Inspection on 22/10/07 for Glen Lyn

This inspection was carried out on 22nd October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Glen Lyn 12/04/07

Glen Lyn 03/10/06

Glen Lyn 17/11/05

Glen Lyn 14/06/05

Glen Lyn 09/02/05

Glen Lyn 12/07/04

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

CARE HOMES FOR OLDER PEOPLE Glen Lyn 2 Tregonwell Road Minehead Somerset TA24 5DT Lead Inspector Shelagh Laver Unannounced Inspection 09:30 22 October 2007 nd 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.V350939.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Glen Lyn DS0000016026.V350939.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glen Lyn Address 2 Tregonwell Road Minehead Somerset TA24 5DT Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01643 702415 Mr Stephen Reaney MRS MELANIE ANN REANEY MRS MELANIE ANN REANEY Care Home 11 Category(ies) of Old age, not falling within any other category registration, with number (11) of places Glen Lyn DS0000016026.V350939.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Any service users in room 11 must be assessed with regard to their mental and physical abilities to use the stair lift to access the room 12th April 2007 Date of last inspection Brief Description of the Service: Glen Lyn is a semi-detached property situated in a residential area of Minehead close to the seafront and town centre. The home is registered with the Commission for Social Care Inspection to provide accommodation for up to eleven people over the age of 65 years, who require assistance with personal care. Glen Lyn has been pleasantly decorated and furnished, and offers a comfortable, homely environment. All bedrooms offer single accommodation and most rooms have an en-suite facility. There is an assisted bathroom, stair lift and call system available at the home. The Registered Providers are Mr and Mrs Reaney. Mrs Reaney is also the Registered Manager. The current fee levels are between £361 and £400 per week. Glen Lyn DS0000016026.V350939.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out over a 4.5-hour period. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are: - excellent, good, adequate and poor. Prior to the visit the home completed a comprehensive and informative Annual Quality Assurance Assessment (AQAA). Service users relatives and staff completed questionnaires. Since the last key inspection there have been two random visits to address requirements and concerns raised by the inspection. Action has been taken to meet requirements and key areas of provision have been reviewed. At this inspection the home appeared to be comfortable and well run. On arrival at the home it was warm and peaceful. Three people were in the sitting room. Others were spending time in their rooms. The inspector was able to spend time in the home talking with staff and service users and observing care practices. The manager, Melanie Reaney was available throughout the day and all records requested were made available. At the time of this inspection there were 8 people living at Glen Lyn. All were seen. Six were spoken to and were able to make their views of living in the house known. What the service does well: People spoken to during the inspection were positive about the care they received at Glen Lyn. One person said, “This place is top hole.” There is an emphasis on individual care needs that is possible in a small home. The AQAA states that Glen Lyn is a ‘home from home.” It continues ‘as a small home we can be truly flexible. We provide care in a homely and relaxed atmosphere”. Glen Lyn DS0000016026.V350939.R01.S.doc Version 5.2 Page 6 Visitors are welcome in the home at any time. Relatives comment cards included statements such as ‘nothing to improve’ ‘feels very relaxed’.’ Residents are treated as individual’. ‘ Provides a good standard of care’. One visitor met with during the inspection said, “This place is superb…if I ever have to into a home I hope it will be like this.” People appreciated the “lovely food- all freshly cooked.” There is attention to peoples individual health needs and regular contact is made with doctors and other health professionals. One person spoke of the care received from her GP who she had had for a long time. The manager will “call him if I am unwell.” People spend their time in a variety of ways. Individual preferences are considered. One person liked to read the papers and do crosswords. Another went out regularly. There is a flexible range of activities provided. Numbers are small and people are consulted. Some people enjoy “everything.” Others wanted more visits to the garden centre and trips out. There was evidence that the manager and staff were exploring new ideas for small group activities. One person appreciated a shopping trip organised for her by the manager. An average of 5 training days are provided in addition to mandatory training. There was evidence of a range of training and encouragement to staff to learn. What has improved since the last inspection? What they could do better: One person has a small moveable bed rail. This must be assessed and action taken to there is no risk of entrapment. The first floor bathroom is showing signs of wear and tear. The radiator remains uncovered. Up dating should be considered. Glen Lyn DS0000016026.V350939.R01.S.doc Version 5.2 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Glen Lyn DS0000016026.V350939.