Inspection on 03/10/06 for Glen Lyn

This inspection was carried out on 3rd October 2006.

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 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 Pippa Greed Key Unannounced Inspection 3rd October 2006 09:15 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Glen Lyn DS0000016026.V312807.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.V312807.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.V312807.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 17th November 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 accommodation and most rooms have an ensuite facility. The home has been awarded a block contract for 8 rooms with Somerset Social Services. The Registered Providers are Mr and Mrs Reaney. Mrs Reaney is also the Registered Manager. Glen Lyn has been pleasantly decorated and furnished, and offers a comfortable, homely environment. There is an assisted bathroom, stair lift and call system available at the home. The current fee levels are between £361 and £400 per week. Glen Lyn DS0000016026.V312807.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last inspection was conducted on 17th November 2005. No requirements or recommendations were made at that inspection. The inspection was unannounced and took place over the course of one day (7hrs) on 3rd October 2006. It was conducted by Regulation Inspector Pippa Greed. The inspector spoke to five service users, two staff, and one visitor visiting the home. The inspector was also assisted by the manager, Mrs Melanie Reaney throughout the inspection process Three service users files were selected for case tracking. As part of the inspection process the inspector used ‘case tracking’ as a means of assessing some of the national minimum standards. This process allowed the inspector to focus on a small group of people living in the home. All records relating to these people were inspected, along with the rooms they occupied in the home. Four staff files were checked and documents related to the running of the home were examined. A tour of the building took place and the communal areas and some service users’ rooms were viewed. Mrs Melanie Reaney is the registered manager and she is supported by two senior care staff. Surveys were sent out to three service users, four relatives, two social workers and two GPs. Two surveys were received from service users as the third named service user has since left the home. Three comment cards were received from relatives. All comments received from relatives were overall positive stating that they were made welcome and kept informed. A relative wrote ‘the atmosphere in the home is cheerful. The owner and staff obviously have the best interests of the clients in mind at all times. I find the home excellent’. Three relatives stated that they have not felt the need to make a complaint, and two stated they were not aware of the homes’ complaint procedure or how to access a copy of the Inspection report. One comment card was received from a social worker, which stated ‘provides appropriate and sensitive care’. All the comments received from service users on the day of the inspection and through anonymous surveys were complimentary about the home and included comments such as ‘They are all very kind’, and ‘The food is excellent. Gives us good meals, always on time, and no complaints’. The inspectors would like to thank the service users, staff and the manager for their support and assistance with the inspection process. Glen Lyn DS0000016026.V312807.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Glen Lyn DS0000016026.V312807.R01.S.doc Version 5.2 Page 7 Two requirements and six recommendations were made at this inspection. It was noted that two bedrooms has shelves at shoulder height that were prominent and sharp edged. It was brought to the manager’s attention as this pose a risk should a service user were to slip and fall against this surface. Staff recruitment files sampled did not contain information in accordance with Schedule 2 of the Care Standards Act. 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.V312807.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.V312807.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6 The quality in this outcome group is good. The home provides a statement of purpose, and service user guide that clearly sets out the objectives and philosophy of the service. An information leaflet is also provided. Prospective service users are given the opportunity to spend time in the home prior to admission. Each service user is provided with a clear statement of terms and conditions that sets out the terms and conditions of residency. Family and friends are made welcome and visit the home at any reasonable time. Service users are provided with respite care in order to maximise their independence and prepare them for their return home. Glen Lyn DS0000016026.V312807.R01.S.doc Version 5.2 Page 10 EVIDENCE: Each service user is provided with a written statement of terms and condition of residency. There is a trial period of two weeks to allow prospective service user the opportunity to find out if the home meets their needs. The service user is also provided with a Statement of Purpose and a Service User’s Guide, which is kept