Inspection on 22/07/08 for Glen Lyn

This inspection was carried out on 22nd July 2008.

CSCI found this care home to be providing an Adequate service.

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 11/07/07

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Glen Lyn 16 Glen Road Sarisbury Green Southampton Hampshire SO31 7FD Lead Inspector Jan Everitt Unannounced Inspection 22nd July 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Glen Lyn DS0000069887.V367459.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Glen Lyn DS0000069887.V367459.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glen Lyn Address 16 Glen Road Sarisbury Green Southampton Hampshire SO31 7FD 01489 602 222 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) joy.leach@saffronland.co.uk Mr Amin Lakhani t/a Saffronland Homes Group Mrs Joy Leach Care Home 43 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Glen Lyn DS0000069887.V367459.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - (PC) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE) 2. Old age, not falling within any other category (OP). The maximum number of service users to be accommodated is 43. Date of last inspection 11th July 2007 Brief Description of the Service: Glen Lyn is a forty-three bedded home registered with the Commission for Social Care Inspection to provide personal care to older people, some of whom may have dementia. Accommodation is provided in a two-storey building. There are nineteen single rooms and twelve shared rooms all with en-suite facilities. There is a wellmaintained enclosed garden to the rear of the building with easy access for service users. Glen Lyn is located on the outskirts of Park Gate village, which are the closest local amenities to the home. There is parking for visitors. The weekly fees range from £350:00 to £450:00. These fees do not include hairdressing, chiropody, newspapers, toiletries and other personal items. Glen Lyn DS0000069887.V367459.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection visit to the Glen Lyn formed part of the process of the inspection of the service to measure the service against the key national minimum standards. The manager returned the Annual Quality Assurance Assessment (AQAA) to the CSCI within the stated timescales and the focus of this visit to the home was to support the information stated in this document and other information received by the CSCI since the last fieldwork visit. The inspection visit took place on the 22nd July 2008 and the registered manager assisted the inspector throughout the visit. The inspector is referred to throughout the report as ‘we or us’ collectively, being a representative of the commission. The general manager of the organisation was also present during the visit. Evidence for this report was obtained from documents and records examined and talking to staff and observing their working practices. A visiting health professional was also spoken with to gain their views of the service. We also looked around the building. Due to a number of the residents having a diagnosis of dementia, verbal feedback was sometimes difficult to establish. However feedback was gained verbally from service users and from observations and non-verbal communication. Those spoken to were generally complimentary about their home and the care they receive. Surveys had been distributed to service users, relatives, care managers, GP and other visiting professionals. One service user survey and six staff surveys were returned to the CSCI. The outcome of the surveys indicated that the staff feel well supported and consider they receive appropriate training that appertains to their role and enhances their understanding of the service user’s needs. The survey received from the service user said that they always received the care and support they need. There were forty one residents living in the home at the time of this visit. None were from any other ethnic group. Glen Lyn DS0000069887.V367459.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The organisation’s head office now look after a number of service user’s monies and it has been reported that separate interest bearing savings accounts for those service users have been opened. There were no records of this in the home at the time of this visit. The home has provided fire training for staff twice in the last year and a questionnaire to complete in between the formal training to test knowledge. The home has individual risk assessments for all service users. Glen Lyn DS0000069887.V367459.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Glen Lyn DS0000069887.V367459.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 DS0000069887.V367459.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): 3 Standard 6 does not apply to this service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a system of assessing prospective service users needs to ensure that the home can meet that person’s needs. EVIDENCE: The manager told us that she and two care assistants, she has trained; undertake the pre-admission assessments either at people’s home or in the hospital setting. A sample of three service users files was viewed. The pre-admission assessments were not kept in the care plans but were in a separate folder. Of the three files viewed, two of the service users had been emergency admissions from Social Services into the step-down beds, they reserve on a permanent basis for this purpose, and therefore pre-admission assessments were not possible. However, the care manager’s care needs assessments are Glen Lyn DS0000069887.V367459.R01.S.doc Version 5.2 Page 10 sent to the home to give them information of the service user’s needs. These were evidenced in the two files. The third service user’s pre-admission assessment was viewed and contained comprehensive and relevant information. Assessments are broad, covering life history, interests and abilities. One staff member said they ask new residents what routines they had at home, such as what time they got up. This was noted to be documented in the care plans and assessments. St 6. This standard is not applicable to this service. Glen Lyn DS0000069887.V367459.