Inspection on 14/06/05 for Glen Lyn

This inspection was carried out on 14th June 2005.

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 22/10/07

Glen Lyn 12/04/07

Glen Lyn 03/10/06

Glen Lyn 17/11/05

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 Judith Roper Unannounced 14th June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Glen Lyn D53 - D02 S16026 Glen Lyn V231079 140605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Glen Lyn Address 2 Tregonwell Road Minehead Somerset TA24 5DT 01643 702415 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Stephen Reaney Mrs Melanie Ann Reaney Mrs Melanie Ann Reaney Personal Care Home Only 11 Category(ies) of Old Age (11) registration, with number of places Glen Lyn D53 - D02 S16026 Glen Lyn V231079 140605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 9th February 2005 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. All bedrooms offer single accomodation and most rooms have an ensuite facility. The home has been awarded a block contract for 8 rooms with Somerset Social Services. The Registered Providers are Mr and Mrs Reaney. Mrs Reaney is also the Registered Manager. Glen Lyn has been pleasantly decorated and furnished, and offers a comfortable, homely environment. There is an assisted bathroom, stair lift and call system available at the home. Glen Lyn D53 - D02 S16026 Glen Lyn V231079 140605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day between the hours of 10.30 am – 2 pm. 11 residents were at the home on the day of the inspection. There are currently no vacancies at the home. The inspector was able to see all residents and to speak with most. No relatives were at the home during the inspection. All staff on duty were able to give time to speak with the inspector. Both owners were available for comment during the inspection. The inspector would like to thank the proprietors Mr. and Mrs. Reaney for their time and hospitality shown to the inspector during her visit. This is the first inspection using the new CSCI reporting format, which focuses on outcome statements for National Minimum Standards. The inspector’s aim on this inspection visit was to seek views on the quality of the service from as many service users as possible and to speak to staff and any visiting relatives (if available). Records examined were care plans, pre-admission assessments, Statement of Purpose and Service Users’ Guide, complaints and concerns records, staff recruitment files and medication records; other records will be examined at subsequent inspection visits. What the service does well: What has improved since the last inspection? What they could do better: The owners are planning to alter the premises to improve upon laundry facilities. Laundry facilities are currently adequate but the new laundry area Glen Lyn D53 - D02 S16026 Glen Lyn V231079 140605 Stage 4.doc Version 1.30 Page 6 will improve access and space. The lounge at the home is acknowledged by the manager to be small in order to seat all 11 residents comfortably. Some residents choose to stay in their rooms and this puts less demand upon the communal space available. However, there is alternative space provided in the dining room for residents to see friends and family. One requirement and four recommendations have been made as a result of this inspection visit. The requirement relates to the display of the registration certificate. Recommendations are made regarding medication storage, obtaining a current medication reference book, staff application forms and residents’ contracts. 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 Lyn D53 - D02 S16026 Glen Lyn V231079 140605 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Glen Lyn D53 - D02 S16026 Glen Lyn V231079 140605 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5. Standard 6 is not applicable. The home has useful and informative printed documents available to prospective residents and their families in order for them to make an informed decision whether to choose Glen Lyn as a care home. Mrs. Reaney is careful and robust in her pre-admission assessments and information gathering about new residents in order to ensure that the home can meet resident’s needs. EVIDENCE: The home’s Statement of Purpose and Service User’s Guide has been updated and amended to reflect current accommodation and services offered. Mrs. Reaney is forwarding a copy of these amended documents to the Taunton CSCI offices for their records. A copy of the home’s Service User’s Guide is provided to every resident on admission. Residents have either a private contractual arrangement with the home or a social services contract. It was recommended to Mrs. Reaney that also included in the home’s contract be a clause outlining why a room move may be Glen Lyn D53 - D02 S16026 Glen Lyn V231079 140605 Stage 4.doc Version 1.30 Page 9 indicated from the contracted room. This could be under urgent health and safety reasons, mobility decline, redecoration etc. Outlining this in the contract would give transparency and protection to both parties. Mrs. Reaney conducts thorough pre-admission assessments for prospective residents and obtains community health assessments for new residents. Staff working in the home are given training that is job specific. Some residents spoken with during the inspection had received information about the home prior to admission; others had been admitted under the block contract scheme without visiting the home before moving in. All residents asked were pleased with the care and service provided at the home. Glen Lyn D53 - D02 S16026 Glen Lyn V231079 140605 Stage 4.doc Version 1.30 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 standard(s) 7,8,9,10. Care plans are accurate and organised clearly with resident consultation. This enables staff to know the current needs of residents in order to give good quality care. Mrs. Reaney has good working relationships with local GPs and district nurses. She is therefore able to work closely with community health care professionals who respect her skills and opinions. The secure storage of medication in the kitchen is fine, but care needs to be taken to ensure that the heat generated in the kitchen though cooking does not compromise the optimal temperatures