Inspection on 05/05/05 for Glen Lee

This inspection was carried out on 5th May 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 14/10/05

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 SO18 4SB Lead Inspector Jan Everitt Unannounced 5 May 2005 9:30 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 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 Version 1.10 Page 3 SERVICE INFORMATION Name of service Glen Lee Address Wavell Road, Bitterne, Southampton, Hampshire, SO18 4SB Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 023 80473696 023 8047 3764 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 Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 18/10/04 Brief Description of the Service: Glen Lee is a purpose built 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 over two storeys and was built in 1964 and offers accommodation in 34 single bedrooms with a lift acces to the first floor. Glen Lee provides care and support for people over 65 years of age with dementia. A community day centre operates from an area of the home that offers respite service and is run by Southampotn Care Association. The building is detached in its own grounds and gardens with a housing estate surrounding the property. Garden furniture is placed on a covered patio area , which is used as the service users smoking area but can also enable service users to enjoy the garden in finer weather. Glen Lee is not designated as a secure provision for persons suffering from dementia or to care for persons assessed as having nursing needs. Glen Lee Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of Glen Lee took place on the 4 May 2005. The registered manager Mr. David Shepherd assisted the inspector throughout the day with the inspection process. The CSCI regulation manager for Glen Lee, Mr. Andrew McMullen attended the home for part of the inspection programme. The inspection focused on a number of the environmental requirements made from the last inspection. 16 standards were assessed on this occasion, 13 of which were core standards to be assessed within the inspection year. The inspector spent a considerable part of the day touring the building and talking with service users, relatives and staff. Comments received from service users and a relative were very positive. Staff spoken with reported an improvement in the management of the home with increased staffing levels and that they felt supported within their roles. A sample of records and documentation were also inspected. The inspection concluded that of the 16 standards assessed, 7 were met, 6 had minor shortfalls and 3 had major shortfalls, one for which the manager received an immediate requirement for action. The ethos and overall quality of care within the home was good and staff displayed a caring attitude to the service users. What the service does well: What has improved since the last inspection? An efficient system has been set up by the senior officer in charge for the ordering, receipt, safe storage and disposal of medication. Glen Lee Version 1.10 Page 6 The small lounges on the first floor have been refurbished and are now being used by the service users. Redecoration of walls, doors and paintwork in most areas of the home has been completed. Staffing levels have improved. Domestic staff will be available in the home every afternoon to ensure a full domestic service for the home throughout the day. All staff have received training in Dementia care and this is ongoing for all new staff. Staff reported feeling more settled and well supported with the new management. The care planning system is centralised into individual folders. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Glen Lee Version 1.10 Page 7 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 Standards Statutory Requirements Identified During the Inspection Glen Lee Version 1.10 Page 8 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 standard(s) 3 Service users’ needs have been assessed before being admitted to the home and therefore assured that theses will be met. EVIDENCE: All assessments of potential service users are undertaken by care managers who liaise with the manager of the home. A service user plan is formulated from the information gathered by the care manager from service users and their carers. The assessment tool used by the care managers identifies all aspects of social and health care. Service users are admitted mostly from their own homes or the hospital environment. Glen Lee Version 1.10 Page 9 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 standard(s) 7, 9 & 10 Service users health, personal and social care needs are set out in their individual care plans. The procedures for dealing with the administration of medication is not consistently adhered to. The home has no medication policy to guide practice. The core standards of privacy, dignity, independence, rights, fulfilment and choice are upheld in this home in general. EVIDENCE: All service users have care plans identifying their needs that inform the practices in the home. All information that is detailed in Schedule 3 of the Care Home Regulations is maintained in the service users’ files which are stored in the staff office. A sample of three service user’s plans were viewed. The care manager undertakes assessments and they form the basis of personal records. A further assessment is undertaken on admission to the home. The respite care clients admission process is similar. The care plans are based on the activities of daily living and detail the level of care the service user needs and action to take to overcome specific problems, these are mainly reviewed monthly. The quality of information is improving Glen Lee Version 