Inspection on 03/01/08 for Glen Rose

This inspection was carried out on 3rd January 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 Rose 30/12/08

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

CARE HOMES FOR OLDER PEOPLE Glen Rose Mount Drive Catisfield Fareham Hampshire PO15 5NU Lead Inspector Michelle Presdee Unannounced Inspection 3rdJanuary 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 Rose DS0000069891.V357182.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 Rose DS0000069891.V357182.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glen Rose Address Mount Drive Catisfield Fareham Hampshire PO15 5NU 07785 550783 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) Mr Amin Lakhani t/a Saffronland Homes Group vacant post Care Home 47 Category(ies) of Dementia (0) registration, with number of places Glen Rose DS0000069891.V357182.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 with nursing only - (N) to service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: Dementia (DE). . The maximum number of service users to be accommodated is 47. 2. Date of last inspection New Service Brief Description of the Service: The home provides nursing care for up to 43 older persons whose primary need is dementia. In addition to the care staff a registered nurse is on duty at any given time of the day. The service is located in a residential area of Fareham, close to the town centre. Accommodation is provided over 2 floors. There are 16 double and 14 single bedrooms. All rooms have en-suite wash hand basins and toilets. Communal areas consist of 2 lounges and a summer lounge. In the basement another large room is available. A passenger lift gives access to all floors. There is parking for visitors. The weekly fees range from £575.00 to £650.00. Glen Rose DS0000069891.V357182.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. During this unannounced key inspection the acting manager, training manager and administrative person assisted us (the Commission). On the day eight members of staff and three visitors were spoken with. Five residents were spoken with, but the majority of residents were unable to communicate verbally, but non-verbal communication was observed. Five of the residents are independently mobile around the home. We looked around the home and saw both lounges, the kitchen, the laundry, the summer house and seven bedrooms. The home sent us their Annual Quality Assurance Assessment on time. This and other paperwork seen on the day including assessments, care plans, staffing records and medication records has helped form the judgements made in this report. What the service does well: What has improved since the last inspection? This is the first inspection of the service following registration. Glen Rose DS0000069891.V357182.R01.S.doc Version 5.2 Page 6 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 Rose DS0000069891.V357182.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glen Rose DS0000069891.V357182.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People can call into the home at anytime and information is available for them to take away to ensure the home is right for them. People’s needs are not always going to be met, as assessments do not include all a persons needs. EVIDENCE: The home has produced a service user guide, statement of purpose and a brochure. The brochure gives details on the organisation that owns the group of homes Glen Rose belongs to and has information added on the particular home. The Commission (we) were advised when people make an enquiry they are invited to call into the home at any time and would be given copies of these documents when they leave. It was noted none of the documents details any information on the complaints procedure, we were advised this is not normal practice and a copy of the complaints procedure was printed off and added to the statement of purpose. Glen Rose DS0000069891.V357182.R01.S.doc Version 5.2 Page 9 Three residents files were sampled and their assessments were viewed. We were advised by the acting manager she has begun to change the process of assessment and care planning and was introducing a new computerised system, which detailed more information and made it easier to input information. The main parts of the information would be printed off so all staff had access to this information. We were shown an old assessment and one, which had been completed on the computer system. It was clear the assessment which had been completed on the computer detailed more information, which was much clearer in its presentation. Nursing staff spoken to stated, they were looking forward to using the new system and felt it would benefit both staff and residents. The assessments of three other residents were seen, these did not give a lot of detail on why the resident had needed nursing care and what all their needs were at this time. More detailed information was needed on their social and mental health needs and what affect this may have on other residents and staff. Verbally we were informed about the needs of a new resident and the effect this may have on other residents in the home. Staff and daily notes recorded concerns over physical and verbal behaviour but no information was recorded on the assessment. Assessments did not indicate nutritional needs and state if food should be liquidised or if the person was able to eat solids. Evidence was seen that relatives had been involved in the assessment process. The home does not provide intermediate care. Glen Rose DS0000069891.V357182.