Inspection on 05/09/06 for Glen Lee

This inspection was carried out on 5th September 2006.

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 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 Chris Johnson Unannounced Inspection 10:00 5 September 2006 th 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.V327126.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.V327126.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 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.V327126.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th October 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.V327126.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of this inspection was to assess how well the home is doing in the meeting of all key National Minimum Standards and compliance with regulations and previous requirements. The findings of this report are based on a number of different sources of evidence. These included: An unannounced visit to the home, which was carried out on 5th September 2006. During this visit a tour of the premises was completed that included looking at service user’s bedrooms and all communal areas of the home. Staff and care records were inspected; staff, residents and relatives were spoken with and staff were observed during their day-to-day interactions with residents. All regulatory activity since the last inspection was reviewed and taken into account including notifications sent to the Commission for Social Care Inspection. Eleven residents and four relatives completed questionnaires prior to the visit and four GP’s and seven members of staff completed comment cards. The acting manager completed a pre inspection questionnaire. During a tour of the building it was found that many of the call bells in service users’ bedrooms were inaccessible. Call bells had been fixed in place on the side of bedside lockers. Many of these were fixed to the opposite side of the locker. This meant that service users would not be able to access them from their bed. In other cases lockers were such a distance from the bed that they were completely out of reach. When discussed with the acting manager it was evident that due to the level of need of several of the service users, they would be unable under the present arrangement to summon help in an emergency. An immediate requirement was made regarding this issue and several further requirements were made following this inspection What the service does well: Staff treat residents with respect and dignity and ensure that their have access to a full range of healthcare support. The meals in the home are good, offering both choice and variety. The opportunity for residents to receive visitors is good and residents are free to make their own decisions about how they spend their time and are supported to engage in a variety of activities. Standards of hygiene are maintained throughout the home. Improvements to the physical environment have been made. However further improvements are necessary to ensure residents comfort and safety Staff are well trained, caring and helpful. They are committed to their role and work well together as a team. Glen Lee DS0000039231.V327126.R01.S.doc Version 5.2 Page 6 Relatives and residents were in agreement that the attitude of the staff and the level of care were to a good standard. One relative commented “ I Cannot speak highly enough about the service”. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Glen Lee DS0000039231.V327126.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Glen Lee DS0000039231.V327126.R01.S.doc Version 5.2 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 the following standard(s): 2,3 and 4 Quality in this outcome area is poor. This judgement has been made using the available evidence including a visit to this service. Improvements are needed in the assessment process to reduce the danger of someone moving into the home whose needs cannot be met. More attention must be paid to ensuring that residents’ rights are fully protected. Residents consider their care needs to be met. However due to inconsistencies in care planning and the lack of detailed information in care plans and staffing levels the home cannot demonstrate that they are meeting peoples’ needs. EVIDENCE: Glen Lee does not provide intermediate care. This standard is therefore not applicable and was not assessed. The files of four residents were examined during the visit to the home. All contained contracts informing them of their rights. However these were out of date and had not been amended to take account of increases in fees. Not all contracts had been signed by either the resident their representative or a representative of Southampton City Council. Glen Lee DS0000039231.V327126.R01.S.doc Version 5.2 Page 9 Pre admission assessment and care notes were looked at for four residents. Assessment documentation was only available for three of the residents. The fourth person had recently moved from another Southampton City Council home and although their care notes had been transferred there was no evidence that the person’s needs had been assessed prior to them transferring. Residents and relatives told the inspector that they considered that care needs’ were being met at the home. One visitor commented, “ I cannot speak highly enough about the service. I feel my husband is well cared for”. These views were reiterated in some of the comment cards