in individual bedrooms. This includes the contract and a summary of care provision. The care plan summary is signed by the service users and reviewed regularly with their key-worker. The Statement of Purpose has also been updated recently. Several service users had visited the home prior to moving in. Most service user stated that they were supported by their family in choosing the home. One survey stated that they received a booklet, a visit from Social Services and a preliminary visit to the home. One service user spoken with confirmed that she was able to stay at the home on a trial basis. The care plan sampled provided evidence of pre-admission assessments. In some cases, the manager conducted a detailed pre-admission assessment and in others was supported by a Community Psychiatric Nurse using the National Health Service (NHS) Self Assessment Tool. Glen Lyn also provides short-term respite care. Glen Lyn DS0000016026.V312807.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11 The quality in this outcome group is good. Care plan sampled evidenced good medical and personal care provided by the home. The home provides lockable cabinet for service users wishing to self-medicate. Hand transcribed entries were supported by two staff signatures. Care plans contained details about service users’ social history. Care plans included information about the service users’ death and dying wishes. EVIDENCE: The inspector sampled three service users care plan. These evidenced good standard of health care provided for the service users. The care plan is detailed and provides information such as profile of service user, routine, mealtime, personal hygiene, special needs, social and relationship, activities and health. Glen Lyn DS0000016026.V312807.R01.S.doc Version 5.2 Page 12 Further details of health care provided were seen in the care plan. These included GP, chiropody, district nurse, optician, and dentist visits. The care plan also implements nutritional assessment and risk assessments, which take into account manual handling and falls risks. Each service user has their copy of the care plan which they keep in their own bedroom. This is provided in the form of a summary. These are signed by the service users and reviewed by staff on a monthly basis. This method helps the manager, staff and service user set up a framework for care planning. This approach is person centred and promotes good practice. Personal risk assessments were seen in the care plan and these were up to date. One risk assessment seen for health and safety will require updating. The care plan included details about service users’ social history, and wishes were taken into account regarding death and dying choices. All service users spoken to confirmed that staff treated them with respect and the day-to-day routines in the home respected their dignity. One service user particularly enjoys having breakfast in bed. Service users surveys stated that they received the care and support from staff that they needed. The inspectors observed staff interacting with service users in a friendly, professional and respectful manner. The proprietor and registered manager Mrs. Reaney is a registered general nurse. She is confident that she has the skills and knowledge to determine whether community-nursing assistance is required. Staff have received medication training updates. In relation to storage of medication and administration, appropriate levels of medication stock was stored. Returned medications were found in good order and room numbers were recorded on the Medication Administration Record. All hand transcribed entries on Medication Administration Record were supported by two staff signatures. The home has recently had a visit from the pharmacy and the outcome was positive. The pharmacist made one recommendation, which was include more detail describing the purpose of medicine. The home is now implementing this advice. It is recommended that photograph ID of service users are placed within the Medication Administration Record file. Also, to include variable dosage recording on Medication Administration Record. Glen Lyn DS0000016026.V312807.R01.S.doc Version 5.2 Page 13 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): 12, 13, 14, 15 The quality in this outcome group is good. The routines of the home are planned around the service users’ needs and wishes. Service users are encouraged to personalise their rooms. Appropriate activities are available throughout the home. The service users are satisfied with the meals served at the home. EVIDENCE: The routines of the home were seen to be flexible to meet individuals’ choices and preferences as far as possible. Service users choose to access activities provided by the home or engage in their own hobbies and pastimes. Service users are actively encouraged to keep in contact with family and friends living in the community. Visitors are made welcome at any reasonable time. Service users can choose to entertain visitors in their room, dining room or in the patio garden. Glen Lyn DS0000016026.V312807.R01.S.doc Version 5.2 Page 14 The home provides an activity timetable, which serves as a guide for the service users and staff team. Examples are: - gentle exercise, hairdressing, mental aerobics – ‘a physical workout for