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, 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Peoples care plans do not give enough information to enable staff to know how to provide overall care for residents. Medication is not well managed in the home and does not ensure peoples safety. Peoples right to privacy and dignity is respected and their wishes at the time of their death are recorded. EVIDENCE: The service user plans of the three assessments viewed were looked at. We were advised the service user plans are being reviewed and a new system is being introduced, which should make the plans more informative and give clearer information. In one file it was noted the resident had smoked when they first came into the home, but we were advised verbally this situation had recently changed. Care plans did not reflect this change or state the reasons for the change. It was noted from daily notes at times the resident had wandered into other residents’ rooms and also at times had shown some violent and aggressive behaviour. Information on these behaviours were not Glen Rose DS0000069891.V357182.R01.S.doc Version 5.2 Page 11 recorded on the care plan and did not give staff any clear information on how to deal with this behaviour when it was exhibited. Care plans gave very little information on how individual social needs were met (how were staff addressing these needs. Risk assessments had been completed for some residents but were mainly in the core areas of falling and nutrition. Risk assessments were not completed on an individual basis and did not include the areas detailed above for example wandering and aggressive behaviour. Evidence was seen to show that care plans were being reviewed on a regular basis. Two agency staff on duty on the day stated they had not seen care plans. They both stated they had worked in the home previously so knew what to do from that experience. When looking in residents’ bedrooms it was noted for those who were bedfast charts were maintained to show they were moved on a regular basis. A nurse in the home stated she was very proud of residents skin care and the home has good links and support from the tissue viability nurse. Fluid intake charts were not available for those residents who were bedfast and needed help with feeding and drinking. All three relatives spoken to stated, they felt the personal care was good and their relatives were well looked after. One stated he felt the home was “fantastic and staff noticed small details about the residents”. Health needs are well met in the home. A range of professionals visit the home including dentist, optician, chiropodist and two doctors visited on the day of the visit. Details of visits are recorded in the service user plan. The home has a policy and procedure for all medication and only the nurses in the home become involved with the medication. One nurse showed us the medical room, which was tidy and is where all medication is stored. The home has two medication trolleys one for each floor, which are taken around the home at the time of administration. All controlled medication is stored in a double locked cabinet. Medication is ordered on a monthly basis and delivered to the home. Each resident’s medication is delivered in a separate bag and is checked when it enters the home. All spare medication is stored in a locked cupboard next to each resident’s name. It was noted medication is not stock piled. Medication in the trolley is kept in a separate box for each resident. At the time of administration the trolley is taken to the resident and the medication is taken out of the individual bottles given to the resident and their medical administration records (MAR) are signed. When looking in the trolley at one resident’s medication it was noted diazepam rectal tubes remained in their box, which the resident had not been prescribed since February. When looking at the MAR sheets of one resident it was noted the MAR sheets detailed the incorrect address of the resident and for fifteen dates at the end of October and beginning of November it was difficult to establish what medication the resident had received. There were gaps in the MAR sheets, when discussing with staff and looking at records it was clear the MAR sheet stated the medication should be administered at differing times to the notes maintained in the resident’s medical notes. The medication was to help with anxiety and worked as a sedative. However there was no evidence as to why this had been Glen Rose DS0000069891.V357182.R01.S.doc Version 5.2 Page 12 administered, staff were unsure what behaviour had lead to it being administered and no protocol or guidance was available. It was agreed in these circumstances protocols should be drawn up to record what behaviours would be considered as necessary to administer the medication and consultation with the manager should take place. It was also noted when looking at another MAR sheet, notes had been added when medication had been changed but these had not always been dated or evidence been provided by the doctor for the change. Prescribed creams were found in the communal areas of three of the seven bedrooms viewed. It was noted in one room the person who the cream had been prescribed for had had her name crossed out and another resident’s name had been written on the container. One pot of cream was out of date. The controlled medication was checked and it was noted this was being stored and recorded appropriately and medication held matched records held. The home had a contract for all refused medication to be collected on a regular basis. Privacy was respected around the home. Interactions observed between staff and residents demonstrated they had a respect for residents. Residents were addressed in a manner, which they preferred and this was recorded on care plans. Screens were seen in double rooms and all bedrooms and bathrooms had appropriate locks. Relatives spoken to felt their relatives were well looked after and treated by staff in a respectful manner. The care plan records information on what a residents wishes are when they die. On the day of the visit a resident died and it was noted staff acted in a respectful manner and privacy was maintained. Efforts were made to contact family members and medical professionals were contacted immediately. Glen Rose DS0000069891.V357182.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. 