Inspection on 17/11/05 for Glen Lyn

This inspection was carried out on 17th November 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 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 Judith Roper Unannounced Inspection 17th November 2005 10:30 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 DS0000016026.V252806.R01.S.doc Version 5.0 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.V252806.R01.S.doc Version 5.0 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.V252806.R01.S.doc Version 5.0 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 14th June 2005 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. All bedrooms offer single accomodation and most rooms have an en-suite 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 DS0000016026.V252806.R01.S.doc Version 5.0 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 – 12 pm. 10 residents were at the home on the day of the inspection. There is currently one vacancy at the home. The inspector was able to see all 9 residents and 5 gave feedback about the service to the inspector. No relatives were at the home during the inspection. Staff on duty were able to give time to speak with the inspector. The proprietor and registered manager Mrs. Reaney was available for comment during the inspection. The inspector would like to thank the proprietor Mrs. Reaney for her and her staff time and hospitality shown to the inspector during her visit. This inspection focused on Standards not inspected or not met at the previous unannounced inspection in June 2005. Some other key Standards were also inspected. Records examined were one care plan, medication records, quality audits of facilities and audits conducted by the home, the fire system service record, menus, current employer’s liability insurance certificate, CSCI registration certificate and staff rosters. 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: No requirements or recommendations have been made at this unannounced inspection. 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 Glen Lyn DS0000016026.V252806.R01.S.doc Version 5.0 Page 6 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. 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 DS0000016026.V252806.R01.S.doc Version 5.0 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 DS0000016026.V252806.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 4. 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. There is an established care team who know the needs of residents and staff receive training appropriate to the care needs of the current residents. EVIDENCE: The home’s Statement of Purpose and Service User’s Guide has been updated and amended in 2005 to reflect current accommodation and services offered. The Taunton CSCI office holds a copy of these documents. A copy of the home’s Service User’s Guide is provided to every resident on admission. Staff working in the home are given training that is job specific. This includes supervised work practice, NVQ training and distance learning training on specific topics related to job role. All residents who expressed an opinion at the inspection were pleased with the care and service provided at the home. Glen Lyn DS0000016026.V252806.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 11. The care plan inspected was organised clearly and demonstrated resident consultation. This enabled staff to know the current needs the resident in order to give good quality care. There was evidence of regular consultation with community health care professionals to support the health needs of the resident. Medication is managed safely in the home with accurate records of medication administration. The home sources appropriate health care professionals for support for palliative or terminal care. The staff have appropriate skills to care for vulnerable residents. EVIDENCE: One care plan of a recently deceased resident was inspected. The individual plan of care was organised clearly, had risk assessments and clinical dependency analyses and was person centred. There was an assessment of falls and a night care plan included in the overall plan. The care plan has been reviewed on a monthly basis and there was good record keeping of consultation with G.P or district nursing services. Care plan summaries are in individual’s room giving residents easy access to their plan of personal care. Glen Lyn DS0000016026.V252806.R01.S.doc Version 5.0 Page 10 The practice at the home is to review care plans on a monthly basis with the resident. This is good practice. The proprietor and registered manager Mrs. Reaney is a registered general nurse and such she has the skills and knowledge to detect community nursing assistance required for any resident without delay. The home has established links with MacMillan nursing care teams for support for equipment or medication in managing palliative or terminal care, but Mrs. Reaney also is aware of the skill mix in her staff team and hence the need for re-assessment of a resident’s need for a nursing home placement should this be more appropriate for the individual. 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. Several staff have recently undertaken an extended course in medication training. Mrs. Reaney also conducted a medication audit at the home in September 2005 as part of her in-house quality assurances audit. This is good practice. Both the medication records inspected and medication storage in the home was satisfactory. Glen Lyn DS0000016026.V252806.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14, 15. Residents spoken with confirmed the flexibility of the daily routine at the home although some appreciated a more set individual routine that had been agreed with them in order to manage some of their worries or daily anxieties. Residents can also help with cooking, or preparing the dining room and this adds to the homely atmosphere at Glen Lyn. Meals are set to a rolling four week menu but individual variation from the daily menu is respected and catered for. EVIDENCE: The home has a weekly activities schedule displayed on the notice board by the front door. Exercise, hairdressing and cooking opportunities are provided. 