Inspection on 12/04/07 for Glen Lyn

This inspection was carried out on 12th April 2007.

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 Lyn 22/10/07

Glen Lyn 03/10/06

Glen Lyn 17/11/05

Glen Lyn 14/06/05

Glen Lyn 09/02/05

Glen Lyn 12/07/04

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

CARE HOMES FOR OLDER PEOPLE Glen Lyn 2 Tregonwell Road Minehead Somerset TA24 5DT Lead Inspector Sally Murphy Unannounced Inspection 12th April 2007 10:15 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 DS0000016026.V335823.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 DS0000016026.V335823.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glen Lyn Address 2 Tregonwell Road Minehead Somerset TA24 5DT 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) 01643 702415 Mr Stephen Reaney MRS MELANIE ANN REANEY MRS MELANIE ANN REANEY Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Any service users in room 11 must be assessed with regard to their mental and physical abilities to use the stair lift to access the room 3rd October 2006 Date of last inspection Brief Description of the Service: Glen Lyn is a semi-detached property situated in a residential area of Minehead close to the seafront and town centre. The home is registered with the Commission for Social Care Inspection to provide accommodation for up to eleven people over the age of 65 years, who require assistance with personal care. Glen Lyn has been pleasantly decorated and furnished, and offers a comfortable, homely environment. All bedrooms offer single accommodation and most rooms have an en-suite facility. There is an assisted bathroom, stair lift and call system available at the home. The Registered Providers are Mr and Mrs Reaney. Mrs Reaney is also the Registered Manager. The current fee levels are between £361 and £400 per week. Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and was completed by two inspectors over one day. On the day of the inspection there were ten service users residing at the home. The Inspectors were able to meet with the Registered Manager, nine service users, and one member of staff. During the course of the key inspection service user views were sought and care practice was observed. A tour of the premises was completed and records were examined in relation to care planning, medication, staff training and recruitment, and health and safety. Two inspectors from CSCI previously visited the home on 29th March 2007 in response to concerns raised regarding the welfare of service users. This matter is continuing to be investigated under Somerset County Councils’ Safeguaring Adults procedure. The Inspectors would like to thank the Registered Manager, Melanie Reaney and the service users for the time and assistance during the recent visits to the home. What the service does well: Glen Lyn provides care to service users within a small, homely environment. The home is situated close to Minehead town centre and seafront. Some service users are able to access these facilities independently. Service users confirmed that trips are also provided. Service users are encouraged to maintain links with the local community. Service users stated that staff were ‘kind’, and said that they always came quickly if help was needed. Interaction between service users and staff was observed to be friendly and respectful. A document outlining the specific plan of care that is to be provided to each service user is kept within their room, and may be accessed by service users. Staff and service users spoken with during the inspection said that they would be able to raise any issues of concern, and felt that these would be taken seriously. Four out of the seven care staff employed have obtained the NVQ level 2 qualification. The Registered Manager is a Registered Nurse and has obtained the Registered Managers Award. Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 6 The Registered Manager has a thorough quality assurance system, and regular audits have taken place regarding: activities, cleanliness, and medication to ensure that standards continue to rise at the home. The home is maintained to a good standard of cleanliness. What has improved since the last inspection? What they could do better: The Statement of Purpose and Service User Guide must be amended to ensure that prospective service users are provided with the full range of information regarding the service. On moving into the home, each service user must be provided with a written contract outlining the terms and conditions of their stay. This should provide details of the sums payable by the service user, Local Authority or relative. Assessments had not been regularly reviewed. Where service users were assessed at being at a high level of nutritional or pressure sore risk, a care plan had not always been developed to meet this need. Some care plans did not contain sufficient detail to enable staff to fully meet service users health and dementia care needs. Records did not evidence that health care services had always been called appropriately, for example when someone had suffered a number of falls, or there was a change in their health. Medication records had been appropriately maintained. Some medications and the key to the medication cabinet had not been stored securely. Many service users spoken with stated that they have breakfast very early, and are encouraged to go to their bedroom at teatime or soon after. The Registered Manager must ensure that service users views are sought regarding the time that they would like to get up and go to bed, and that appropriate actions are taken. Risk assessments must be completed in relation to service Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 7 users going out independently, and appropriate procedure put in place to ensure their safety. The policy on the Safeguarding of Vulnerable Adults must be reviewed to ensure that it complies with appropriate guidance. The whistle blowing policy must include the contact details of an external agency that staff may contact, such as CSCI. Duty rotas evidenced that there are not always sufficient staff on duty at all times to meet service users needs. Duty rotas showed that some staff had worked a significant number of hours without adequate periods of rest between shifts, thus potentially placing service users at risk. The home has not operated a robust recruitment procedure in relation to one staff member, who has frequently worked alone at the home. The file for this staff member does not contain evidence that they have not received appropriate first aid or moving and handling training. Some aspects of maintenance require attention to ensure that service users live within a safe environment. All records relating to service users must be stored securely in accordance with the Data Protection Act and must be available for inspection. 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 DS0000016026.V335823.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, & 5. (Standard 6 does not apply). Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective service users are provided with some information regarding the home. The Statement of Purpose and Service User Guide need updating to ensure that they provide all necessary information. Service users had not been provided with a written contract outlining the terms and conditions of their stay. Prospective service users have the opportunity to visit the home, and assess the facilities provided. EVIDENCE: The home has a Statement of Purpose that provides details of the services and facilities provided. This document was examined during the inspection and it Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 10 was found that this did not contain the name and address of the Registered Provider and Manager, the arrangements for consultation with service users regarding the operation of the care home, or the complaints procedure. The Service User Guide provides further information regarding the service provided, the accommodation, and qualifications of staff. Some information, such as that relating to staffing numbers and qualifications was out of date. The Service User Guide must also include a copy of the most recent inspection report, a copy of the complaints procedure and service users’ views of the home. The Inspectors were provided with a copy of the written contract. This provides details of the room to be occupied, the care and services provided and any costs not included in the weekly fee. The contract did not provide details of the fees payable by the service user, Local Authority, or relative. A signed copy of the contract was not found within any of the service user files examined. Six service user plans were examined. During this inspection it was found that an assessment of need had been completed prior to three service users being admitted to the home. The assessment for the fourth service user had been completed after they had moved into the home. A further assessment had not been signed or dated. One service user plan did not contain evidence of a preadmission assessment being completed. Following the inspection, the Registered Manager provided further information regarding pre-admission assessments for all service users at the home. This confirmed that the assessment for one service user had not been signed and dated, and that for two further service users, the records did not clearly evidence that an assessment had taken place prior to them being admitted to the home. The Registered Manager advised that service user files have now been re-organised so that these may be more easily accessible. Service users confirmed that they had been encouraged to visit before making a decision to move into the home. Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Care plans generally provided staff with appropriate information to meet service users personal care needs. Assessments had not been regularly reviewed, and appropriate plans had not always been developed where high levels of pressure sore or nutritional risk were identified. Some care plans did not contain sufficient detail to enable staff to fully meet service users health and dementia care needs. Records did not evidence that health care services had always been called appropriately. Medication records had been appropriately maintained. Some medications and the key to the medication cabinet had not been stored securely. Service users confirmed that staff treat them with dignity and respect. Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 12 EVIDENCE: Care plans are maintained for each service user. Copies of assessments and correspondence are kept within the office, whilst plans to address identified needs are stored within service users’ rooms. During the course of this inspection, six care plans were examined in detail. Care plans included a photograph of the service user. Care plans generally provided clear instructions to staff on how to meet service users personal care needs. One of the care plans seen had been signed by the service user. This is good practice, and should be encouraged for all service users, where appropriate. Daily records are maintained and monthly summaries completed. Staff must ensure that daily entries contain sufficient detail. For one service user the monthly summary made reference to an incident