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 adequate. This judgement has been made using available evidence including a visit to this service. Care plans provide care staff with information ensuring that service user’s needs are met. However, the plans need to be more personal centred and more specific to each service user. Health care needs are documented with a range of services available to meet service users health care needs. Medication records are accurate to ensure the safety of service users. Privacy is not consistently respected in the home. Staff treat service users in a respectful manner. EVIDENCE: A sample of four-service user’s care plans was viewed. The care plans were not person centred although they contained assessments for falls, skin integrity, nutrition manual handling, the care plans written to manage any risk were core care plans and written as the same for all with occasional specific action noted for that person. A nutritional risk assessment viewed for one Glen Lyn DS0000069887.V367459.R01.S.doc Version 5.2 Page 12 service user identified that there was a high risk of poor nutrition, but the care plan was not specific in describing how that should be managed and how often that person was to be weighed. This was discussed with the manager and she told us that all service users, if possible, are weighed monthly and the records for these are maintained in a separate file. During a tour of the building one resident was observed to be in bed and very unwell. There were fluid and food charts by his bed. These charts were not up to date and would not inform accurately the fluid and food intake of that person over a 24-hour period. It was observed that the care plans for this resident, whose needs were changing, did not reflect his current care needs. This was discussed with the manager who said that this resident’s needs changes daily and whether he stayed in bed, up in his chair or up in the lounge area, was dependent on how he was feeling on the day. The district nurse attended that day to monitor and reassess the resident, and suggested he be got out of bed for a short period of time. It was noted that there was an appropriate pressure relieving mattress and profile bed in place for this resident. There was no evidence of service users signing their care plans but the mental frailty of the residents would prohibit them from participation and agreement. Care plans were observed to being reviewed monthly for all service users. The care planning system was discussed with the manager who told us that the new computerised care planning system in currently being installed and she and the staff have yet to receive training. The organisation’s general manager was in attendance and showed us the new system on the computer and it was anticipated that this system would be more person centred and individualised for each service user. The manager said this would be operational within the next six months; therefore requirements will not be made around this standard. Records showed that residents have access to healthcare professionals such as doctors and nurses. At the time of this visit the GP visited the home to review some residents health status. District nurses visit residents who have pressure area needs and equipment is evident throughout the home, such as pressure relieving mattresses and cushions. Daily notes documented when a resident had had any medical interventions from health professionals. A chiropodist visits the home regularly and the home has a denture cleaning service contract. The manager told us that for those who have their own teeth, dentistry is a more difficult service to access, unless they have completed a special form, which the home has yet to obtain. A dentist will attend the home but residents with their own teeth have to pay for this service and the manager says that few residents have sufficient funds for this. Glen Lyn DS0000069887.V367459.R01.S.doc Version 5.2 Page 13 We observed part of a medication round, which was being undertaken by a senior carer. The correct procedures were followed and the resident was observed to take their medication at that time. There were no residents able to manage their own medication at the time of this visit. The medication administration records (MAR) were examined and these were found to be in order and documented appropriately, with coding to indicate why a service user had not had their medication. The medication records were examined. Medication and prescribed creams were stored appropriately. However, when visiting a bathroom, we observed that the cupboard in the bathroom was unlocked and was storing topical skin creams prescribed for a specific resident. This was discussed with the manager who conceded that this should have been stored in the resident’s own room, or if for some reason this was not possible, then stored in a locked environment and to be used only by that resident, for whom it was prescribed. The medication trolley is kept in a locked room when not in use. The cupboards were viewed and there was no evidence of over stocking of resident’s medication for ‘as needed’ use only. The room did not have hand washing facilities of paper towels and only washing up liquid as a hand wash. This was discussed with the manager who said she would ensure that full hand washing facilities were installed in this room. We audited the records in the controlled drugs register and found them to be correct. Senior staff have completed a Safe Handling of Medication course and these are the only staff that administer medication. The manager anticipates a refresher course on medication management and for more staff to undertake a medication