Inspection on 14/10/05 for Glen Lee

This inspection was carried out on 14th October 2005.

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 12/07/07

Glen Lee 13/02/07

Glen Lee 05/09/06

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 Jan Everitt Unannounced Inspection 14th October 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Glen Lee DS0000039231.V254740.R01.S.doc Version 5.0 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.V254740.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Glen Lee Address Wavell Road Bitterne Southampton Hampshire SO18 4SB 023 80473696 023 8047 3764 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.V254740.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th May 2005 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. Glen Lee DS0000039231.V254740.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 14 October 2005. This was the second inspection for the inspection year of 2005/6 and Mr. David Shepherd, the registered manager and a care coordinator assisted the inspector throughout the process. The inspection took place over a period of 4.5 hours. The inspection focused on the requirements made from the last inspection in May 2005 and looked at the remaining core standards to be assessed during this inspection year. Seventeen standards were assessed, eleven of which met the standards and six being identified as having minor shortfalls. The requirements from the previous inspection that have not been fully complied with have been discussed with the operational manager. The inspector toured the building and spoke with several service users and staff. The service users spoken with reported to be happy living in the home. The atmosphere in the home was happy and that of a team that work together well. The agency staff on duty at the time were familiar with the home and the service users needs. The ethos and overall care and services delivered in the home were good and staff displayed a caring attitude to the service users. The inspector viewed a sample of records and documentation. What the service does well: What has improved since the last inspection? Glen Lee DS0000039231.V254740.R01.S.doc Version 5.0 Page 6 The medication policy is now in place and available to all staff members. The manager has maintained a copy of the recruitment information as stated in Schedule 2 of the Care Home Regulations of a newly employed carer, which is held by the human resource department. He reported that he would, in the future, photocopy all documentation so that it is available for inspection. Thermostats have been fitted to all hot water outlets that service users have access to. 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 Glen Lee DS0000039231.V254740.R01.S.doc Version 5.0 Page 7 contacting your local CSCI office. Glen Lee DS0000039231.V254740.R01.S.doc Version 5.0 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.V254740.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not assessed on this occasion. EVIDENCE: Glen Lee DS0000039231.V254740.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 The service users’ health and personal and social care needs are set out in care plans and are being met. Service users are protected by the home’s policies and procedures for dealing with their medication. Service users’ privacy, dignity, independence, rights, fulfilment and choice are upheld in this home in general. EVIDENCE: The inspector viewed a sample of care plans. A comprehensive pre-admission assessment is undertaken and is followed through on admission. The assessment tool covers the activities of daily living from both a physical and psychological perspective and from this, needs are identified and care plans written to guide practice. Risk assessments are undertaken on all service users. The care coordinator assisting the inspector reported that much of the information about the service user is gained from the relatives as most of the service users have a degree of mental frailty. The care plans are not consistently reviewed monthly but in general they are detailed and relevant to the clients. Nutritional assessments are undertaken but in one sample of care plans viewed, the assessment identified the service user as being at risk but no Glen Lee DS0000039231.V254740.R01.S.doc Version 5.0 Page 11 weight chart could be evidenced as part of the monitoring process to address the risk. The inspector observed that a number of service users’ plans were all together in one large file. This was discussed with the manager who reported that he was attempting to centralise all the documentation. The inspectors view was that with so much paperwork in one file the carers would be less inclined to read them and use the documents to inform their practice. A recommendation will be made that each service user has their own file and these be maintained in a separate cupboard in the office area and carers to be encouraged to use the documents and also to record outcomes from the care delivered. The coordinator reported that district nurses do attend the home to meet any nursing needs any of the service users have, such as pressure ulcers, catheter care. The primary health team will provide specialist equipment should it be assessed as necessary. Health professionals such as chiropody, dentist and opticians visit the home regularly and the manager reports that he monitors the frequency of the visits to ensure all service users receive these services appropriately. The manager reports that the psychogeriatrician visits the home monthly to attend a multidisciplinary meeting at which time residents’ management of care is reviewed. The new medication policy is now in operation. The senior care coordinators are trained to order, receive, administer medications and return of medication. The inspector viewed the medication trolley and the records. The monitored dosage system is used in the home. The cupboards did not evidence over stocking of medications and lotions. The MAR sheets were viewed and demonstrated that medication was being signed for appropriately. The inspector observed part of a drug round and correct procedures were being followed. The inspector did observe that the medicine room had a need to be tidied and organised. The inspector observed how carers interacted with the service users and these observations demonstrated that the staff treat service users with respect and are courteous and that they are aware of the core values of care. The core values of care and the practices that underpin them are discussed and are part of the induction programme. This programme is undertaken partly at the City College and is the TOPSS induction programme. Those service users spoken with were complimentary about the services in the home and how they are cared for. The requirement from the previous inspection with regards to facilities for service users to use a telephone in private has been discussed and plans are in place to create this facility within a visitors room that is to be converted from a store room in the coming year. Glen Lee DS0000039231.V254740.