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. Residents said that the daily routine was flexible to allow for then to rise or retire at their own pace and others said that they needed a more structured daily routine and this was agreed between them and the home as it helped them with their memory or reduced anxiety. Glen Lyn DS0000016026.V252806.R01.S.doc Version 5.0 Page 12 Lunch was observed being prepared at the home. Mr. Reaney does most of the cooking on weekdays and care staff cook at weekends. Mrs. Reaney was cooking a homemade lunch on the day of the inspection. Resident individual choice was offered in addition to the usual rolling four weekly menu. The kitchen was clean. 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 DS0000016026.V252806.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17. There have been no complaints made to the home since the last inspection. At the last inspection residents confirmed that any issues of concern raised by residents are treated at Glen Lyn seriously and without prejudice. Residents confirmed that they had the opportunity to take part in the civil process at the last general and local elections in May. Resident’s rights are part of the staff training induction and NVQ package. EVIDENCE: Mrs. Reaney keeps a concerns and complaints book at the home. There have been no complaints made to the home since the last inspection nor has the CSCI received any complaints in this timescale about the home directly. The home’s complaints procedure is supplied to residents with the Service User’s Guide. Residents confirmed that they had exercised either a postal vote or visited the local polling station if this was their wish at the May elections. Glen Lyn DS0000016026.V252806.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 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. The home is clean and inviting, providing a good standard of attention to keeping the premises hygienic and the risk of cross infection low. EVIDENCE: All bedrooms at Glen Lyn are for single occupancy. Most rooms have an ensuite 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. 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 of the inspection. Cross infection and Glen Lyn DS0000016026.V252806.R01.S.doc Version 5.0 Page 15 infection control measures are organised well. The laundry facility is being moved over to a more spacious area of the home, thus freeing up a room for clinical and office tasks. Residents may come and go at the home as they choose but must inform a staff member and sign out. Glen Lyn DS0000016026.V252806.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30. Staffing at the home is stable and sufficient numbers of staff are on duty to care for the current residents and their fairly low levels of dependency. Half of the care staff employed hold an NVQ qualification indicating a skilled workforce. In addition some staff are currently studying toward this award and there is a commitment by the proprietors to on-going staff training that is organised on an annual staff training cycle. EVIDENCE: There are currently no staffing vacancies at the home. A minimum of two 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 current needs of the mix of residents in the home. Staff are encouraged to achieve NVQ awards in care. Most care staff have achieved or are working towards this care qualification. Some staff hold care qualifications beyond the minimum level 2 NVQ and this is good practice. One night worker does not have this award and it is advised that the proprietors try to encourage the staff member to gain this award due to them lone working at night. A professional care qualification held by all night staff would support the proprietor’s arrangement of lone night working (with on call support) more robustly by demonstrating the breadth of independently assessed competency of the night workers. Staff application forms have been amended as recommended at the last inspection to include a statement regarding exemption of the Rehabilitation of Glen Lyn DS0000016026.V252806.R01.S.doc Version 5.0 Page 17 Offenders Act 1974 and a staff declaration regarding this criminal convictions disclosure, in addition to CRB/POVA checks routinely sourced. There have been no new staff employed since the last inspection. Staff induction is linked to Skills Council competencies and the home has an annual staff training plan that meets statutory requirements and addresses clinical needs in the home. Glen Lyn DS0000016026.V252806.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 36, 37. Management at the home is highly organised with systematic managerial processes and procedures, thus giving a strong managerial direction at the home. Formal quality assurance processes are regularly carried out to assess the effectiveness of the service and satisfaction of the residents who use the service. Staff are supervised and are given structured opportunities to discuss their job role and training needs. Records are maintained and stored appropriately. Residents have convenient access to their personal/private care records. 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. The home conducts a number of internal quality assurance audits throughout the year that are ordered and methodical. The results of quality audits are published in the home’s seasonal in-house newsletter, which is given to all residents and next-of-kin. Glen Lyn DS0000016026.V252806.R01.S.doc Version 5.0 Page 19 Occupancy levels are high and there are no staffing vacancies. The home displays a current certificate of employer’s liability insurance. Formal staff supervision with records of the session takes place approximately every two months. Mrs. Reaney also carries out regular supervised practice of staff such as in observing medication administration or personal care tasks. Records are stored securely but every resident also has a summary of their care plan for their own information in their private bedroom. The fire alarm system was routinely serviced the day before the unannounced inspection and no recommendations were made to the home by the servicing engineer as a result of this servicing visit. Glen Lyn DS0000016026.V252806.R01.S.doc Version 5.0 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 3 X X 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 X 3 X X X X X X 3 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 X X 3 3 X 3 3 X Glen Lyn DS0000016026.V252806.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 DS0000016026.V252806.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street 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. 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