that was not evidenced in the daily records. Moving and handling assessments had been completed for all service users. The moving and handling assessment for one service user, and some nutritional and pressure risk assessments had last completed on 31.05.05. Not all documentation had been signed or dated. Pressure risk assessments had been completed for each service user. Within the care plan for one service user who was assessed as being at high risk, there were clear instructions to staff outlining the actions to be taken to address this, however this was not evident in each of the care plans where a high risk of pressure risk was identified. The daily records for one service user stated: ‘very small breaks between buttocks applied sudocrem and notified Melanie’. The records did not contain evidence of the District Nurse being contacted to assess the wound or provide any pressure relieving equipment. Nutritional risk assessments had been completed. The pre-admission assessment for one service user stated that they had a poor appetite. Weight records indicated that they had lost 3.5 kg between September 2006 and March 2007, however there was not a nutritional care plan in place to address this need. The review completed for a further service user stated that they did were not drinking sufficient fluids and that they should have 1.5 litres per day. However it was not apparent how this was being monitored to ensure that this need was being met. One service user has non-insulin dependent diabetes. The care plan states that staff should ‘observe for signs of hypo/ hyperglycaemia’, however it does not describe these symptoms. The care plan does not provide details of the Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 13 normal BM range for this service user, or the actions to be taken by staff should it fall above or below this range. The daily records for one service user states that they ‘keep having nosebleeds, however it is not clear from the records whether advice has been sought from the GP regarding this and the care plan did not give clear instructions to staff on what to do if a bleed should occur. A detailed care plan had been developed to ensure that appropriate infection control measures are taken in relation to one service user who has MRSA. Appropriate plans had been developed where service users were identified as being at risk of falls. One service user has dementia and requires a high level of support and supervision from staff members. Glen Lyn is not registered to provide dementia care, and as a small home does not have sufficient staff on duty to fully meet this service users’ needs. The daily records for this service user state that they can be ‘very aggressive’ however a specific plan or risk assessment had not been developed to address this, and the home does not have a policy on managing aggression. Accident records were examined for the period from the last key inspection until this visit. It was found that one service user had suffered a high number of falls, and that during one afternoon they had five falls. The records state that on three of these occasions they hit their head, however records do not evidence that the GP was contacted. On a further occasion the records state that they were ‘very vague and not responding to my questions’. Again there is no evidence that the GP was contacted. A number of falls are recorded for a second service user. However there is no plan of action identified in the monthly audit of accidents and incidents at the home. Care plans included evidence of service users being referred to the Continence Nurse, Rehabilitation team, and District Nursing Team. A chiropodist regularly visits the home. Denture cleaning tablets were found within a further four service users rooms. Denture cleaning tablets can pose a serious risk of injury if swallowed; therefore a risk assessment must be completed in relation to each service user who has access to these. The recording, administration and storage of medication was examined. Medication had been stored securely within locked cupboards. However, the key was not held securely and was on the worktop, and potentially may have been accessed by any staff member, service user or visitor to the home. The home has appropriate storage arrangements for Controlled Drugs. The Registered Manager advised that the home does not hold any homely remedies Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 14 and would request a prescription from the GP should a service user require these medications. Medication Administration Records (MARs) included a photograph of the service user. MAR charts had been appropriately maintained. An opening date had been recorded for prescribed creams. The home has a copy of the BNF providing information on medication, and patient information sheets are maintained. The care plan for one service user evidenced that the GP had been contacted to request a change of medication, as the prescribed analgesia was causing constipation. A risk assessment had not been completed in relation to one service user who self-medicates a prescribed cream. The home maintains a record of medication that is returned to the pharmacy. A quantity of medication was found within the office. The Registered Manager advised that this was duplicate medication sent from the service users previous pharmacy. Medication that is awaiting return to the pharmacy must also be stored securely. The Registered Manager completed an audit of medication records and administration on 2/4/07, and confirmed that appropriate actions have been taken to address the issues raised. Service users spoke highly of the care that they receive. Staff were observed knocking on doors before entering and interaction was friendly and respectful. Service users confirmed that they are treated with dignity and that staff always come quickly when they ring the bell. Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 15 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 !5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A range of activities is provided. Service users are encouraged to maintain links with the community. Service users do not exercise choice and control over the times that they get up and go to bed. Service users generally gave positive feedback regarding the meals provided. EVIDENCE: Service users generally stated that there were sufficient activities provided to meet their social needs. Service users are able to participate in a range of activities including: exercise, arts and crafts, games and puzzles. On the day of the inspection one service user was going for a walk with a member of staff. Service users may arrange for a member of care staff to support them with additional activities on a one-to-one basis at the cost of £6 per hour. Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 16 Care plans address social and spiritual needs. Life histories had not been completed. One service user stated that they ‘had no-one to chat to’ and appeared socially isolated. Some service users are able to go out independently to access facilities in the town centre and go to the seafront. The care plans for these service users were examined, and appropriate risk assessments had not been completed for them going out alone. There were no clear plans in place for the actions that should be taken, if the service user not return at the time they had stated. One service user attends Stroke Club. Service users confirmed that trips are provided. A minister regularly visits the home, to spend time with those service users who wish them to. Details of the Age Concern Advocacy service are displayed. Many of the service users spoken with stated that they had breakfast very early in the morning, around 6- 6.30am, as this is provided by the night staff. Service users also explained that they are encouraged to go up to their bedroom during the early evening, for example they are told ‘I have put your TV on upstairs’ so that staff can clean the lounge and dining room. One service user stated that they go up to their bedroom from 5 pm onwards each evening. Service users are able to eat in the dining room, or their bedroom as they prefer. Tables in the dining room have been pleasantly laid. The home has just begun using the summer menu. The mid day meal was cold ham, boiled potatoes and salad, with vol-au-vents and salad for tea. The Inspectors discussed with the Registered Manager whether the calorific value of these meals were sufficient, and advised that she may wish to seek advice from the Dietician, to ensure that the menu meets the needs of the service user group. The home had good stocks of fresh fruit and vegetables available. One service user felt that it was a long time between tea at 4.30-5pm and breakfast at 6.30am. The Registered Manager advised that a snack is available later in the evening, and will ensure that service users are aware that this is available. Generally service users provided positive feedback on the meals provided. Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are confident that their complaints will be listened to and taken seriously. Policies on adult abuse, whistle blowing and managing aggression must be further developed to ensure that service users are not put at risk. EVIDENCE: The home has a complaints procedure. There have been no complaints received by the home since the last inspection. Staff and service users spoken with during the inspection said that they would be able to raise any issues of concern, and felt that these would be taken seriously. The home has a policy on Adult Abuse. This states that the home should investigate the incident and interview the alleged perpetrator. This guidance does not comply with guidance provided by the Department of Health or Somerset County Council. The whistleblowing policy does not contain the contact details of an external agency that staff may contact, such as CSCI. Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 18 The home does not have a policy on managing aggression. Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 19 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): 19,20,21,22,23,24,25 & 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live within a comfortable environment. There are adequate communal areas, and bathing facilities to meet service users needs. Service users have the equipment they require to meet their needs. Service users rooms have been personalised to reflect service users individual tastes and preferences. Some aspects of maintenance require attention to ensure that service users live within a safe environment. The home has taken appropriate measures with regard to infection control. Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 20 The home had been maintained to a good standard of cleanliness. EVIDENCE: Glen Lyn is a large Victorian property situated close to the centre of Minehead and the seafront. The property has been pleasantly decorated and furnished. There is an ongoing programme of re-decoration within the home. Communal areas consist of a lounge and dining room. The carpet within the dining room has started to ridge and requires re-fitting. There is a garden at the rear of the garden that has a pond and seating areas for service users. The kitchen is situated at the rear of the property. There are six cupboards that have the doors missing. The Registered Manager has advised that this has been completed to create an open plan shelving area. The communal bathroom is located on the first floor. Service users have the choice of having a bath or shower. The enamel on the handrail in the shower has split and requires replacement. Some service user rooms have en suite toilet facilities. There was a malodour within one service users en suite bathroom. There is a toilet on the ground floor close to the communal areas. This room has also been used to store commodes and the hoist. Some equipment must be removed from this room, so that the base of the hoist does not cross in front of the toilet, and the hoist may be accessed easily. A broken wall light was found within the en suite bathroom for room 2. There are stair lifts to the first and second floor. These are not continuous; therefore service users must be able to transfer from one stair lift to the other. There is a bath hoist, and call bell system available to service users. Service user rooms are located on the ground, first and second floor. Service users are encouraged to bring personal possessions with them into the home when they move in. Since the last inspection, two service user rooms have been redecorated and had new carpets fitted. The carpet in room 1 requires cleaning. The headboard within room 11 is marked and requires thorough cleaning. Trailing wires were noted within some service user rooms, and appropriate action must be taken to ensure that they do not pose a risk hazard. The home is well ventilated. The window in room 4 is poorly fitting. Perspex has been fitted to one side, and paper and a towel to the other window to reduce draught. All window openings, (with the exception of room 5) that are above the ground floor have been restricted. The radiator in the en suite bathroom of the room on the second floor is the only hot surface that has not had a guard fitted. Portable heaters had been used throughout the property. Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 21 Risk assessments must be completed in relation to using these within the home. Hot water outlet temperatures were tested and found to be within appropriate limits. The home has emergency lighting fitted. This had been tested every three months. It is recommended that this is checked on a monthly basis. The laundry is situated in an outbuilding. The home has a domestic style washing machine. Alginate bags were available. Appropriate hand washing facilities, gloves and aprons had been provided for staff throughout the home. Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There have not been sufficient staff on duty at all times to meet service users needs. Some staff have been provided with the training required to undertake their role. The home has not operated a robust recruitment procedure. EVIDENCE: On the day of inspection there was the Registered Manager and one Care Assistant on duty. The Registered Manager advised that there are generally two staff on duty throughout the day and one waking staff at night. Duty rotas were examined for the period of 01/11/06 – 18/2/07. Some records have not been completed in full, and do not always record the hours worked by the Registered Manager and Provider. The duty rotas evidence that on occasions staff have worked alone between 1-3pm. Duty rotas also evidence that on 12/02/07 one person worked from 1-6.30pm, followed by a nightshift, then stayed on until 10.30am. On 14/02/07 a member of staff Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 23 worked from 3-6.30pm, then a nightshift finishing at 8am, and returned to work at 3pm the same day to work until 6.30pm. Following the concern raised with CSCI in March 2007, the Registered Manager has agreed that two staff will be on duty at all times. Since the visit to the home on 29th March 2007 the Registered Manager has completed dependency assessments in relation to service users needs. These have indicated that nine of the current service users have low dependency needs, and one person has medium dependency needs. The home have asked for this service user who has medium dependency needs to be re-assessed with a view to them being moved to a more suitable placement. The home has a small staff team. The Registered Manager is supported by seven care staff. The Registered Manager has advised that the home is currently advertising to fill two staff vacancies. Four of the seven care staff employed have obtained the NVQ level 2 qualification. During the visit to the home on 29th March 2007 an immediate requirement was made in relation to the recruitment procedure carried out for one staff member, as a full employment history, a second reference and a POVA First check had not been obtained prior to them commencing work at the home. This recruitment file and the file relating to a member of staff who has recently appointed were examined during this inspection. It was found that the outstanding documentation required on the 29th March 2007 had not yet been obtained. The training record for this member of staff did not contain evidence of first aid training, or moving and handling training taking place. Following the inspection, the Registered Manager has forwarded a copy of the record of Induction training for this staff member. The file for the second member of staff was found to contain all required documentation. The application form does not comply with Age Discrimination legislation and requires updating. A record had not been maintained of the interviews with these staff. Their staff files did not contain a copy of terms and conditions, or job description. A staff training and development plan is displayed the office, outlining which topics will be covered. These included: nutrition, medication, health and safety, first aid dementia, visual impairments and abuse. Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 24 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): 31,32,33,34, 35,36,37 & 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Registered Manager is an experienced manager and is approachable. Records relating to service users must be stored securely in accordance with the Data Protection Act, and Care Standards Act 2000 and must be available for inspection. Fire safety records, and equipment servicing records had been appropriately maintained. The Registered Manager must take further action to promote the health and safety of service users. EVIDENCE: Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 25 The Registered Manager is Melanie Reaney, who is a Registered Nurse. She has many years experience of providing care to older people and has obtained the Registered Managers Award. Staff and service users spoken with during the inspection spoke highly of the care that she provides, and stated that they would be able approach her to raise any issues of concern. The Registered Manager has a thorough quality assurance system, and annual audits have taken place regarding: activities, cleanliness, and medication. During the visit to the home on 29th March 2007 the Registered Manager advised the Inspectors that they also conduct a medication audit on a weekly basis, but that it is not formally recorded. This should be recorded to evidence the measures being taken to safeguard service users at the home. Surveys were last issues to service user in July 2006. There are not formal service user meetings. The Registered Manager provides a newsletter every three months that is sent to service users and their families. The home does not assist any service user in managing their finances. There is a lockable drawer or cash tin within each room for service users to store any valuables. Staff receive an appraisal every six months. A copy of the appraisal for one staff member was forwarded to CSCI. This addressed areas of practice and identified training needs. During the inspection supervision records were examined for five staff members. Staff had received supervision approximately every two months. The records maintained did not contain sufficient detail to evidence the aspects of practice addressed, or record any learning or development needs. During the previous visit to the Inspectors wished to examine care records and medication records for some residents who had previously resided at the home. The care plan for one service user could not be located, and the medication records for a further service user have subsequently been forwarded to CSCI following the visits. The Registered Manager must ensure that the records are stored securely and in accordance with the Data Protection Act 1998 and Care Standards Act 2000. Records relating to service users must be stored for three years, and be available for inspection. Fire safety records were examined. Fire safety equipment had been serviced and tested as required. All staff members had received appropriate fire safety training. The hoist, bath hoist, and stair lift had been serviced in accordance with LOLER Regulations. The gas safety certificate and electrical hard wiring certificate had been appropriately maintained. The wheelchairs are regularly checked. The home has procedures in place to reduce the risk of Legionella. Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 26 The home has completed a hazard identification and risk assessments in relation to food preparation. The Environmental Health Officer visited on 12/10/06. Action has been taken to address some of the requirements made. The fridge freezer still requires defrosting. As previously described within the Environment section, a number of maintenance issues require attention to ensure that service users live within a safe environment. The cover to the boiler is loose, exposing the motor workings. This must be secured to ensure that it does not pose a risk to service users. Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 27 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 2 1 2 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 1 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 2 3 2 3 3 2 2 3 STAFFING Standard No Score 27 1 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 2 1 2 Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 28 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 OP1 Regulation 4 (1) [c] Requirement The Statement of Purpose must be amended to ensure that it contains: - the name and address of the Registered Provider and Manager - the arrangements for consultation with service users regarding the operation of the care home - the complaints procedure. The Service User Guide must be amended to ensure that it contains: - a copy of the most recent inspection report - a copy of the complaints procedure -service users’ views of the home. 2. Glen Lyn Timescale for action 22/06/07 OP2 5 (1) [a] &3 The written contract must contain details of the fees DS0000016026.V335823.R01.S.doc 31/05/07 Version 5.2 Page 29 payable by the service user, Local Authority, or relative. A copy of the contract must be given to each service user. 4. OP7 15 (1) Care plans must be reviewed monthly and specific plans of care updated as required. Moving and handling assessments must be regularly reviewed. Care plans must contain evidence of consultation with service users. Entries within care plans must be signed and dated. 