received. However the home cannot fully demonstrate that this to be the case. Due to inconsistencies in care planning and the lack of detailed information in care plans. A further contributory factor to this is staffing levels. This has been discussed in standards 9, 15 and 27 of this report. Glen Lee DS0000039231.V327126.R01.S.doc Version 5.2 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 and 10 Quality in this outcome area is poor. This judgement has been made using the available evidence including a visit to this service. Residents consider their care needs to be met. However care planning is poor and does not provide sufficient information to ensure that all needs are met. Poor medication practices put residents at risk. Staff treat residents with respect and dignity and ensure that their health care needs are met. EVIDENCE: Improvements have been made in the frequency that care plans are now reviewed. The care plans for four residents were examined and all had been reviewed on a regular basis or to reflect any significant change in the person’s care needs. Whilst it was evident that progress had been made to improve on the level and accuracy of information recorded in care plans, such as residents personal histories there remains room for further improvement. All four care plans lacked sufficient detail and guidance and did not fully address all assessed and identified needs or risks. Care plans were unclear and confusing. Often when a review had taken place and where there had been a change to the care plan the change was made on the original care plan rather than a new care plan be written. Information was therefore confusing and at Glen Lee DS0000039231.V327126.R01.S.doc Version 5.2 Page 11 times contradictory. There is a risk that information will be missed or misinterpreted. Some care plans identified a need but did not provide sufficient detail or instructions to staff as to how this need was to be met. Not any of the care plans examined had been signed by the residents and it was unclear as to the level of involvement and contribution that they had made to their own plans. Many of the residents living at the home have dementia care needs and these are not adequately addressed within care plans. All four plans examined contained an assessment referred to as ‘The Bradford Dementia group wellbeing profile’. Although each one had been scored none of the well/ill being indicators had been completed. Staff clearly need more training in care planning. In discussion with staff involved in writing care plans, they were aware of the need to keep the plans up to date but had not had specific training in writing and developing care plans. Although they said that they did have the opportunity to discuss and review them in supervision. Feedback cards were received from four GP’s prior to the visit. All responded positively regarding the level of communication, staff understanding of residents’ needs and all expressed satisfaction with the level of care provided. Records were available to demonstrate that residents have access to a range of services such as GP’s, Dentists, Chiropodists and district nurses. The Commission for Social Care Inspection had received two notifications of medication errors being made at the home since June 2006. One occurrence involved a resident not being administered their medication and the second concerned a resident being administered their insulin twice when it should have only been given once. Observation of staff medication practices during the visit to the home showed that staff are still not following correct procedures and are therefore putting residents at risk. The following issues were identified as a cause for concern: 1. Procedures for the recording of medication are not always followed. The staff member administering the medication told the inspector that she had omitted to record administering one resident’s medication in the morning as she had forgotten to do this. This could have led to a serious medication error. This was reported to the manager. 2. The staff member was initially using the same pot to dispense the medication into rather than use separate pots for each person. 3. Medicines were being handled by hand. One tablet needed to be cut with a pill cutter. The tablet was handled several times by the staff member and when asked she said that the pill cutter could be used several times as they are unable to wash it and get it properly dried for each use. 4. Several residents have been prescribed ‘as required’ (PRN) medicines and there was not any guidance to inform staff regarding the use of Glen Lee DS0000039231.V327126.R01.S.doc Version 5.2 Page 12 these. Neither was it referred to in their individual care plan. Consequently the decision to offer PRN medication often rests upon the member of staff and this is clearly unsatisfactory. 