Inspection on 11/07/07 for Glen Lyn

This inspection was carried out on 11th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Glen Lyn 22/07/08

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

CARE HOMES FOR OLDER PEOPLE Glen Lyn 16 Glen Road Sarisbury Green Southampton Hampshire SO31 7FD Lead Inspector Beverley Rand Unannounced Inspection 11th July 2007 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 Lyn DS0000069887.V346228.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 Lyn DS0000069887.V346228.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glen Lyn Address 16 Glen Road Sarisbury Green Southampton Hampshire SO31 7FD 07785 550783 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) Mr Amin Lakhani t/a Saffronland Homes Group Mrs Joy Leach Care Home 43 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Glen Lyn DS0000069887.V346228.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 43. Date of last inspection This service is a new registration. Brief Description of the Service: Glen Lyn is a forty-three bedded home registered with the Commission for Social Care Inspection to provide personal care to older people, some of whom may have dementia. Accommodation is provided in a two-storey building. There are nineteen single rooms and twelve shared rooms all with en-suite facilities. There is a well-maintained enclosed garden to the rear of the building with easy access for service users. Glen Lyn DS0000069887.V346228.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection. The home has recently been reregistered as a new service after being changed from limited company ownership to individual ownership. Owing to this and the Commission having some concerns about various aspects of the home this early visit has taken place to see how outcomes are for those living in the home now. Prior to the visit the inspector reviewed the one comment card received from a relative and the Annual Quality Assurance Assessment form completed by the manager. During the inspection the inspector looked around the home, spoke with two residents, four staff and the manager. The inspector also looked at records such as care plans and recruitment records. What the service does well: What has improved since the last inspection? This is the first report under the new registration. Glen Lyn DS0000069887.V346228.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Glen Lyn DS0000069887.V346228.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 Lyn DS0000069887.V346228.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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures prospective residents’ needs are assessed. EVIDENCE: In recent months the manager has reviewed assessments for current residents and has a new format in place for new ones. The manager is trained with regard to assessments and has trained two care assistants in this regard. Assessments are now broader, covering life history, interests and abilities. One staff member said they ask new residents what routines they had at home, such as what time they got up. Glen Lyn DS0000069887.V346228.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ have care plans in place which staff are familiar with. Medication procedures ensure residents are protected. Residents access healthcare and staff treat residents with respect. EVIDENCE: Care plans cover information such as personal preferences, mobility, nutritional needs, pressure areas and challenging behaviour. The inspector looked at three care plans and found they generally contained a good level of information. However, one did not have a risk assessment regarding a piece of equipment being used by the home. The inspector spoke with staff who were aware as to individual needs and routines. Records showed that residents have access to healthcare professionals such as doctors and nurses. The manager said a book is kept for nursing staff visiting the home whereby concerns are noted, unless urgent enough to require a visit sooner. District nurses visit residents who have pressure area needs and equipment is evident throughout the home, such as pressure relieving Glen Lyn DS0000069887.V346228.R01.S.doc Version 5.2 Page 10 mattresses and cushions. Files showed information regarding residents’ medical health needs, such as Tinnitus. Medication and prescribed creams were stored appropriately and records were maintained showing when residents had been given their medication. The inspector audited the records for controlled drugs and found them to be correct. Most staff have completed a Safe Handling of Medication course and new staff are expected to do so soon. The manager said that new staff do not give medication. Instead, they will watch and witness other staff administering before being supervised by the manager. This arrangement starts with times of day which have less medication. Staff gave examples as to how they respected residents’ privacy and dignity such as using screens, closing doors and curtains. Staff were seen to be respecting residents in daily activities. Glen Lyn DS0000069887.V346228.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy the activities and meals, can personalise their bedrooms and receive visitors in private. EVIDENCE: A resident who was asked said they preferred to sit quietly but did enjoy going on bus trips organised by the home. Staff told the inspector they tried to ensure that everyone who wanted to go on a bus trip had the opportunity to do so. Other activities include listening to music, watching videos, nail painting, bingo, a football table, (which the manager said was very popular), indoor golf putting and games such as Connect 4. The home keeps an activity file for each resident which shows what activities they have been involved so this can be monitored. Visitors can visit the home at any time and residents confirmed this. Staff said visitors are offered a drink and a private room to see their relative or friend. A resident who was asked said they had brought their own possessions into the home and this was generally seen whilst looking around the home. Glen Lyn DS0000069887.V346228.R01.S.doc Version 5.2 Page 12 The inspector was told that the food was, ‘first class’ and ‘quite nice’ by a resident. Staff brought a morning snack of orange segments and yoghurt biscuits and explained to residents what the snack was before offering it. Residents were also offered a choice of hot and cold drinks. A resident confirmed that they were always offered a choice. Staff said residents are offered an alternative if they do not want the main meal of the day and that new residents are asked about their likes and dislikes when they move in. The menu is reviewed monthly. Staff are aware regarding special dietary needs such as diabetes or allergies. If residents need a pureed diet, each food item is pureed separately. The menu was generally recorded but the food provided to those who had an alternative was not recorded. The inspector advised that this must be done to ensure nutrition could be monitored. Glen Lyn DS0000069887.V346228.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures are in place to ensure residents are safe and can complain if they wish. EVIDENCE: The home has a complaints procedure in place which was available to residents. However, it did not state that the home will respond to a complaint within 28 days. The inspector was advised that it had been recently reprinted and the sentence must have been omitted by mistake, as it was previously there. Staff confirmed that residents had a right to complain and explained how they would respond to complaints. The home has received one complaint which was dealt with within 28 days. Staff had knowledge regarding different types of abuse and safeguarding adults. All said they would report any suspicions of abuse to the manager and that they knew where the policies and procedures were. Two were aware of the other agencies which would be involved but the other two were not. However, they were confident that there was always a manager available within the company. The manager confirmed that the local authority would be involved in investigating any allegations of abuse. Some staff had received training in this area and there is training booked in the near future. Glen Lyn DS0000069887.V346228.