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 14 Service users expectations and preferences of how they wish to spend their days and recreational interests are not consistently recorded in care plans and not always met. The service users are able to maintain contact with family and friends and within the local community if they wish. Service users are helped to make choices and maintain control over their lives for as long as possible and within the constraints of the home. EVIDENCE: There is no structured programme of activities within the home; the care coordinator described it as ‘ad-hoc’. She reported that every afternoon a game or a quiz takes place. Service users are given the choice of whether to participate or not. It was observed that the social history of service users is not always recorded and therefore previous interests and hobbies are unknown. The coordinator reported that she is aware that interests are not recorded and she is endeavouring to improve this. The coordinator reported that activities are adapted to make them more appropriate to the client group. The home has a very involved, proactive relatives group that organise parties and the festive events throughout the year and these are always well attended. The church group attend the home and the vicar attends the home monthly for a service or service users may visit community churches if they Glen Lee DS0000039231.V254740.R01.S.doc Version 5.0 Page 13 are able. She also reported that the home is trying to obtain the services of the mobile library. The inspector did not observe activities during this visit. Service users are given autonomy and choice as to how they undertake the activities of daily living. A service user spoken to confirmed that he could wander about and do as he pleased around the home. The service users in the home are not generally able to manage their own financial affairs and the manager reports relatives usually undertake this. The previous report highlighted that the three rooms 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, must be made available to those service users at all times. This has been deemed as unacceptable and restrictive to these service users choices of visiting their rooms during the day. This has been further discussed with the operational manager. Most service users were observed to be sitting in the lounge areas around the reception entrance. Service users have access to an advocate, which is usually a care manager, should they need representation. The home has an open visiting policy and the visitors’ book demonstrated that visitors attend the home daily. The ladies from the church also attend the home. Service users are able to entertain their visitors in their own rooms or one of the small private lounges on the first floor. Glen Lee DS0000039231.V254740.R01.S.doc Version 5.0 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Service users and their relatives and friends can be confident that their complaints will be listened to and acted upon. EVIDENCE: The complaints policy flow chart was observed on the manager’s office wall. It detailed the trail of how to make a complaint and if not satisfied to whom you direct it at the next level. It appears a complex trail and does not mention the CSCI as an integral part of the process. The service user information booklet that is available readily in the home and is on display around the home, directs service users/relatives how to make a complaint. Again it does not include the name, address and contact number of the CSCI. The National Care Standards Commission, now discontinued, is quoted in the back of this booklet as a ‘useful contact number’ and there it quotes the address and phone number. This will be discussed with the operational manager. Glen Lee DS0000039231.V254740.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 25 26 Service users live in a safe and well-maintained environment. The home is clean and hygienic. EVIDENCE: The home is clean and homely. The manager reports that all beds have been replaced since the last inspection. The manager reports that the plans for further alterations to relocate the offices and medical room remain in draft only. An extensive redecoration programme took place in a number of rooms last year and although the colours are vibrant, the manager reports that service users can familiarise themselves with their own area. The carpet in the reception area is in need of replacing and the inspector observed the housekeeper attempting to shampoo this on the day of the visit. The home has a pleasant enclosed garden and grounds in which service users can wander safely. The manager reported that thermostats have now been fitted to all hot water outlets used by service users. Glen Lee DS0000039231.V254740.R01.S.doc Version 5.0 Page 16 The laundry was visited by the inspector who found it to be clean and well organised and fit for purpose. The inspector observed that call bell points were attached to bedside cupboards and were at times not positioned well. The manager reported that he was putting forward that call bell points be repositioned to enable more flexibility with where furniture can be positioned. Glen Lee DS0000039231.V254740.