5. Current practice is that one member of staff is solely responsible for administering medication at any given time. This means that the staff member has to leave the trolley unattended while taking people’s tablets to them. 6. Current practice when administering eye drops is that after each administration the staff member uses a cloth hanging on the rail at the back of the medication trolley to wipe their hands on. This was used several times and clearly poses a risk of cross infection. The staff member did interact well with residents when giving out medication and when not in use medicines are safely and appropriately stored. Many residents’ medication files had photographs on them for ease of identification. This is good practice and should be extended to include all residents. The problems identified highlight the need to have two members of staff supervising medication at any given time. Due to the large number of residents this would seem a much safer system. Relatives and GP’s reported that they could visit residents in private and all residents who returned a comment card responded that their privacy was respected. Staff were observed during the visit to treat residents with respect and dignity. Glen Lee DS0000039231.V327126.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. The meals in the home are good, offering both choice and variety. The opportunity for residents to receive visitors is good and residents are supported to make their own decisions about how they spend their time and are to engage in a variety of activities. EVIDENCE: Musical activities took place in the afternoon of the visit with staff support. Residents were observed to join in by singing, dancing, using an instrument or just observing and or listening. Staff were enthusiastic and sought to involve as many residents as wished to join in, in a variety of different ways. Progress had been made towards documenting residents’ interests’ in care plans. The majority of residents who completed a comment card responded that the home provided suitable activities. Some others felt that there needed to be more opportunity to go on outings. In discussion with residents some commented that they would like to see more activities. In conversation staff said that staffing levels can restrict the time spent with residents and what activities could be provided. Glen Lee DS0000039231.V327126.R01.S.doc Version 5.2 Page 14 Residents were observed to be free to choose where and how they spent their time. Residents told the inspectors that they were free to spend their time as they chose and that there were not any restrictions imposed upon them. 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. Requirements have been made on both occasions that these rooms must be made available to those service users at all times. At the time of this inspection no action had been taken to remedy this. Visitors spoken with during the visit said that they were made to feel very welcome at any time and one commented that they were invited to social events, which they considered to be very good. Another said, “I am offered a meal if I visit around lunchtime”. Feedback cards from relatives confirmed that they could visit whenever they wished and that they were made to feel welcome and that the home kept in contact with them as necessary. Eight of the eleven residents who returned a comment card responded that they liked the food at the home the remaining three answered that they liked it sometimes. Residents spoken with reported the food to be good. Sample menus sent to the Commission for Social Care Inspection prior to the visit demonstrated there to be plenty of choice and variety and that specific dietary needs are catered for. This was substantiated from observations made during the visit to the home. In discussion with the cook it was established that new menus were being introduced and that photographs were being taken of different dishes on the menu to assist residents with making choice. This will prove especially beneficial to residents with dementia care/communication needs. Good food and kitchen hygiene practices were observed to be in operation. There was not however enough staff to provide support to all residents who required one to one assistance during meal times. This is discussed in standard 27 of this report. Glen Lee DS0000039231.V327126.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using the available evidence including a visit to this service. Satisfactory systems are in place for residents to address any concerns or complaints that they may have and staff receive appropriate training in adult protection procedures. EVIDENCE: Most residents who completed a questionnaire responded that they knew how to make a complaint if they were unhappy about anything and residents are provided with this information when they move in. Amendments had been made to the complaints procedure as required at the previous inspection. This now includes the address and contact number of the Commission for Social Care Inspection. The home maintains a complaints log and from examination it was evident that complaints are monitored and that appropriate action is taken to address any concerns or complaints. In discussion with staff and feedback from staff comment cards it was clear that staff were aware of the correct procedures to follow in the event of someone wishing to make a complaint. Adult protection training is organised for all care staff and the inspector saw from staff training records that refresher training is provided and implemented into the training plan for all staff. Adult protection issues were discussed with staff and they were able to demonstrate that they were aware of reporting procedures. Evidence was seen that the home follows correct reporting procedures, passing on any concerns that they may have to the relevant agency in line with the local Authority’s Adult Protection Procedure. All residents spoken with reported that they felt safe and well looked after by the staff. Glen Lee DS0000039231.V327126.