course at the local college in the coming months. Staff gave examples as to how they respected residents’ privacy and dignity such as using screens, closing doors and curtains. Staff were observed to be respecting resident’s wishes in their daily activities. It was observed that staff and residents demonstrated respect within their relationships. We observed that when the GP was visiting the home a resident’s bedroom was being used as a consultation room and each resident was being taken to this room to see the doctor. A member of staff was spoken to and confirmed this was the arrangement. This is considered to be poor practice and an invasion of a person’s privacy. A resident’s room should not be used for any other purpose other than for that resident who occupies it. Glen Lyn DS0000069887.V367459.R01.S.doc Version 5.2 Page 14 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,& 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a range of social activities to meet service users needs. Service users are able to exercise choice and make decisions about their lives. Visitors are made welcome to the home and they can see service users in private. A varied menu is available and good quality food is served to service users, giving them choices EVIDENCE: The home does not employ a person specifically as an activities organiser. The home does not have an organised activities programme on display; just posters of what activities do take place. Carers told us that, whatever activities take place on a day to day basis and what activity is decided on is dependant on the service user’s moods, how service users are responding and the level of their participation in whatever group activity is taking place, there are, therefore no set days of the week for specific activities. Carers told us that activities do take place every day. Glen Lyn DS0000069887.V367459.R01.S.doc Version 5.2 Page 15 Service user’s life profiles are written describing their past life, social history, hobbies, occupation and family life. Much of this information is dependant on talking to relatives to gain details. One carer reported that these are very useful and are used by the carers to gain insight into what sort of activity or communication the service user will respond to. An example of this was the carer was helping a resident do a puzzle and she had chosen a puzzle of a picture of a country garden because she had read that this resident lived in the country and had enjoyed her garden and flowers. This enabled the carer to talk to the resident about this garden. We sat and observed the routine of the day. There was excellent interaction between the carers and the service users. There was a great deal of one to one activities going on and whilst one carer was playing soft ball with a service user they were talking about his childhood and the places he liked to visit. Another carer was playing scrabble with a service user and told us that he enjoys a game most days. The lounge area was a busy area and service users were observed to be wandering about quite freely and going out into the very pleasant garden to chat with one another. Two service users had struck up a friendship and were wandering and chatting together most of the day. All activities the service users take part in are recorded in individual files, these were seen and demonstrated that carers are not documenting the full extent of their interaction with the service user and not fully acknowledging the value of their talking to service users and stimulating their memories about their past histories before their dementia, as observed during the day. The home has recently had a sensory room installed. This was seen but the manager told us it has not been used to date. The home has now acquired the services of a visiting hairdresser who comes every week. One service user was asking if she could have her hair done and we observed a considerable number of lady residents had had their hair washed and set by the end of the day. The home has the use of the outings bus once a week and a carer told us that about four residents go out in the morning and the same number in the afternoon. They visit the seaside or go to the New Forest for tea. The residents are accompanied on the outing by staff. The home has an open visiting policy and visitors are offered drinks and there is a quiet area for them to see their relatives. The visitor’s book demonstrated that the home is visited regularly, but the manager told us that there are a number of residents who do not get many visitors. The care plans and assessments demonstrated that resident’s preferences and choices of times to go to bed and get up, likes and dislikes of foods are recorded. Staff told us they are aware of their preferences and one resident told us that she likes to get up early in the morning. Glen Lyn DS0000069887.V367459.R01.S.doc Version 5.2 Page 16 On looking around the home there was evidence that residents can bring items of personal belongings and furniture. Most rooms had been personalised, however there was evidence of some rooms being very sparse. The manager told us that some residents do not have relatives and therefore the home attempts to personalise the rooms with pictures. The cook was spoken with. She has been in post for some time and is very familiar with the resident’s likes and dislikes and she and the manager plan the five-week cyclical menu around these. The manager told us that the resident’s mental capacity would not allow them to be involved with the planning of the meals. The menus are varied and nutritious. The cook was observed to be baking scones and she told us that she makes cakes most days and that day residents were to have scones and cream with their afternoon tea. It was observed that as the day of this visit was particularly warm, the residents were being offered regular cold drinks and ice-lollies were distributed during the afternoon, which