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a well decorated home but would benefit from the environment being odour free. EVIDENCE: The home has continued to be re-decorated and carpeted. One bedroom in particular was noted to be decorated in the colours requested by a resident and they confirmed this. Work has been done to brighten the bathrooms by the painting of murals of dolphins and other sea life and there was a new bath in place. However, the inspector observed that one of the baths was close to and facing a wall shelf unit which contained a supply of toilet rolls and incontinence pads. Both the manager and staff agreed that this was not very homely and agreed to look into how they might change the layout of the bathroom. Glen Lyn DS0000069887.V346228.R01.S.doc Version 5.2 Page 15 Most of the bedroom doors are not locked but the rooms do have a lockable storage facility. The inspector noted that soap was not kept in en-suite toilets which were used independently. Staff explained this was because some residents would walk into other residents’ rooms and eat the soap. The inspector was concerned about how hygiene could be maintained for the majority of residents. The manager said it was not generally possible for bedroom doors to be locked, as residents were free to go into their rooms throughout the day and would be more confused to find it locked and not be able to manage a key themselves. The manager started to look into how this situation might be resolved during the inspection. Communal toilet facilities had hand wash basins, liquid soap and paper towels. There was an unpleasant odour throughout most of the ground floor of the home. The manager said she was aware of this as it was an ongoing issue. Work had been done around replacing carpets and cleaning them, (the carpet cleaner was replaced on the day of the inspection as it had broken). Some residents had particular challenging behaviours around incontinence which contributed to the problem. There are signs around the home on bright paper to indicate rooms such as dining room and toilet. Bedrooms have residents’ names on them and one was seen to have a photograph of a resident. The manager said that residents tend to take photographs and pictures off of the walls and doors. The back garden is secure and attractive with seating and summer bedding. A gardener visits the home once a week. The home has a laundry and separate sluice room. A resident said they had, ‘no trouble with clean clothes’. Staff explained how they worked with regard to health and safety and infection control. Protective gloves and aprons were readily available. Glen Lyn DS0000069887.V346228.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust recruitment procedures are in place to protect residents. Residents’ needs are met by well trained and qualified staff. EVIDENCE: The manager said there are generally six staff on duty in the morning and five in the afternoon. Three staff are on duty at night and they are all awake. In addition to care staff there cooks and kitchen assistants, two cleaners, a laundry worker and gardener. Some staff are agency staff and the manager said they ensure consistency wherever possible. If the agency do send new staff, a letter is sent to the home confirming that they have the appropriate checks in place, a photograph is taken of them and they undertake an induction. A resident said the staff were, ‘pleasant and helpful, nice to talk to’. The home has recruited new staff and files showed the appropriate checks had been completed. The manager said that references were always completed before the new staff member could start work. References were dated as to when they were written but not received. The manager was advised to record the date of receiving the references to fully evidence that they were in place prior to staff starting work. Glen Lyn DS0000069887.V346228.R01.S.doc Version 5.2 Page 17 Eight of the twelve care staff have achieved a National Vocational Qualification, (NVQ) level 2 in care. The home promotes NVQs and the manager said the kitchen assistants were starting a relevant NVQ course. New staff undergo a thirteen week induction which is based on the national induction standards. A staff member told the inspector that their induction period had included reading care plans and policies and procedures. There is a training programme in place which includes Communication, Care Planning, Dementia, Food Hygiene and Moving and Handling. An audit has recently been done to identify training needs of individual staff. Glen Lyn DS0000069887.V346228.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is run by an experienced manager. Residents’ financial interests are not protected. The home is run with regard to health and safety although staff would benefit from more fire safety training. EVIDENCE: The registered manager has achieved the NVQ4 in care and the Registered Manager’s Award. She has managed the home for seven years and has worked within the home for fifteen years. The home undertook a residents’ survey with regard to activities earlier in the year. The inspector was told that relatives had not recently been asked to complete a survey due to the Commission asking them to complete a survey. Glen Lyn DS0000069887.V346228.R01.S.doc Version 5.2 Page 19 The manager said a general survey to include staff would be undertaken in August. Survey forms are given to district nurses and doctors. The home looks after substantial amounts of money on behalf of residents. However, the money is looked after in one account which attracts interest. The home planned to ask residents to sign a piece of paper to say they would agree to any accrued interest being used to offset administration charges. The Commission sees this as unacceptable as residents are entitled to interest on their money. The manager should refer to the Commission’s publication, ‘In Safe Keeping: supporting people who use regulated care services with their finances’, which gives guidance in this regard. Records and receipts are kept for how residents spend their money. Fire equipment is tested regularly and records are maintained. Fire safety training has been provided but some staff have not done this training in over a year. Maintenance certificates were seen for equipment such as the hoist, lift and stair lift. Portable electrical testing had been done. Temperatures were recorded for food and fridges. Glen Lyn DS0000069887.V346228.R01.S.doc Version 5.2 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. 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 X X 3 Glen Lyn DS0000069887.V346228.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? N/A 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 OP35 Regulation 13 (6) Requirement The home must find a suitable banking system or other way of managing money which ensures any interest accrued on residents’ monies is paid to them and not offset against administration charges set by the home. The service must consult with the fire authority with regard to the regularity of fire safety training and action accordingly Timescale for action 30/09/07 2 OP38 23 (4) 30/09/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Glen Lyn DS0000069887.V346228.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Glen Lyn DS0000069887.V346228.R01.S.doc Version 5.2 Page 23 - 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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