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,22,24 and 26 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Standards of hygiene are maintained throughout the home. Improvements to the physical environment have been made. However further improvements are necessary to ensure residents comfort and safety. EVIDENCE: During the visit to the home a tour of the premises took place that included all communal areas of the home including bathrooms, toilets and lounges. The kitchen and bedrooms were also inspected. Residents were able to freely access all parts of the home apart from the three bedrooms discussed previously. Several residents were observed to access and use the garden and they said that they enjoyed this facility. The garden was well maintained secure and private and offers sheltered areas as well as a sensory wooded walk. Improvements had been made since the last inspection. Furniture and some carpets had been replaced in the small lounges and some bedrooms had been repainted. Glen Lee DS0000039231.V327126.R01.S.doc Version 5.2 Page 17 The foyer carpet had still not been replaced, despite requirements being made on two previous occasions. This carpet is very stained and looks dirty. The acting manager stated that the carpet is steam cleaned regularly but this made little difference. Other carpets in some communal areas are also in need of replacement. It was found that many of the call bells in residents’ bedrooms were inaccessible. Call bells had been fixed in place on the side of bedside lockers. Many of these were fixed to the opposite side of the locker. This meant that service users would not be able to access them from their bed. In other cases lockers were such a distance from the bed that they were completely out of reach. When discussed with the acting manager it was evident that due to the level of need of several of the service users, they would be unable under the present arrangement to summon help in an emergency. Some of the call bell cords were tangled up in drawers. One resident’s locker was positioned across the room from out of reach of the bed. The resident is frail and uses a wheelchair. The call bell cord did not reach the bed. The acting manager said that the locker is moved. When the call bell cord was looked at it was broken. An immediate requirement was made regarding access to call bells and this has been dealt with separately to this report. Many of the bedrooms were bare and were not homely in appearance. All the rooms viewed had vinyl flooring. Most were un-personalised and there were very few pictures on the walls or personal belongings. The beds that were replaced by the previous manager are unsuitable. They are a bulk purchase. The beds are small and narrow with a small wooden headboard. This tends to add to an institutional feel and is less than homely. Further to this bedside lights were also screwed/fixed to bedside lockers. The acting manager said that new overhead lights had been ordered for each bedroom. Some of the bedside lockers had locks and some of the keys had been lost, as have some bedroom door keys. Therefore not all residents are able to lock their doors or lock away their valuables. The manager said that this was going to be addressed. Some bedrooms did not have any net curtains or equivalent to safeguard the resident’s privacy. Bedrooms downstairs were of a particular issue where residents could easily be observed in their rooms from the garden. Whilst no residents or visitors made any adverse comments about the bedrooms they only described them as adequate. Most bedroom doors are left open during the day. One resident was observed to be in bed asleep in the afternoon and her door had been left wide open. It was unclear whether this was her wish. It was noted that none of the bedroom doors had closures on them therefore they tend to stay open and this may be the reason that they remain open. Each corridor is protected by a fire door at either end and the inspectors and acting manager were unclear whether this afforded sufficient protection from fire and smoke inhalation. Consultation will need to be made with the local fire authority to confirm whether any action needs to be taken. Glen Lee DS0000039231.V327126.R01.S.doc Version 5.2 Page 18 Infection control procedures were observed to be followed and cleaning staff and a laundry assistant were on duty during inspection. Staff spoken with were aware of infection control procedures and said that they had the necessary equipment such as gloves and aprons. The home is kept clean and tidy and good standards of hygiene are maintained. The home seeks the advice of other agencies such as Environmental Health appropriately. There was a strong adverse odour in one area of the home and the inspectors were informed that this was coming from the sluice room. There was very little ventilation in this room and this was thought to be the cause. Glen Lee DS0000039231.V327126.R01.S.doc Version 5.2 Page 19 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 and 30 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. Staff are well trained and undergo a thorough recruitment process. They are caring, helpful, are committed to their role and work well together as a team. Staffing levels are maintained but are not adequate to meet the current needs of all residents. EVIDENCE: Staffing levels remain constant and were found to be at the same level as at previous inspections. The rota and the number of staff on duty during the visit demonstrated this. However as has been discussed in previous reports there is a need to keep staffing levels under review to ensure that the needs of residents can continue to be met. Evidence from this inspection would suggest that the current staffing levels are not adequate to meet the current needs of residents. Evidence from observation of the medication administration procedures as discussed in standard nine of this report would support the fact that staffing levels are not always sufficient as would observation of the level of support required by residents at meal times. There was clearly not enough staff to provide one to one support to all residents who require this level of support. One resident was observed to be falling asleep with her head almost resting on her plate. Another resident was seen taking food off another resident’s plate whilst she was asleep. In addition one resident was eating her food with her knife. This went on for some time until the resident starting eating with her Glen Lee DS0000039231.V327126.R01.S.doc Version 5.2 Page 20 hand. Staff were present during this, however they were engaged in assisting other residents whom also needed a high level of support. It took the resident a considerable amount of time to eat her dinner and would have certainly been cold. In discussion with staff they did comment that given a wish to improve the service this would be to have extra staff to be able to spend more time with residents. This was also a comment made in five of the six staff comment cards returned prior to the visit. Several of who felt that there needed to be three staff on each floor at all times. Residents spoken with or whom returned a comment card commented on the caring attitude of staff. Comments included, “The staff are very good”. All residents who completed a comment card responded that they felt well cared for, that the staff treated them well, that they liked living at the home and felt safe there. Visitors also commented that the staff were very good and that they were satisfied with the overall care provided. One person commented, “ I have visited many care homes and I can honestly say this one is run by caring, helpful staff who do their uppermost in very difficult circumstances”. The inspectors observed there to be a relaxed and friendly atmosphere between the staff and residents. In discussion with staff and through comments made in comment cards it was evident that staff were committed to their role and that they worked well together as a team. Staff training records were received with the pre-inspection material. Staff members have undertaken a range of training relevant to their roles and responsibility. A training plan was in place for the current year to ensure that staff receive regular updates in the core areas of training such manual handling, fire, adult protection and first aid Basic. More specific training in areas such as dementia care is also provided. All staff involved with food preparation undertake food hygiene training and COSHH training is provided to all domestic staff. A high proportion of staff have been trained to NVQ level 2 or above with more planned for the current year. The records of recently employed members of staff were examined and it was found that all satisfactory checks had been undertaken and that each staff member had been through a thorough recruitment procedure. All staff contacted confirmed this to be the case. Glen Lee DS0000039231.V327126.R01.S.doc Version 5.2 Page 21 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): 31,33,35,36,37 and 38 Quality in this outcome area is adequate. This judgement has been made using the available evidence including a visit to this service. The home does not always comply with requirements and some of this would appear to be out of the manager’s control and lay with the City Council. At present the home has no quality assurance system in place and therefore cannot fully demonstrate that the home is run in the best interests of residents. EVIDENCE: Since the previous inspection the registered manager has left the employment of Southampton City Council. An acting manager has been in post for several months and is supported in her role by a senior manager within the local authority. Southampton City Council has liaised appropriately with the Commission for Social Care Inspection during this period and there are no concerns regarding the management arrangements. Glen Lee DS0000039231.V327126.R01.S.doc Version 5.2 Page 22 Several requirements were made at the last inspection and action had been taken to address some of these. Those outstanding are mainly to do with resources however they do need to be addressed. This report has highlighted areas that require more attention and several of these will require additional resources. It was reported that the manager is accessible and approachable to residents and staff. Staff said that they received a good level of support and had regular supervision and appraisals. This was substantiated through examination of staff files. The home has corporate policies and procedures in place provided by the local authority. 