1.10 Page 10 with a new care planning system in place. All new staff need to be trained in the effective use of care plans. The manager reported that it is not always possible for service users to sign care plans but that their representative/relative may do so as evidence of their participation and agreement to the planned care. The inspector found it difficult to ascertain from the service users spoken with, they’re level of involvement and understanding of the care planning process. There was no evidence of a specific medication policy to guide the ordering, recording receipt, storage, administration and disposal of medicines. The systems in place have been devised by a senior officer who ensures that the ordering of medicines is accurate and no over-stocking of medicines occurs. The cupboards were clean and well organised. The lack of medication policies was discussed with the manager and a requirement will be made. The inspector viewed medication charts and observed that some were not completed with a signature or a reason for medication not being administered. One medication chart was signed to say the medication had been administered and the medication was still in the monitored dosage system box. The reporting and recording of medication errors was discussed with the manager and the need for policies to be in place. Training in the administration of medication is given to specific staff members. Service users spoken with confirmed that there are no restrictions on how and when they wish to undertake their daily routines and that their privacy is respected if they wish to stay in their room. Staff were observed to communicating well with the service users and treating them with courtesy and respect. The district nurse visiting the home undertook the treatments in the service user’s own room. The manager reported that GPs are not always willing to wait for service users to return to their room for consultation and will speak with them in the public lounge area. It was advised that the manager takes issue with this in future. At the time of the inspection the public phone was fitted in the treatment room. The manager reports that this is to be converted into a visitors’ room and allow privacy when using the phone. The treatment room is to be moved to another area. Service users generally need help with opening their mail. A visiting relative was spoken with and reported that she was very satisfied with the care her father was receiving and that he was happy being at the home. Glen Lee Version 1.10 Page 11 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 standard(s) 12,14 & 15 Service users are able to participate in social activities provided by the home and that satisfy their social, recreational and religious expectations. Service users are encouraged and supported to exercise choice and control over their own lives. Service users receive an appealing balanced diet throughout the day in pleasant surroundings of their choice. EVIDENCE: The home does not employ an activities organiser and the care staff undertake activities. The activities are documented in the diary on a day-to-day basis and include dominoes, bingo, and coffee mornings. The home does not have a visiting hairdresser at the present time and the manager is making every effort to procure the services of another hairdresser in the area. The vicar visits the home once a month to give a service. None of the service users in residence attends a church in the community. Service users interests are documented as part of the assessment process. Service users spoken with reported they could join in the activities if they chose to do so. There will be a recommendation that a more structured activities programme be implemented to take account of the complex needs of the service users. The inspector evidenced that individual rooms had been personalised with pictures and personal belongings and the manager reported that this is Glen Lee Version 1.10 Page 12 encouraged so that service users have familiar objects around them. Pieces of furniture can be bought into the home and an inventory of this is maintained. The service users in this home are not generally able to manage their own financial affairs and the manager reports relatives usually undertake this. The inspector witnessed the lunchtime meal being served. Menus are planned but can be changed by the cook. The daily menu was displayed on a chalkboard in the hallway and had been changed that morning. The cook reported that alternative choices are available at meal times if requested and the inspector evidenced a service user having soup and sandwiches for his lunch, which, she was informed; he chooses to have every day. The manager reported that he is in the process of discussing menu changes with the cooks. Three cooked meals are provided each day and snacks are available at suppertime and throughout the 24-hour period if requested. The cook provides homemade cakes each day. The inspector observed that many of the service users needed assistance with their feeding and this was undertaken on a one-to-one basis in a respectful way. Service users spoken with at this mealtime reported that the food was good and plentiful. Glen Lee Version 1.10 Page 13 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 standard(s) 18 Service users are protected from abuse. EVIDENCE: The home had an adult protection procedure that all staff have had training on and which forms part of the induction programme. This is followed by a further two-day course. There have been no reports of abuse in the home in the last year. Staff spoken with described the process they would follow should they witness or suspect abuse and demonstrated good knowledge of