all communal areas of the home including bathrooms, toilets and lounges. The kitchen and bedrooms were also inspected. All areas of the home were clean and tidy and furniture was in a good state of repair. A great deal of work has been carried out in the home to improve the appearance and fabric of the home. Improvements have been made since the last inspection and items of furniture and some carpets have been replaced and all bedrooms had been decorated. The inspector was informed that the home had used a specialist with experience in shades and Glen Lee DS0000039231.V327132.R01.S.doc Version 5.2 Page 17 colour for people with dementia to be involved in this process. All of the bedrooms seen had vinyl flooring and there were pictures on the walls and some service users had their own belongings and some rooms had been personalised. All rooms had new bedspreads and all had curtains or blinds on windows. Call bells were available to service users and bedside cabinets and lighting were satisfactory and the inspector was informed that further work to improve the bedrooms is due to commence in the next 2 weeks. Service users at present still do not have lockable storage in their rooms. The manager explained that new bedside cabinets were on order for all of the bedrooms and these had lockable drawers, she expected these to be delivered in the next few days. It is acknowledged that action is being taken to address this issue, however until they are provided, it will remain a requirement for lockable storage to be available in all service users rooms. Infection control procedures were observed to be followed and antiseptic gel dispensers were situated around the home. The laundry at the home contains 2 industrial washing machines and 2 industrial tumble driers and the home employs dedicated laundry and domestic staff and suitable protective equipment is provided. The home was clean pleasant and hygienic with no unpleasant odours. Glen Lee DS0000039231.V327132.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staffing numbers and the mix of staff currently meets the needs of service users. Staff morale was good and there was a good rapport between service users and staff. Service users are protected by the homes recruitment procedures and the home provides training for staff to enable staff to support service users effectively. EVIDENCE: The homes staff rota was examined and this showed that the home provides 2 senior staff members plus 5 carers between 0730 – 2130 and between 2130 – 0730 there is 1 senior staff member and 2 other care staff members awake throughout the night. Staffing numbers were discussed with the homes manager and the inspector was told that at present she felt that staffing levels were sufficient. However she will continue to monitor staffing levels based on service user needs. The home employs a total of 29 staff, and of these 29, 27 already hold or are working to achieve National Vocational Qualifications and the home was commended for supporting staff to obtain recognised qualifications. The home has policies and procedures in place with regard to recruitment and staff recruitment records were inspected for 3 staff members, these contained all of the required information including 2 x references and POVA/CRB checks. Glen Lee DS0000039231.V327132.R01.S.doc Version 5.2 Page 19 The inspector discussed staff training with the manager and she stated that there is a clear induction for new staff and this induction is carried out at a local college, mandatory training is carried out in adult protection, fire safety, moving and handling, first aid, COSHH and dementia training. Southampton County Council has a training co-ordinator and there is a rolling programme of training that is available for staff and this includes: health and safety, communication, reporting and recording, mental capacity act, challenging behaviour and diversity. Senior staff undertake medication training and complete a full four-day first aid course. Staff training records were inspected and these were kept in individual staff files and those seen showed that staff were provided with the training required to enable them to support service users effectively. Glen Lee DS0000039231.V327132.R01.S.doc Version 5.2 Page 20 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, 37 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management arrangements in place at the home are generally satisfactory, although the manager has only recently been permanently appointed and in due course will need to formally apply to be registered with the Commission for Social Care Inspection. Quality assurance procedures are in place and service users financial interests are protected by the homes policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. The health, safety and welfare of service users and staff are not always protected by the arrangements in the home and service users could be at risk from the fire risk assessment for the building being out of date and from some of the requirements from the fire officers inspection not being completed. Glen Lee DS0000039231.V327132.R01.S.doc Version 5.2 Page 21 EVIDENCE: The management arrangements in place at the home are satisfactory and the manager has been running the home in an acting capacity since July 2006 and has recently been appointed permanently, she is currently undertaking the Registered Managers Award and has NVQ4 in care. In due course she will need to formally apply to be registered with the Commission for Social Care Inspection. The homes manager stated that satisfaction surveys have been sent out to relatives, GP surgeries, district nurses and to service users and these are currently being collated and results will be published. She stated that she intends to undertake regular quality control audits. Financial arrangements in the home remain unchanged from previous inspections and the home does not manage any of the resident’s monies. The local authority manages these in individual accounts and the manager receives a statement every month for all service users as to the balance they have in the account. Records in the home were kept secure and photographs of service users and staff were available in the home. Health and Safety policies are in place and available to all staff members and staff have undertaken training in health and safety. The home pre inspection questionnaire indicated that annual servicing survey of fire alarms system and fighting equipment was carried out on 6/12/06, boilers and gas installation December 2006, electrical wiring in March 06, hoists and lifting equipment on 26/9/06 and the lift was serviced on 5/10/06. The fire log was inspected and all relevant training and testing is carried out within the specified timescales. All service users and staff spoken to were happy with the health and safety arrangements in the home. A visit by a fire officer highlighted that emergency lighting should be provided at external fire exits and this has not yet been carried out, however the inspector was informed that this issue would be rectified when the electrical contractors carried out their work in the next 2 weeks. It was also indicated that a new fire risk assessment was needed. This had not been carried out at the time of this inspection, the last fire risk assessment being dated 10 May 2004. Glen Lee DS0000039231.V327132.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 1 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 3 X 2 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X 3 2 Glen Lee DS0000039231.V327132.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation Reg. 15 (1) (2) Requirement Monthly reviews of service users care plans must provide clear evaluation and give information on service users progress and must reflect if there is any change in the service users needs. 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. The home must ensure that there are clear policies and procedures in place with regard to medication issues in the home, these policies must include clear information for staff for the administration of “when required” medication so that staff have clear guidance and know in what circumstances medication should be given and the procedures they should follow. DS0000039231.V327132.R01.S.doc Timescale for action 02/04/07 2 OP7 13(4)(a) (b) & (c) 16/04/07 3 OP9 13 (2) 02/04/07 Glen Lee Version 5.2 Page 24 4 OP14 12(1) (a) (b), (2), (3), (4) This is a partial repeat requirement from the inspection to the home carried out on 5/9/06 The three rooms situated in the day centre area must be made available to the residing service users throughout the day. This is a repeat requirement from inspections to the home carried out on 5/5/05, 14/10/05 and 5/9/06 Service users must be supplied with secure lockable storage in their rooms. This needs to be appropriate to their needs. This is a repeat requirement from the inspection to the home carried out on 5/9/06 Evidence must be provided that the requirements regarding emergency lighting at external fire exits and for a new fire risk assessment to be carried out, which were made during the fire officer’s inspection of the home have been completed. This is a partial repeat requirement from the inspection to the home carried out on 5/9/06 28/02/07 5 OP24 16(2)(c) 02/04/07 6 OP38 13 & 23(4)(a) 16/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Glen Lee DS0000039231.V327132.R01.S.doc Version 5.2 Page 25 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. Extracts may not be used or reproduced without the express permission of CSCI Glen Lee DS0000039231.V327132.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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