were enjoyed by most of the residents. We observed the lunchtime meal being served. This was enjoyed by most of the residents and little waste was noted. There was a choice of two main courses on the menu. Diabetic diets and pureed diets are provided for and the cook told us she is familiar with the different needs of various diets. Most of the residents spoken to at the time of this meal told us that they had thoroughly enjoyed it. Care assistants were observed to be assisting those who needed prompting to eat in a kind and encouraging manner. They sat with them talking and encouraging them to eat their meals. One resident verbalised her aversion to having to sit with another resident who eat with her hands. It was suggested that this resident could be moved to another table. Service user’s weights are monitored and recorded monthly if they are able to stand on the scales. The manager said that the ‘sit-on’ scales are borrowed from another home if a service user cannot stand on scales and if a nutritional risk has been identified. Glen Lyn DS0000069887.V367459.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 good. This judgement has been made using available evidence including a visit to this service. The home had a clear and satisfactory complaints procedure to address the concerns of residents and relatives/representatives. Staff that have been appropriately recruited and trained safeguards people who use the service. EVIDENCE: The home had a complaints procedure in place that was available to residents and was included in the Service User Guide and also displayed on the wall. The complaints log was viewed and complaints received since the last inspection were recorded appropriately. The CSCI have received one complaint in the last year and this was passed to the operational manager who had dealt with this and continues to liaise with the complainant. The AQAA states that the home has received one complaint in the last twelve months that was resolved within the 28-day period. A service user survey returned indicated that they would know how to make a complaint and who to talk to if they were not happy. The home has the Hampshire Safeguarding procedures in place. The manager talked through the procedures the home takes with the involvement of other agencies, should there be any report or incidence of abuse. Staff spoken Glen Lyn DS0000069887.V367459.R01.S.doc Version 5.2 Page 18 demonstrated their knowledge regarding abuse and what procedure they would take if they wished to report it. They also were aware of where the policies and procedures are kept. Five of the six surveys returned from staff said they would know what to do if a service user had nay concerns about the home. The induction programme includes the safeguarding procedures and training files evidence that staff received abuse training in October 2007. The home receives confirmation of a clear Criminal Records Bureau (CRB) and Prevention of Vulnerable Adults (POVA) checks. Bedrails are used in the home and risk assessments are undertaken prior to their use. Bumpers cover the portable bedrails to reduce risk of entrapment. Glen Lyn DS0000069887.V367459.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 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home ensures that the premises, décor and furnishings are maintained and a programme of ongoing refurbishment and replacement is in place. The policies and procedures of the home protect residents from infection, however there are practices in the home that do not safeguard residents from infection and personal safety. EVIDENCE: We visited all areas of the home. There were areas on the ground floor that were in need of redecoration and refurbishment. Furniture in some bedroom had exposed chipboard on the surface and needed replacing. We observed that curtains in some rooms were hanging off of rails and were in need of hooks to attach them to the rail. Some of the rooms were sparse and the manager said this was because the resident would remove any movable objects from the room. Glen Lyn DS0000069887.V367459.R01.S.doc Version 5.2 Page 20 It was observed in one room visited that a television bracket fitted to the wall next to where a resident’s chair was position, was no longer in use and had been left in place sticking out at head level to the resident sitting in the chair and presented a high risk of knocking his head and causing a potential head injury. This was immediately pointed out to the manager who showed us the maintenance book that evidenced that this had been requested to be removed some seven days previously. It was also noted that there were a number of maintenance jobs that had not been completed. We told the manager that unless the bracket was removed by the end of the day, this would be made an immediate requirement of this inspection. The maintenance person attended the home immediately and removed the bracket and completed some of the other jobs listed in the book that were over due. The first floor bedrooms and areas were cleaner and more aesthetically pleasing, many of which had been recently re-decorated with replacement furniture and flooring. Some residents had personalised their rooms with pieces of their own furniture. The home has two bathrooms and two shower rooms. One bathroom has a Parker bath installed. the other bathroom has an assisted bath hoist. The manager said the whet room is well used. It was observed in the ground floor bathroom that this room was cluttered and untidy and was used as a storage area for pads and other equipment. It was in need being de-cluttered and organised and able to be used by residents should they choose to have a bath in this room. We observed the bathroom cabinet was left open and exposed a variety of toiletries, prescribed topical medication and chemical tablets for cleaning dentures. This was discussed with the manager who was informed that this posed a risk to service