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glen Lyn DS0000016026.V350939.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): 2 3 6 Quality in this outcome area is good. People who enter the home have an assessment prior to entering the home that ensures the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two care files were examined. Each contained evidence of assessment prior to entering the home. There were detailed dependency indicators and hospital discharge notes. In one file another professional had also completed an assessment. Comment cards from people confirmed that they had a contract. The Statement of Purpose and Service User Guide had been up-dated. Glen Lyn DS0000016026.V350939.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 Quality in this outcome area is good. The health needs of people are met. Medication administration is safe. People are treated with respect at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two care plan files were examined in detail. The files contain life histories, risk assessments, dietary assessments and guidance on moving and handling. The actual care plan is comprehensive and detailed. There were some examples of good practice. In one plan the manager had consulted with a specialist nurse to give sensitive and detailed guidance on the care required for one person with Parkinson’s disease. In another plan the importance of promoting independence was detailed. There was clear guidance for action to be taken if a person was ill. Plans had been up-dated and reviewed. Staff sign to demonstrate they have understood some parts of the care plans. There is a copy in each person’s bedroom so that staff have easy access. It was clear that people had access to specialist staff including district nurses, Glen Lyn DS0000016026.V350939.R01.S.doc Version 5.2 Page 11 community psychiatric nurses, opticians and chiropodists. Comment cards received prior to inspection confirmed people received the care and support they need. There was evidence that people were assisted to keep appointments related to their health. The manager undertakes a medication audit. The last had been completed on 22/10/07. There are plans to improve the medication storage facilities to meet future regulations. MAR sheets were maintained accurately. Staff were heard speaking politely and kindly to people. Glen Lyn DS0000016026.V350939.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Quality in this outcome area is good. People are encouraged to make choices about how they spend their day. There is a programme of activities available. Food is plentiful and wholesome. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People confirmed they were able to spend their day as they chose. There was one person who went out each day with a companion. During the morning of the inspection some people chose to spend time in their rooms others came to the sitting room. There was an exercise activity based on South America. The manager and a carer had recently attended an innovative training session “Time to Move” that had “given us lots of ideas. In the afternoon there was musical entertainment. Various activities are tried, both planned and spontaneous. Tickets have been purchased for a Christmas party in Minehead. Visitors are welcome in the home. Two people had visitors during the inspection. People have been to the garden centre and there have been visits from an “Activity Angel” running a reminiscence session. There was detailed feed- back showing peoples involvement. Glen Lyn DS0000016026.V350939.R01.S.doc Version 5.2 Page 13 The food is home-cooked and of a good standard. Each day there is a choice although the printed menu shows one main meal. On the day of the inspection lunch was tasty and nutritious. There were fresh vegetables and a choice of puddings. There is a choice of puddings served from a trolley. On the day of the inspection there was home cooked apple cake and fruit salad. The tea menu has a warm choice in the week and sandwiches are available. People are encouraged to eat in the dining room but some ate in their rooms. There is a different roast meat on the menu each Sunday and three vegetables accompany every lunch Glen Lyn DS0000016026.V350939.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 17 18 Quality in this outcome area is good. Service users are confident that their complaints will be listened to and taken seriously. The home has developed appropriate polices regarding adult abuse; whistle blowing to ensure that service users are not put at risk. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Comment cards returned prior to inspection confirmed that people knew whom to contact if they are not happy. During the inspection people spoke of their confidence in the manager who “will always listen and sort things out if we need it.” Recruitment records showed that action is taken to protect people. Staff have received Protection of adults training. Policies and procedures in the home have been reviewed and up-dated. Glen Lyn DS0000016026.V350939.