the procedure. The home has a policy available on dealing with aggression and should an incident take place a specific reporting format is available and it is also recorded on the care plan. No forms of restraint were evidenced as being used in the home at the time of the inspection. Glen Lee Version 1.10 Page 14 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 standard(s) 19, 21 & 25 Service user live in a safe but not well maintained environment. Service users have sufficient lavatories and washing facilities available to them. Service users live in comfortable surroundings although there is a degree of risk from identified areas. EVIDENCE: Generally the home has had a great deal of redecoration over the past six months. Certain areas have been painted with vibrant colours with coordinating colours in the rooms. The manager reported that some of the rooms had to be toned down because the colours were too vibrant. There was no service user or staff consultation as to the colours but specialist advice was sought as to appropriate colours, from an organisation that deals with the care of those with dementia. Two smaller lounges on the first floor have been refurbished with redecoration and furniture that was chosen by the staff. Service users spoken with reported that they were very pleased with these areas of the home. Service users also reported that they were satisfied with their surroundings and felt comfortable and safe. The inspector observed that Glen Lee Version 1.10 Page 15 much of the bedroom furniture was old and in need of replacement. Call bells continue to be attached to lockers and in some cases were not in easy reach when service users are in bed. The lighting in the corridors was switched on and made a noticeable difference to the quality of light in the corridor areas. There are three rooms in the home that are not accessible to the residents occupying these rooms during the day because a day centre is held in the area of the home that house these rooms and is locked off to other parts of the home. This was discussed with the manager who reported that the residents of these rooms generally attend the day centre, as they are respite care residents. The inspector deemed this as unacceptable and restrictive to service user’s choice of going to their rooms during the day if they so wish. Further discussion with the local authority will take place on this issue. There are further plans for refurbishment and alterations to the home in the near future. The manager described the proposed rearrangements of offices and the treatment room, which will allow more appropriate accommodation for staff and service users and privacy when using the public telephone. The floors in all bedrooms are laid with lino and some rooms would benefit being carpeted to make the appearance more warm and homely. Service users did not comment on this issue. The home has a pleasant enclosed garden that the manager reports the service users use in the better weather. On the day of the inspection it was observed that a number of service users were wandering around the garden area. One service user commented that he enjoyed the outside and liked to go into the garden regularly. The Environmental Health Officer visited the kitchens in May 04, the inspector viewed the report that was satisfactory and gave no recommendations. The inspector observed that there were pieces of old unused furniture and equipment stored around the home in various areas which prohibited the safe storage of hoists and wheelchairs currently in use and therefore posed a risk to service users. The manager immediately arranged for the staff to move unwanted items and store equipment safely. The home has sufficient toilet and washing facilities. A disabled toilet facility is to be created on the ground floor. The home has two assisted baths and one shower room. The temperature of the hot water emitting from the shower on the ground floor could be unacceptably high and presented a risk to the service users. This facility was taken out of service immediately until a plumber could rectify the position of the thermostats on the taps. An immediate requirement was made and a plumber was called whilst the inspector was present in the home. Glen Lee Version 1.10 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30 Service users needs are not consistently met because of lack of permanent care staff being employed in home. The homes recruitment practices do not at all times ensure protection of service users. Staff are trained and competent to undertaken their jobs and care for the service users in residence. EVIDENCE: The home has increased staffing levels since the last inspection and were adequate at the time of the inspection although there were two agency staff in attendance. A recent recruitment event has resulted in the recruitment of two more housekeeping staff being employed along with care staff. Some of these staff have not yet completed the recruitment process, therefore agency staff are continuing to attend the home to supplement staffing levels. A service user spoken with commented on the fact that there are different agency staff at different times and that this bothered her not knowing the carer. The home does strive to have the same agency carers attending the home and the manager reports that he is satisfied with the continuity of care from them. Senior staff spoken with reported that they were looking forward to the sleepin duty being stopped and will give the home three waking staff on duty at night which will be more conducive for monitoring service users throughout the night in this large home and also less hours of continuous duty for the officer in charge. A sample of staff