users. Prescribed medication should be kept securely in the service user’s room and used only by the person for whom it is prescribed. Toiletries should be returned to the appropriate resident’s room to avoid communal use and the risk of cross infection. Denture cleaning chemicals must be maintained in a locked environment as this poses a risk of a service user ingesting these, unaware of the potential danger of doing so. On observing some of the bed linen it was noted some sheets were very thin and threadbare and were in need of replacing. The AQAA identified that the home has a maintenance programme of ongoing redecoration of the home and there has been a considerable amount of redecoration in the home in the last twelve months. The manager informed us that new floor coverings are on order for all the communal areas on the ground floor. It has been acknowledged that there has been a problem with odour in this area and currently carpets are being cleaned twice daily. Glen Lyn DS0000069887.V367459.R01.S.doc Version 5.2 Page 21 Currently the home has four profile beds that have been purchased by the resident but the manager told us that the home has a programme of replacing all divan beds with metal-framed beds. The back garden is well maintained and very pleasant with seating around the patio area. The home has a gardener who attends to this. Service users were observed to be enjoying the garden as the day of this visit was particularly warm. The home was generally clean although there were areas that needed to be more organised to enable cleaning to take place. The home employs an agency to supply staff for cleaning duties. The home has hand-washing facilities of soap dispensers and paper hand towels in all bathrooms and toilets. The training matrix identified that staff have received training on the principles of infection control. Staff spoken to confirm that they had had this training, one saying that she needed a refresher course. The policy of the safe handling and correct storage of all COSHH chemicals was in place and being observed by cleaning staff, who did not leave cleaning chemicals unattended whilst the home was in the process of being cleaned. Glen Lyn DS0000069887.V367459.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 good. This judgement has been made using available evidence including a visit to this service. Service users needs are met by sufficient numbers of staff that are trained and competent to do their jobs. Service users are in safe hands and are protected by the policies and practices of the recruitment of staff. EVIDENCE: The staff rotas evidenced that 6 carers plus the manager were on duty the morning of the visit. The manager told us that this is generally the compliment of staff on each morning, with 5 carers in the afternoon. 3 waking staff are on duty throughout the night. The ancillary staff on duty each day are the cook, kitchen assistant, 2 housekeepers, the receptionist and a laundry person. At the time of this visit there was sufficient staff on duty to meet the current needs of the service users in residence. Staff surveys returned to CSCI two say there is always sufficient staff in duty, three say ‘usually’ and one ‘sometimes’. Staff spoken to say that they did have sufficient staff of most of the time but there were times when they were busies than other. It was observed that carers were not rushing about and were able to spend quality time with service users on activities and talking to Glen Lyn DS0000069887.V367459.R01.S.doc Version 5.2 Page 23 them. It was observed that there was no delay in responding to call alarm bells, although a considerable number of the residents would be unable to use the alarm call effectively. The training matrix and the AQAA identified that nine of the sixteen care staff have achieved the NVQ level 2 or 3, thus achieving over 50 of care staff being qualified to this level. A further four carers are about to commence this. New staff undertake a thirteen-week induction programme and is based on the Skills for Care induction standards. Feedback from 6 staff surveys indicated that the induction is good and covered everything they need to know to do the job. Evidence of a completed induction programme was seen in a staff file of a more recently employed carer. A sample of four staff personnel files was viewed of the most recently employed staff members. The records demonstrated that all appropriate checks such as CRB, POVA and two written references had been requested and received by the home. The home employs a multi-cultural staff group. The manager has a training matrix that is stored on the computer. This was accessed and demonstrated that staff do receive a variety of appropriate training. Most staff have done the Dementia Awareness training and the manager encourages all staff to undertake this. Staff spoken to told us that they have found this training very beneficial in their work. The records seen also demonstrated that the manager regularly supervises and undertakes an annual appraisal for staff from which training needs are identified. The manager has received training in supervision and appraisal of staff Staff surveys and those staff spoken to at the time of this visit confirm that the management team is supportive and indicated that they have regular meetings with their supervisor and receive the right support and have the experience to meet the needs of the service users. The manager acknowledged to us that she is aware that training for Challenging Behaviour has been identified as being needed by staff and she will address this as a priority training need. All health and safety mandatory training is provided annually and the matrix evidenced that staff are in general, up to date with this. Glen Lyn DS0000069887.V367459.