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 & 29 Staffing levels are maintained appropriately and care is delivered by a caring responsive staff with adequate skills and training. Service users are supported and protected by the council’s recruitment practices. EVIDENCE: The staff rotas were viewed and demonstrated that sufficient staff were on duty during the day to meet the needs of the service users who were in residence at the time of the inspection, but this needed to be reviewed should dependency levels rise. There are two waking carers and one coordinator on duty during the night. This was discussed with the manager as to the frequency of the coordinator needing to be disturbed and whether there was an indication for a third waking care staff. The manager reported that this is under discussion with the management. It was observed that agency staff attend the home frequently and the manager reported that the home is actively trying to recruit into their vacant positions and that a recruitment day is planned for all local authority homes. The agency staff that attend the home are familiar with the home and are the same staff continuously if feasible. The home was observed to be clean but there is no housekeeping staff after 1400. The manager reported that he is trying to recruit another housekeeper to bring the numbers to a full complement of housekeeping staff. A sample of one recently employed carer’s recruitment file was viewed. This demonstrated a robust process with references, CRB and POVA clearance being obtained before employment commenced. Historically all recruitment files and Glen Lee DS0000039231.V254740.R01.S.doc Version 5.0 Page 18 records are maintained at the human resource department in the local authority office and have been unavailable for inspection. A requirement from the last inspection to have these records made available was made. The manager now reports that as each new member of staff is recruited he photocopies all the documentation to maintain in the home and to be made available for inspection. The manager reported that he is involved with the recruitment process and undertakes all of the interviews, for which notes are maintained. The home is endeavouring to employ 50 of care staff that are NVQ level 2 trained. Various staff have gained NVQ levels 2, 3 and 4. The manager reports that it is difficult to maintain 50 of staff trained at this level because as staff leave there is a gap before other staff can be trained. At the time of the inspection a further 5 staff had commenced NVQ at levels 2, 3 and 4. Glen Lee DS0000039231.V254740.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35, 36 & 38 The home provides the service users with a safe environment but fails to seek the views of the service users and their relatives about the quality of the services delivered in the home. The home does have systems in place to safeguard service users from potential financial abuse. EVIDENCE: The appointed person visits the home monthly to undertake a tour of the building and to examine a sample of records and audit various aspects of the home and to speak with service users. A copy of the report is then written and forwarded to the CSCI. The manager is involved with the audits undertaken in the home in relation to the financial aspects, but reports that he does not send out questionnaires or seek the views of service users and relatives in a more structured way other than being available to speak with them on a day-to-day Glen Lee DS0000039231.V254740.R01.S.doc Version 5.0 Page 20 basis. A requirement will be made form these findings. The home has corporate policies and procedures in place provided by the local authority. The home does not manage any of the service users’ 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. The manager maintains a float in the home for sundries that service users may request or need. An invoice and a receipt are then forwarded to finance department for reimbursement. Staff are provided with training in all aspects of Health and Safety and records were available to support this. The servicing certificates were viewed for the gas boiler, the electrical appliance testing and the hoist and were in order and current. Servicing certificates for other systems were in a locked cupboard in the boiler room, to which the manager does not have access. The situation with regards to the manager not having access to these, for inspection, remains under discussion with the operational managers of the local authority homes. The kitchen was visited and was found to be clean and well organised. Glen Lee DS0000039231.V254740.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 3 X X X X X 3 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 X X 2 X 3 X X 2 Glen Lee DS0000039231.V254740.R01.S.doc Version 5.0 Page 22 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 Timescale for action 31/01/06 2 OP12 Reg. 16(2)(n) (m) 3 OP14 Reg 13(2)(3) 4 OP16 Reg 33 (7) Care plans must be reviewed monthly or to reflect any change in the service users’ needs. Care plans must reflect the social needs appropriate to individual service users and to include a social history. A programme of activities must 31/01/06 be demonstrated that is appropriate for the client group taking into account their past social history, their wishes and feelings. Care plans must reflect what activities they have participated in and the degree of interaction within the group. The three rooms situated in the 31/12/05 day centre area must be made available to the residing service users throughout the day. This was a requirement from the previous inspection report of 04/05/05 with a time scale of 30/06/05. The complaints policy must 31/12/05 identify the address and contact number of the CSCI in the procedure for making complaints. DS0000039231.V254740.R01.S.doc Version 5.0 Glen Lee Page 23 5 OP19 Reg 23(2)(b)( d) 5 OP33 Reg 24 (1) 6 OP38 Reg 23(4) Old and worn carpets must be 31/12/05 replaced in the reception area of the home. This was a requirement from the previous inspection of 04/05/05 with timescale for an action plan for when this was to take place by 31/07/05 A service user/family & friends 31/01/06 satisfaction survey must be undertaken periodically to ascertain the views of the service users and families to ensure the home is meeting the aims and objectives of the home. The results of this should be published and made available to service users and families. You are required to make 31/12/05 available for inspection the records of the servicing of systems within the home. This was a requirement from the previous inspection report of the 04/05/05 with a timescale given 31/07/05. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations It is strongly recommended that care plan documentation be maintained in individual service users’ folders and be stored for easy access for care staff. Glen Lee DS0000039231.V254740.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 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.V254740.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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