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. A requirement was made at the last inspection regarding the need to introduce a system to ascertain the views of service users, relatives, representatives or stakeholders to enable the home to assess whether it is meeting its aims and objectives and to put an improvement plan in place. At the time of this inspection this had not been achieved. 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 Commission for Social Care Inspection. Generally record keeping is maintained to a satisfactory standard. However it was found that photographs were not available on all staff or resident files. Otherwise records were stored correctly, securely and confidentially. It would however be advisable to reorganise some of the residents’ files to ensure that staff have ease of access to risk assessments etc. There had been an improvement regarding access to service contracts since the last inspection. A selection of these were viewed and demonstrated that regular checks and servicing of equipment such as the fire system is carried out. Generally safety is promoted within the home although this was found to be compromised by the lack of access to call bells, shortfalls in medication procedures and the fact that requirements made by the fire officer had not been addressed. A visit by a fire officer on 19/05/06 had highlighted that a new fire risk assessment was needed. This had not been carried out at the time of this inspection. Glen Lee DS0000039231.V327126.R01.S.doc Version 5.2 Page 23 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 2 2 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 2 X 2 X 2 STAFFING Standard No Score 27 1 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 2 2 Glen Lee DS0000039231.V327126.R01.S.doc Version 5.2 Page 24 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 OP2 Regulation 5 Requirement All service users must be issued with an up to date contract/ terms and conditions detailing the correct fee and these should be signed by the service user or their representative and a representative of SCC. Full assessments must be completed prior to admitting service users and records are to be kept of these. Care management assessments must be obtained prior to admission for any resident who is fully or partially funded. All care plans must be reviewed. They must be more detailed and provide specific support instructions and fully address all assessed and identified needs including the identification of any risks and how these are to be managed. Written guidance must be produced in respect of any resident prescribed PRN medication. This must be incorporated into their care plan. The registered person must DS0000039231.V327126.R01.S.doc Timescale for action 10/11/06 2 OP3 OP37 14 (1) 10/11/06 3 OP7 15 (2) (b) (c) 01/12/06 4 OP9 13 (2) 10/11/06 5 Glen Lee OP9 13 (2) 10/11/06 Page 25 Version 5.2 6 7 OP9 OP14 13 (2) 13(2)(3) 8 OP19 23(2)(b) (d) 9 OP24 16 (2) (c) 10 OP24 12 (4) (a) 11 OP24 OP38 23 (4) (a) 12 13 OP26 OP27 16 (2) (k) 18 (1) (a) 14 OP33 24 (1) ensure that sufficient staff are on duty to make certain that safe and accurate procedures are followed when administering medication. Procedures must be followed for the receipt, recording, and administration of medication. The three rooms situated in the day centre area must be made available to the residing service users throughout the day. (Previous timescales of 30/06/05 and 31/12/05 not met). Old and worn carpets must be replaced in the reception area of the home. (Previous timescales of 31/07/05 and 31/12/05 not met). Service users must be supplied with secure lockable storage in their rooms. This needs to be appropriate to their needs. Service users must be consulted as to whether they wish to have net curtains or similar in their bedrooms and these must be fitted as necessary. You must consult Hampshire Fire and Rescue to determine which doors within the home can be left open and which doors require closures. Action must be taken accordingly. Action must be taken to keep the home free from offensive odours. The needs of all current service users must be reviewed and staffing levels adjusted accordingly. A service user/family & friends 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 DS0000039231.V327126.R01.S.doc 10/11/06 01/12/06 01/12/06 01/12/06 01/12/06 10/11/06 10/11/06 01/12/06 31/12/06 Glen Lee Version 5.2 Page 26 15 OP37 16 OP38 17(1)(a) 17 (2) Schedule 3 and 4 23(4) (a) objectives of the home. The results of this should be published and made available to service users and families. (Previous timescale of 31/01/06 not met). A photograph of each service user and staff member must be held on record. Evidence must be provided that the requirements from the fire officer’s inspection of the home have been completed. 10/11/06 10/11/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP12 Good Practice Recommendations It would be advisable to reorganise some of the residents’ files to ensure that staff have ease of access to risk assessments etc. That a review of the current activities available to Service users is carried out in consultation with them. That more outings / opportunities for Service users to get out into the community are created. More frequent checks should be carried out of residents’ bedrooms to ensure their safety, privacy and dignity. 3 OP19 Glen Lee DS0000039231.V327126.R01.S.doc Version 5.2 Page 27 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. 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