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, 33, 35 & 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 qualified, competent and experienced to run the home. The home has no effective quality assurance system in place. The health and safety of the service user and staff are promoted, however there are areas of risk to service user’s safety within the home. EVIDENCE: The registered manager has been in post for eight years and has worked at the home for many years. She has achieved her Registered Managers Award (RMA). She continues to attend appropriate training courses and discussed undertaking the Approved First Aid Course. A general manager, who visits the home at least monthly, supports the manager. Glen Lyn DS0000069887.V367459.R01.S.doc Version 5.2 Page 25 There was no evidence of a full quality audit system in place for the home. The general manager visits the home monthly and writes a monthly report on her findings. These records are maintained in the home. The manager undertakes various other audits as part of the quality assurance system. She tours the home once a week to check on cleanliness, which she says is difficult with agency cleaners, whose work is not always consistent. Surveys have been distributed to relations of the service users and comments have come back saying ‘staff are always friendly and welcoming and always offer a cup of tea’. The returned surveys have not been analysed to date and therefore no report has been made. The manager told us that a satisfaction survey to relatives and other stakeholders is to be distributed next month. The manager did plan a relatives meeting but no one attended and will not arrange a further one. The manager has an open door policy and will talk to relatives when they visit the home. The AQAA states that service user’s families’ deal with their monies. For those who do not, and are managed by the home, the previous report made a requirement that all service users’ monies be placed in a separate interest bearing savings account. The management of service users’ monies has now been taken out of the home and is managed by the head office. The general manager, who was present at the time of this visit, told us that all monies looked after by the organisation are in separate savings account and the resident received interest on that money. There was no records in the home that this is taking place and the manager told us that she receives a print out once a month of the balance of each residents account. Should they wish to know how much money they have. A further requirement will be made. The home has a fire risk assessment and an environmental risk assessment that are undertaken by the manager. We saw these. Although there were risk assessments in place it was identified on the tour of the premises that the chemical tablets for denture cleaning were left in an open cupboard in a bathroom that a service user would have freed access to and who may not have an awareness of how dangerous these tablets could be to their health and safety. The fire log was seen and evidenced that checks on the systems take place at appropriate intervals. The fire alarm system was serviced in March 2008. Staff fire training takes place every six months with questionnaires in between. Records of who has attended fire training were demonstrated on the training matrix. A sample of servicing certificates for hoists, lift, PAT testing and other equipment were in place and current. Glen Lyn DS0000069887.V367459.R01.S.doc Version 5.2 Page 26 The accident records were viewed. These are stored appropriately and the manager keeps a copy of the accident form. She periodically analyses these and identifies if there is a resident who is falling regularly, she will then refer them to the falls clinic. The falls clinic will visit the home to give advise and risk assess the person, and if necessary, provide equipment such as hip protectors to reduce the risk of fractures. Glen Lyn DS0000069887.V367459.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X 2 2 Glen Lyn DS0000069887.V367459.R01.S.doc Version 5.2 Page 28 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. 1. Standard OP10 Regulation 12(4)(a) Requirement The registered persons must ensure that service user’s privacy is respected and that service user’s rooms are not used as a doctor’s consulting room for other service users other than the resident to whom that room belongs. The registered person must ensure that all prescribed topical medication and personal toiletries are stored appropriately in the service user’s room for whom it belongs or for who it is prescribed, and not left in unlocked bathroom cabinets for communal use putting residents at risk of cross infection. The registered person must put in place an effective quality assurance system to measure the home’s success in meeting the aims and objectives and the statement of purpose. Records of all monies deposited by a service user for safekeeping or received on the service users DS0000069887.V367459.R01.S.doc Timescale for action 30/09/08 2. OP26 12(1)(a) 31/08/08 3. OP33 24(1)(3) 30/11/08 4. OP37 17(2) Schedule 4 (9)(a) 30/09/08 Glen Lyn Version 5.2 Page 29 5. OP38 13(4)(a) behalf must be kept in the home. The records must also show any money used on their behalf and the purpose of this. All chemicals used for denture cleaning must be maintained in a locked environment to prevent service users being exposed to risk. 31/08/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP3 OP8 OP26 Good Practice Recommendations It is recommended that the pre-admission assessment be maintained with the care plans. It is recommended that the home obtain the relevant documentation that will allow service users to obtain a free dentistry service. It is recommended that disposable hand towels and soap dispenser be fitted in the medical room that houses the medication trolley and equipment. Glen Lyn DS0000069887.V367459.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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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