for storage for some medications. Residents said that their privacy and dignity is maintained at the home. This is an indicator that the home is managed professionally and that resident’s are respected as individuals. EVIDENCE: Four care plans were inspected. They were organised clearly, had current risk assessments and clinical dependency analyses and were person centred. Care staff on duty said that they use care plans daily and that they find them useful in guiding care needed for each residents. Care plan summaries are in Glen Lyn D53 - D02 S16026 Glen Lyn V231079 140605 Stage 4.doc Version 1.30 Page 11 individual’s room and some residents spoken with were aware of their care plans. Care plans demonstrated that residents had been consulted in the formation and review of the plans. Care records demonstrated that appropriate community health care professional support is obtained for residents. The district nurse was visiting a resident during the inspection for leg ulcer care. As Mrs. Reaney is a registered general nurse she has the skills and knowledge to detect community nursing assistance required for any resident without delay. Medication records were inspected. Mrs. Reaney audits medication records weekly. This includes bringing to attention any gaps or omissions in records to the responsible staff member. 5 staff members are currently in the process of completing an extended course in medication training. This is commendable. It was recommended to Mrs. Reaney during the inspection that she obtain a current edition of the British National Formulary (BNF) prescribed medications guide, as her copy in the home was several years old. It was also recommended that as the medications are stored in two locked cupboards in the kitchen, which can become hot when cooking is taking place, that thermometers are obtained for the cupboards to ensure that medications are not stored above 25 degrees Celsius. Daily records should be maintained and remedial action taken if this temperature is exceeded. Residents spoken with confirmed that their dignity and privacy is maintained by staff at the home. Residents can lock their bedroom doors if they choose and hold the key. During the inspection staff were observed knocking on the doors of resident’s bedrooms and waiting for the residents to invite them into the room before entering. Glen Lyn D53 - D02 S16026 Glen Lyn V231079 140605 Stage 4.doc Version 1.30 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15. The owners provide and review activities at the home to ensure that residents are occupied, entertained and fulfilled. Visitors are welcomed and residents know that they may invite whom they choose into the home. Meals are liked by residents in terms of variety, quantity and choice. Residents can also help with cooking, or preparing the dining room and this adds to the homely atmosphere at Glen Lyn. EVIDENCE: The home has a weekly activities schedule displayed on the notice board by the front door. Exercise, hairdressing and cooking opportunities are provided. Residents said that they enjoyed scheduled trips out and also make their own arrangements for going out with friends and family. Several residents were knitting or completing crosswords from the daily paper after lunch in the lounge. The lounge is quite small and therefore residents use the dining room or their bedrooms if they want to see visitors in a more private space. There is a patio area in the back yard for use by residents in good weather. The seaside town of Minehead also provides ample public spaces for residents to enjoy with friends and family. If the risk assessment is favourable, residents can and do have facilities for making hot drinks in their rooms. The visitors’ book indicated that friend and families visit frequently at various times of the day or week. Glen Lyn D53 - D02 S16026 Glen Lyn V231079 140605 Stage 4.doc Version 1.30 Page 13 Lunch was observed being prepared at the home. Mr. Reaney does most of the cooking on weekdays and care staff cook at weekends. Residents confirmed that choice is offered for meals and that alternatives can be provided for something different other than the rolling four weekly menu. All residents spoke positively regarding the quality of meals provided at the home. The proprietors confirmed verbally that all staff who cook at the home hold a current food hygiene certificate. The kitchen was clean and organised. Cleaning rotas for the kitchen were seen. The dining room at the home is pleasant. Residents can have their meals in their room if they prefer this. Mrs. Reaney monitors resident’s weights and nutritional assessments for residents are regularly reassessed to ensure that residents are receiving adequate sustenance and nutrition. Glen Lyn D53 - D02 S16026 Glen Lyn V231079 140605 Stage 4.doc Version 1.30 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16.18. Issues of concern raised by residents are treated at Glen Lyn seriously and without prejudice. Staff feel comfortable expressing their views to the owners. This creates an atmosphere of openness and sincerity at the home. EVIDENCE: Mrs. Reaney keeps a concerns and complaints book at the home. This was examined. The book shows a clear record of issues raised and of remedial action taken with outcomes. There have been no complaints raised since the last inspection visit. The home’s complaints procedure is supplied to residents with the Service User’s Guide. During the inspection one resident raised an issue to do with minor maintenance in his room to Mrs. Reaney. She agreed a plan to rectify this with the resident. Other residents also told the inspector that they find both owners and staff approachable and sympathetic to issues or concerns raised. Staff on duty spoken with confirmed that the owners are approachable and that the ethos at the home is open and frank. Mrs. Reaney completes POVA first and CRB checks for new staff prior to them commending duties. Glen Lyn D53 - D02 S16026 Glen Lyn V231079 140605 Stage 4.doc Version 1.30 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25,26. The environment at Glen Lyn is homely and comfortable providing a relaxing atmosphere is which to live. The communal lounge is a little small and could only seat all 11 residents