5. OP8 15 (1) & Schedule 3 Pressure risk and nutritional risk 11/05/07 assessments must be regularly reviewed, and an appropriate plan of action developed where a service user is identified as being at risk. Service user weights must be regularly reviewed so that any change in weight can be identified and appropriate actions taken. The diabetes care plan must include details of the symptoms of them becoming hypo or hyperglycaemic. It should also record their normal BM range and the actions to be taken by staff should it fall above or below this range. Staff must be provided with clear instructions regarding the actions they are to take when an individual service user becomes aggressive. Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 30 11/05/07 Care plans must include details how a specific plan of action will be monitored to evidence that it is meeting the assessed need. Service users must be provided with appropriate support to access health care services when they are unwell, or have suffered a fall. This must be recorded within the care plan. Individual risk assessments must be completed in relation to the use of denture cleaning tablets. 6. OP9 13 (2) The key to the medication cupboards must be kept by the person who is responsible for administering medication during that shift. All medication must be stored securely. A risk assessment must be completed in relation to a self administration of medication, for the one service user who selfmedicates a prescribed cream. 8. OP13 13 (4) [b] Risk assessments must be completed in relation to service users going out independently, and appropriate procedures put in place, for example if the service user does not return at the time they had stated, for example, how long staff would wait before going to look for them, or contacting the Police. Service user views should be sought regarding the time they get up and go to bed. These preferences should be recorded with their care plan, and DS0000016026.V335823.R01.S.doc 27/04/07 04/05/07 7. OP14 12 (2) 04/05/07 Glen Lyn Version 5.2 Page 31 appropriate action taken. 8. OP18 13 (6) The policy on the Protection of Vulnerable Adults must be reviewed to ensure that it complies with guidance from the Department of Health and Somerset Social Services. The whistle blowing policy must include the contact details of an external agency that staff may contact such as CSCI. The Registered Manager must develop a policy on the management of aggression. 9. OP19 23 (2) [b] The following aspects of maintenance must be completed: - carpet within the dining room has become loose, and required re-fitting. - the hand rail within the shower must be replaced. - the wall light within the en suite bathroom of room 2 must be repaired. 10. OP21 23 (2) [j] Appropriate action must be taken to address the malodour within one en suite bathroom. Equipment must be removed from the ground floor bathroom, so that the hoist does not pose a trip hazard to service users accessing the toilet, and the hoist can be easily accessed. 11. OP24 23 (2) [d] & 13 (4) [a] The carpet within room 1 requires cleaning. The headboard in room 11 Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 32 25/05/07 25/05/07 04/05/07 04/05/07 requires cleaning. Appropriate action must be taken to ensure that service users are not at risk from trailing wires within their rooms. 12. OP25 23 (2) [b] Appropriate action must be taken in relation to the poorly fitting window in room 4. Risk assessments must be completed in relation to: - the use of portable heaters - the unguarded radiator in the en suite bathroom of room 11 and any appropriate action taken. 14. OP27 18 (1) [a] & 13 (4 ) [c] There must be sufficient staff on duty at all times to meet service users needs. Staff must be provided with appropriate periods of rest between shifts. 15. OP29 19 (1) (b) (i). It is required that the manager ensures that all staff employed at the home have information in accordance with Schedule 2 of the Care Home Regulations 2001 on their recruitment file. (Previous timescale of 30/11/06 not met). 16. OP30 18 (1) [c] (i) Staff must be provided with first aid and moving and handling training, and an appropriate record maintained. Records relating to service users must be kept securely in accordance with the Data DS0000016026.V335823.R01.S.doc 29/06/07 13. OP25 13 (4) [a] 01/06/07 27/04/07 16/04/07 25/05/07 17. OP37 17 (3) & 4 04/05/07 Glen Lyn Version 5.2 Page 33 Protection Act 1998, and Care Standards Act 2000 and be available for inspection. 18. OP38 13 (4) [a] The freezer must be defrosted. The cover to the boiler must be secured, to ensure that it does not pose a risk to service users. 04/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP12 Good Practice Recommendations It is recommended that the manager consider recording in each service users’ care plan, individual or group activities attended and service users feedback. It is recommended that the Registered Manager seek advice from the Community Dietician to ensure that the menu meets the needs of the service users. It is recommended that the emergency lighting be tested on a monthly basis. It is recommended that an interview record is maintained, and that staff are provided with a written statement of terms and conditions. It is recommended that supervision records include details of the areas of practice addressed, and any learning or development needs. 2. OP15 3. 4. OP25 OP29 5. OP36 Glen Lyn DS0000016026.V335823.R01.S.doc Version 5.2 Page 34 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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. 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