the mind’, ‘The Bakers Oven’ – baking, cooking and food preparation, hand massage, arts & crafts, individual or group games, reminiscence sessions every four weeks, visits from local keyboard musician, foot spa, gardening activity, and activities related to art, music, theatre and films. Activities were seen during the inspection, which were craft activity in the morning, and gentle exercise in the afternoon. One service user was encouraged to participate in feeding the fishes and tending to plants. Another service user received a visitor. The inspector received positive feedback through discussion with service users. One advocate commented through survey that the overall care provided at Glen Lyn is very good. One service user survey commented that there were not enough activities provided. However, four out of five service users were asked about activity and they confirmed that activities are being provided regularly. The inspector spoke with a visitor who regularly visits the home. The visitor informed the inspector that staff make her feel welcome and commented that ‘staff are lovely towards the service users’. The visitor also confirmed that activities are provided and that a lady visits weekly to provide singing session and staff were seen to do picture games at other times. The manager and staff team have been proactive in preparing a communication card for an expected respite service user. The communication card shows a selection of pictures such as ‘I want…hot drink, cold drink, wash, clean teeth, lie down, eat, too hot or too cold’. The prospective service user requires support with making their choices known. It is good practice that this is anticipated prior to arrival how best the staff can support this person. The home issue a newsletter every three months with news and up coming events planned for that quarter. Lunchtime routine was observed during the inspection. A colourful poster displayed the menu on the dining room door. Staff also verbally inform each service user what the lunch time option will be. A choice of two meals and two puddings were offered. The dining area is situated in a bright and spacious room overlooking the front garden. Tables were attractively presented with napkins, vase of flowers, and condiments. Pickles and butter were provided in individual dishes for each person. A choice of cold drinks were offered. Service users was heard to say ‘oh the food is always good’. There were good-natured banter and interaction between staff and service users. The food served was fresh, of good quality and homemade. Mealtime was seen to be unhurried, and support was available for service users if needed. Glen Lyn DS0000016026.V312807.R01.S.doc Version 5.2 Page 15 It is recommended that the manager considers implementing an activity document for each service user to record activities attended be it individual or group, and also their feedback on their likes or dislikes. Glen Lyn DS0000016026.V312807.R01.S.doc Version 5.2 Page 16 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, 18 The quality in this outcome group is good. Service users were confident that they could raise complaints or concerns with senior staff. Systems are in place to ensure that service users’ rights are respected. The home has policies and procedures in place to ensure the protection of service users living at Glen Lyn. The homes’ complaints procedure did not fully meet the national minimum standards and regulations. EVIDENCE: None of the service users spoken to had any complaints about the home and all were clear that should they have any complaints, they would speak to the manager or another senior member of staff. Service user felt that the manager would deal with any problems. Staff spoken to were clear that they would pass on any complaints to the manager. Staff and service users confirmed that they would not hesitate to approach the manager or a senior member of staff should they have any concern. All service users are registered to vote and their legal rights protected by the homes values, policies and procedures. Five service users voted by postal ballot and two visited the polling station. Glen Lyn DS0000016026.V312807.R01.S.doc Version 5.2 Page 17 Protection of Vulnerable Adult (POVA) first and Criminal Records Bureau (CRB) checks were undertaken for newly recruited staff. The Abuse and Whistle blowing policy were seen and these did not include the Commission of Social Care Inspection and local Social Services contact details. However, it was shown on the Complaints procedure displayed in the hallway and evident in the Service Users Guide. The manager agreed to update the policy to reflect current contact details. CSCI has not received any complaints about the home directly. The home has received one minor complaint this year. The manager has written an account describing the nature of the complaint, how the situation was resolved and reassessed the situation through feedback from the service user. A clear audit trail was evident. Glen Lyn DS0000016026.V312807.R01.S.doc Version 5.2 Page 18 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): 21, 22, 23, 24, 25, 26 The quality in this outcome group is good. The home provides an overall safe environment. The home has a homely environment, which provides aids