at a squeeze. However, the present residents are comfortable as not all choose to use the lounge at one time. EVIDENCE: All bedrooms at Glen Lyn are now for single occupancy. Most rooms have an en-suite facility. Rooms are situated on the ground, first and second floor. There is a stair lift for access to the upper floors. Residents on the upper floors therefore need to have a good level of independent mobility. The home has a mobile patient hoist available and an assisted bath. There are two communal bathrooms. Residents have the choice of a bath or shower. Communal space comprises of a lounge and a separate dining room. There is some garden space provided. There is a toilet close to the lounge for residents to use. All 11 resident’s bedrooms were seen. Bedrooms are personalised and comfortable. Call bells are available in bedrooms, toilets and bathrooms and communal areas. The home was clean to a good domestic standard on the day Glen Lyn D53 - D02 S16026 Glen Lyn V231079 140605 Stage 4.doc Version 1.30 Page 16 of the inspection. Cross infection and infection control measures are robust and organised well. The laundry facility is adequate but the owners are planning to improve this facility in the near future by relocating the laundry to a different area of the house. Residents may come and go at the home as they choose but must inform a staff member and sign out. A resident confirmed this protocol. The home currently meets the requirements of the local fire brigade station. Glen Lyn D53 - D02 S16026 Glen Lyn V231079 140605 Stage 4.doc Version 1.30 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29. Staffing at the home is stable and sufficient numbers of staff are on duty enabling residents to receive continuity of care and person attention. More than half of the care staff hold an NVQ qualification indicating a skilled workforce. Recruitment practices are robust in order to protect vulnerable adults. EVIDENCE: There are currently no staffing vacancies at the home. A minimum of two care staff are on duty during the day and at night there is a waking staff member in the home and an on-call staff member either on the premises or at the owner’s home in the next street. Staffing levels are sufficient to meet the needs of the mix of residents in the home. Staff are encouraged to achieve NVQ awards in care. Most care staff have achieved this care qualification. Staffing recruitment files for 2 newly appointed staff members were examined. The information in the files was in accordance with Schedule 2 of the National Minimum Standards. A recommendation was made to Mrs. Reaney that she reintroduces the statement on staff application forms that the home is exempt from the 1974 Rehabilitation of Offenders Act and that staff sign a declaration regarding criminal convictions in addition to CRB checks. Glen Lyn D53 - D02 S16026 Glen Lyn V231079 140605 Stage 4.doc Version 1.30 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,35,37,38. Management at the home is highly organised and respected by staff and residents. Health and safety issues are addressed and kept under risk assessment review in order to keep the environment and residents safe. EVIDENCE: Mrs. Reaney is a registered general nurse and she holds the Registered Manager’s Award. Glen Lyn is quality rated by Somerset County Council. Both residents and staff alike said that they find Mrs. Reaney approachable and tolerant. Systems of management in the home appeared ordered and methodical. Staff on duty said that they are given direction, support and supervision from Mrs. Reaney. Glen Lyn D53 - D02 S16026 Glen Lyn V231079 140605 Stage 4.doc Version 1.30 Page 19 The home is not currently managing any financial affairs on behalf of residents. Extra fees or personal shopping is invoiced to the residents. The home’s management is not currently handling personal cash of residents. Records were stored securely and a discussion was held regarding repositioning some personal information about a resident in their bedroom to a more discreet place in that room. COSHH chemical risk assessments and safety data sheets were organised well. Mrs. Reaney conducts a monthly audit of any accidents in the home to detect trends in order for remedial action/further risk assessment. Mrs. Reaney said that at all times there is at least one staff member on duty that holds a current first aid certificate. On the day of this inspection a qualified electrical was attending to some routine electrical maintenance work in the home. Glen Lyn D53 - D02 S16026 Glen Lyn V231079 140605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 x x 3 x 2 3 Glen Lyn D53 - D02 S16026 Glen Lyn V231079 140605 Stage 4.doc Version 1.30 Page 21 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP37 Regulation Care Standards Act 2000. Part II, Section 28 (1). Requirement Both pages 1 and 2 of the Registration Certificate must be displayed in a conspicuous place in the home. Timescale for action 14/07/05. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP2 Good Practice Recommendations It is recommended that stated in the residents contract be reasons why a move from the contracted room to an alternative room in the house may be indicated (such as decreased mobility, urgent health and safety considerations etc). It is recommended that the manager obtains a current edition of the British National Formulary (BNF) prescribed medication guide. It is recommended that the manager purchases thermometers to record the temperatures in the two cupboards in the kitchen where medications are stored. The temperature inside the cupboard should not exceed 25 degrees Celsius and daily records should be maintained. It is recommended that the manager reinstates the statement of exemption under the Rehabilitation of D53 - D02 S16026 Glen Lyn V231079 140605 Stage 4.doc Version 1.30 Page 22 2. 3. OP9 OP9 4. Glen Lyn OP29 Offenders Act 1974 on staff application forms and that staff sign this declaration regarding criminal offenses/cautions. Glen Lyn D53 - D02 S16026 Glen Lyn V231079 140605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Glen Lyn D53 - D02 S16026 Glen Lyn V231079 140605 Stage 4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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