recruitment files was viewed. None of the files contained copies of birth certificates, passports or driving licence with only one file having a photograph of the employee as evidence of their identity. The manager Glen Lee Version 1.10 Page 17 reported that he had seen these documents to obtain information for the CRB and POVA checks and that he had not taken copies to maintain in their personnel files. There was no evidence in the files that CRB and POVA checks had been undertaken on two of the three files. The manager reported that these staff are working under supervision until such times as the appropriate checks have been received. The Human Resource department based at the city council maintains copies of terms and conditions of employment. Requirements will be made around the recruitment process. The home has an induction programme that is based on the TOPSS standards that all new staff progress through. There was evidence on staff files of completed induction programmes. All staff receive training in Dementia care. There was evidence that staff training files have been set up containing copies of attendance certificates for the training courses staff have undertaken. Glen Lee Version 1.10 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 & 38 Service users are safeguarded by the financial procedures of the home. The health, safety and welfare of service users and staff are promoted and protected in most areas of health and safety. EVIDENCE: The home has the appropriate insurance cover certificate displayed on the wall. The accounts department at the city council maintains the home’s accounts. The manager is involved with the business planning for the year and acknowledges that more investment is needed into the home to maintain and improve the environment and service. Policies are in place appertaining to Health and Safety legislation. Staff are provided with training in all aspects of health and safety. The requirement to ensure that all records are available for inspection has not been met. However, the manager informed the inspector that he could call the appropriate department to request personnel to come to the home to unlock the cupboard containing the maintenance records. The issue of the manager Glen Lee Version 1.10 Page 19 not being able to hold a key for this cupboard continues to be under discussion with the SCC works department. These records will be viewed at the next inspection The accident book was viewed and completed correctly and Regulation 37 notices are being received by the CSCI accordingly. A fire procedure is in place and displayed. The home has a policy in place for securing the building throughout the day and night. Glen Lee Version 1.10 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 1 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 2 15 3 COMPLAINTS AND PROTECTION 2 x 3 x x x 1 x STAFFING Standard No Score 27 2 28 x 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x x 3 x x x 2 Glen Lee Version 1.10 Page 21 yes Are there any outstanding requirements from the last inspection? 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 9 Regulation Requirement Timescale for action 30.6.05 Reg A medication policy must be 13(2)Sche produced to guide practice and dule 3 (k) be made available to all staff who administer medication. The policy should include selfadministration, covert administration of medication and a drug error policy and procedure. Medicine prescription charts must be signed by the administering carer once they have been witnessed to be taken by the service user. Reasons for non-adminstration must be documented on the chart by means of a code 2. 10.2 Reg 16(2)(b) Medication charts must not be signed to indicate medication has been adminstered when it has not been taken. This constitutes a medicine error and should be dealt with as per medication error policy .. A telephone facility must be 15.7.05 provided which is suitable for the needs of the service users and make such facilities available to be used in private Version 1.10 Page 22 Glen Lee 3. 14 Reg 13 (2)(3) Reg 23(2) (b) (d) 4. 19 5. 25 Reg 13 (4) (a) 6. 29 Reg 19 (1) Sch 2 1-6 7. 38 Reg 23 (4) An action plan must be submitted to the CSCI within the given timescales. This requirement remains outstanding from the last two inspection reports.. The 3 rooms situated in the day centre area must be made available to the residing service users throughout the day. An action plan must be submitted to CSCI detailing planned renewals of worn and stained carpets and further planned alterations to the home. The thermostat on the shower in the ground floor shower room must be adjusted to ensure that service users are not at risk of scalding This was an immediate requirement of this inspection and a plumber attended the home the day of the inspection but could not complete the task.. You are required to obtain in respect of all staff the information and documentaion specified in paragraphs 1-7 of Shcedule 2 of the Care Home Regulations. You are required to make available for inspection the records of the servicing of systems and records of fire equipment testing and fire training. 30.6.05 31.7.05 15.6.05 30.6.05 31.7.05 8. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Glen Lee Version 1.10 Page 23 No. 1. Refer to Standard 12 Good Practice Recommendations It is recommended that a more structured activities programme be produced that is appropriate for service users with mental frailty to participate. Glen Lee Version 1.10 Page 24 Commission for Social Care Inspection 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 Version 1.10 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. 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