and equipment to meet the care needs of the service users. Communal space is adequate. Service users have some options of where to meet relatives and friends in privacy and comfort. The home was clean and hygienic on the day of inspection. EVIDENCE: Glen Lyn is a large Victorian house. All bedrooms at Glen Lyn are for single occupancy. Most rooms have an en-suite facility. Rooms are situated on the ground, first and second floor. There is a stair lift for access to all levels. Service user placed on the upper floor has a good level of independent mobility. The home has a mobile patient hoist available and an assisted bath. Glen Lyn DS0000016026.V312807.R01.S.doc Version 5.2 Page 19 There are two communal bathrooms. Service users have the choice of a bath or shower. Communal space comprises of a lounge and a separate dining room. There is patio garden to the rear of the property, which has a secure pond, bird tables, guinea pig hutch and garden benches. There is a toilet close to the lounge for service users to use. Call bells are available in bedrooms, toilets and bathrooms and communal areas. The home was clean, tidy and odour free on the day of the inspection. A tour of the premises was undertaken and the inspector viewed all the communal areas and some of the service users’ private bedrooms. All service users’ rooms viewed had been personalised to reflect individuals’ choices and preferences. Service users are able to bring in personal items including small items of furniture within the space constraints of their room and in agreement with the manager. The home has recently completed an refurbishment upgrade as part of an ongoing programme. The kitchen has been redecorated and the manager has purchased a new cooker and microwave. Room 6 have new carpet and chair. The manager have made plans for new bedroom furnishings to be delivered. The kitchen area was inspected and found to be clean and hygienic. Food stored were correctly labelled and fridge/ freezer temperatures were within the correct range. Records were maintained for cooked meat temperatures. Meals were observed to be freshly prepared on the day. Cleaning schedules were displayed on the wall. Adequate laundry facilities are provided and service users spoken to confirmed their clothes were always well laundered and returned to them promptly in good condition. The home is generally well maintained and has a homely feel. One requirement was made relating to shelving units in room 4 and 8. These shelving had sharp edgings at shoulder level that pose a risk should service user fall against this. It was also noted that one bedroom en-suite (room 5) had loose lino around toilet base. It is recommended that this be replaced. Glen Lyn DS0000016026.V312807.R01.S.doc Version 5.2 Page 20 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 The quality of this outcome group is good. Staffing levels are good and the staff were qualified to provide a good level of care. Service users have confidence in the staff that care for them. All staff are clear regarding their role in what is expected of them. EVIDENCE: On the morning of the inspection, there were one general assistant, one care assistant staff, one cook and the manager. During the afternoon, there were two care assistant. One waking night staff was rostered for night duty. On call support is provided by the manager. There are currently nine care staff excluding Mr and Mrs Reaney, five of which are qualified to NVQ 2 and above therefore the staff team have the skills and experience to provide a high standard of care. Four staff files were checked. All files contained Criminal Records Bureau (CRB) disclosure. Some of these files contained photograph identification, two written references. However, it is required that that the manager ensures that all staff employed at the home have information in accordance with Schedule 2 of the Care Standards Act on their recruitment file. Glen Lyn DS0000016026.V312807.R01.S.doc Version 5.2 Page 21 The home provided information on the pre inspection questionnaire and staff recruitment files about staff training completed recently and this included mandatory training, administration of medicine, dementia care, nutrition, and vision impairment awareness. Staff spoken to confirmed that they were supported and encouraged by Mrs Reaney to attend training to obtain skills and qualifications relevant to their role. Staff spoken with confirmed that the manager operated an ‘open door’ policy that is they felt able to approach her with any queries. Staff stated that they have received induction, appraisals and regular formal one to one supervision. Service users spoken to were very complimentary about staff and they were described as ‘kind and helpful’. Glen Lyn DS0000016026.V312807.R01.S.doc Version 5.2 Page 22 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): 31, 32, 33, 34, 35, 36, 37, 38 The quality in this outcome group is good. The manager has the required qualifications, skills and experience and is competent to run the home. Service users and staff are kept informed and involved in the running of the home. Service users are able to take responsibility for their own finances but if they are not able to do so robust systems are in place to safeguard their financial interests. The