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 22 23 24 25 26 Quality in this outcome area is good. People live in an attractive comfortable environment. It is safe and adapted to most peoples needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is furnished and decorated as a domestic home. It is comfortable and well presented. People who returned comment cards said that it is always fresh and clean. A tour of the building confirmed that bedrooms are comfortable and personalised. Some rooms have been redecorated recently. Bathrooms and ensuites were very clean. Some contained appropriate equipment to promote independence. Where required there are infection control measures such as gloves, hand washing facilities for staff and paper towels. Glen Lyn DS0000016026.V350939.R01.S.doc Version 5.2 Page 16 There is a comfortable sitting room, dining room and paved garden area. The bathroom on the second floor is showing signs of wear and includes an uncovered radiator. There are plans in place to up-date bathing facilities. There is a stair lift that accesses all three floors however the lift is not continuous and a realistic assessment of peoples’ mobility is important in assessing their suitability for the home. Glen Lyn DS0000016026.V350939.R01.S.doc Version 5.2 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 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. The skill mix and numbers of staff on duty meet peoples’ needs. The recruitment policy and practices in the home are robust and protect people in the home. There is a flexible training programme in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a staff team of 9 at Glen Lyn. 5 comment cards were received from staff. All stated have they have received induction training, and manual handing and were clear about service users needs. A review of three staff files showed a robust system of recruitment including POVA and CRB checks prior to employment. References had been obtained. There were records of regular supervision. The home uses an in-house training system suitable for a small home. Staff had completed Health and safety, Moving and Handling, Infection control and Protection of Vulnerable Adults training. Common Induction standards are used now for new employees. A review of four weeks duty rota showed that according to the rota there was at least two staff on duty. Mr and Mrs Reaney provide a major part of the staffing at the home with Mr Reaney regularly working a split shift from 9-1 Glen Lyn DS0000016026.V350939.R01.S.doc Version 5.2 Page 18 and 6-9. Mrs Reaney is also working in excess of fifty recorded hours in some weeks. People said that help was available when needed. Glen Lyn DS0000016026.V350939.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 36 38 Quality in this outcome area is good. The home is well run in the interests of the people who live there. There are organised health and safety systems in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager is Melanie Reaney, who is a Registered Nurse. She has many years experience of providing care to older people and has obtained the Registered Managers Award. Staff and service users spoken with during the inspection spoke highly of the care that she provides, and stated that they would be able approach her to raise any issues of concern. There is a comprehensive system of quality assurance in the home. There is a plan for audits and questionnaires. Policies and procedures have been Glen Lyn DS0000016026.V350939.R01.S.doc Version 5.2 Page 20 reviewed and up-dated. People living in the home have been having regular meetings. The minutes of the meetings are signed. There is a main topic for each meeting. These have included a review of how people spend their time. Staff receive an appraisal every six months. During the inspection supervision records were examined for three staff members. Staff had received supervision approximately every two months. Fire safety records were examined. Fire safety equipment had been serviced and tested as required. Staff members had received appropriate fire safety training. The hoist, bath hoist, and stair lift had been serviced in accordance with LOLER Regulations. The gas safety certificate and electrical hard wiring certificate had been appropriately maintained. The wheelchairs are regularly checked. The home has procedures in place to reduce the risk of Legionella. The home appeared well maintained. Glen Lyn DS0000016026.V350939.R01.S.doc Version 5.2 Page 21 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 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 2 3 3 3 3 x 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 3 3 X X 3 3 2 Glen Lyn DS0000016026.V350939.R01.S.doc Version 5.2 Page 22 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 OP38 Regulation 13 4 (b) Requirement The manager must assess the small bed rail discussed and ensure the person is safe from any risk of entrapment. Timescale for action 10/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP21 Good Practice Recommendations The first floor bathroom should be considered for refurbishment. Glen Lyn DS0000016026.V350939.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Glen Lyn DS0000016026.V350939.R01.S.doc Version 5.2 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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