home has clear health and safety policies and regular checks take place to ensure that the home is a safe environment. Some areas of health and safety will require improvement. EVIDENCE: Mr Stephen Reaney and Mrs Melanie Reaney are the registered providers. The registered manager is Mrs Melanie Reaney and she is supported by two senior staff. Glen Lyn DS0000016026.V312807.R01.S.doc Version 5.2 Page 23 Mrs. Reaney is a registered general nurse. She is an experienced manager who has completed the Registered Manager Award. She regularly updates her knowledge in relevant training specific to her service users needs. The home has established links with MacMillan nursing care team for support such as equipment or medication in managing palliative or terminal care. Mrs. Reaney is also aware of the skill mix in her staff team and the need to monitor service users’ changing needs. Should a nursing home placement be more appropriate for the service user? Service users spoken with confirmed that they felt able to approach the manager and senior staff if they wanted to raise issues. The manager informed the inspector that the home currently does not directly handle the service users financial affair. Six service users take responsibility for their own personal finances with relatives support. Three service users have power of attorney in place. Records are kept for the management of personal allowances. Staff spoken with confirmed that they felt well supported and able approach the manager and senior staff should they wished to discuss day to day running of the home. Staff confirmed that formal supervision is provided. Staff recruitment files also evidenced regular supervisions. A tour of the premises was made and the majority of areas seen were free from hazards. It was noted that two bedrooms had shelving units that pose a risk of injury should a service user trip or fall against this. It was also noted that that the lino around one en-suite toilet would need to be replaced. Please refer to Environment section for more details. The home displays a current certificate of employer’s liability insurance. Records were seen that showed the following; fire equipment, stair lift, call bell and electrical equipment were subject to regular checks and had been serviced. However, the home does not contract an external agency to test and check the water system as preventative strategy against Legionella. This is recommended practice. The accident book was checked and there were five accidents in July and two in August. These related to slips and falls. The manager records comments on current trends and identify course of action. Appropriate action was made and care plans updated. The home conducts a number of internal quality assurance audits throughout the year that are ordered and methodical. The audits are carried out on service users satisfaction, cleaning, activities, finance, and many more. The results of quality audits are published in the home’s seasonal in-house newsletter, which is given to all service users and next-of-kin. Glen Lyn DS0000016026.V312807.R01.S.doc Version 5.2 Page 24 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 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 3 3 3 3 3 2 Glen Lyn DS0000016026.V312807.R01.S.doc Version 5.2 Page 25 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) (a) Requirement It is required that the manager complete an environmental risk assessment to take into account the edging, and position of shelvings in room 4 and 8. It is required that the manager ensures that all staff employed at the home have information in accordance with Schedule 2 of the Care Standards Act on their recruitment file. Timescale for action 10/11/06 2. OP29 19 (1) (b) (i). 30/11/06 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 OP18 Good Practice Recommendations It is recommended that the Abuse and Whistleblowing policy be updated to include contact details for Local Authority Social Services and Commission for Social Care Inspection. It is recommended that photograph ID of service users are placed within the Medication Administration Record file. Also, to include variable dosage recording on Medication Administration Record DS0000016026.V312807.R01.S.doc Version 5.2 Page 26 2. OP9 Glen Lyn 3. OP25 4. 5. 6. OP12 OP37 OP26 It is recommended that the water system in the home be tested at least annually by external agency for the presence of Legionella micro-organisms in the water supply and a strategy for the prevention of this disease be developed. It is recommended that the manager consider recording in each service users’ care plan, individual or group activities attended and service users feedback. It is recommended that the manager implements a communication book in the form of bound lined book which is appropriately secure. It is recommended that the manager arranges for the lino around the en-suite toilet in room 5 to be replaced. Glen Lyn DS0000016026.V312807.R01.S.doc Version 5.2 Page 27 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. Extracts may not be used or reproduced without the express permission of CSCI Glen Lyn DS0000016026.V312807.R01.S.doc Version 5.2 Page 28 - 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. 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