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. People are provided with some group activities but individual activities need to be arranged to meet all people’s needs. People where able can exercise choice in areas of daily living. Visitors are made welcome to the home and can visit at any time. Residents enjoy meals with a well balanced diet being provided. EVIDENCE: It was difficult due to resident’s communication to establish if they felt the home met their social and cultural interests and needs. Care plans detailed very little information in this area. Group social events take place and one relative explained how much his relative had enjoyed the ‘animal day’ and photographs had been displayed around the home of this event. We were advised a lady calls and plays the harp, which residents enjoy and other group activities are arranged. No joint religious services are offered but communion is offered on an individual basis. In discussion with staff if was noted one resident whose first language was not English had started speaking her first language, however staff had not given any consideration into trying to find someone who could the residents first language. Glen Rose DS0000069891.V357182.R01.S.doc Version 5.2 Page 14 The three visitors on the day confirmed they can call into the home at any time and are always made welcome. All visitors assisted their relatives with their meals on the day of the visit. They confirmed they could see their relative in private or in the communal rooms. From observations on the day it was noted residents were able to exercise choice over areas of daily living. It was noted in the daily notes one resident had refused a bath and their choice had been respected. One visitor stated their relative always looked nice and always wore her own clothes. The residents that were able did move around the home freely. On the day of the visit an agency cook was on duty. He stated he had been given clear instructions on his duties and the kitchen was well stocked with all equipment in working order. Food stocks were seen which demonstrated there was plenty of good quality food; choices were available and fresh fruit and vegetables were available. A three-week rotating menu is followed. One visitor stated his relative always enjoyed the meals. On the visit corned beef hash, or spaghetti bolognaise, creamed potatoes, creamed swede spinach and bread and butter pudding or jelly were served. 24 meals were liquidised, 10 were soft, 10 were normal and three diabetic diets were followed. When looking in the lounge upstairs at lunchtime we were informed all nine residents in the lounge needed help with feeding and five more residents in their rooms needed feeding. However only two members of staff were on duty as two members of staff were at lunch. One member of staff in the lounge was standing leaning over residents trying to feed them, whilst another member of staff was trying to feed the residents in their rooms. Glen Rose DS0000069891.V357182.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. People know who and how to complain and believe they will be listened to. The home provides information on abuse but further training is needed to ensure staff are aware of the correct procedure to follow if abuse is suspected for the safety of residents. EVIDENCE: All relatives spoken to stated, they were aware of the complaints procedure and all stated they would first of all speak to the acting manager, who they felt confident would listen to their concerns. Three surveys from relatives, carers all stated they knew how to make a complaint. The Commission has received no complaints about this service. A copy of the complaint procedure was seen and this details all the necessary information. The home has information on abuse and all staff have been issued with a copy of the whistle blowing procedure. The training manager confirmed all staff have received training on abuse and on the adult protection procedure. However records could not be found to demonstrate how many staff had received this training and when it last took place. In discussion with three staff members it was clear none knew what steps should be taken if abuse was Glen Rose DS0000069891.V357182.R01.S.doc Version 5.2 Page 16 suspected. All stated they would contact their manager but did not know what agencies should be informed if their manager was unavailable. Glen Rose DS0000069891.V357182.R01.S.doc Version 5.2 Page 17 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, 24, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All communal areas are clean but not all bedrooms are clean and provided people with a warm and comfortable environment. Parts of the environment created a risk for people. EVIDENCE: We looked in two lounges, the summer lounge, the kitchen, the laundry, two main bathrooms and seven bedrooms. It was noted in some parts of the home the home was warm and in other areas it was cold. Two residents on the day stated they were cold. We were advised part of the home has under floor heating making this part of the home warm and the other part not as warm. It was noted portable heaters were used in the downstairs lounge which had been positioned so as they did not pose a risk to residents. In one bedroom the resident stated she was cold, there was already a portable heater in the Glen Rose DS0000069891.V357182.R01.S.doc Version 5.2 Page 18 middle of this room. We were advised this lady is not mobile so there is no risk to her, but other residents who wander could go into this room, which creates a risk. There was a large ripple in the middle of the carpet, which would be easy to trip on. The summerhouse, which is open was very cold and would have been too cold to sit in. All communal areas were clean. In the two main bathrooms it was noted items on trolleys are stored in these rooms, which we were advised when the rooms are in use they are wheeled out. The items stored included two hairbrushes, a razor and shaving cream, shampoo, hand gel and hand cream. The home has two other bathrooms but we were advised these are not used, one was locked from the outside, the other is on the basement and it was noted the bath was very low. We looked in seven bedrooms, we were advised residents could personalise their own bedrooms. One bedroom was looked at with a relative of a resident, the bed frame, bed rails were not clean, and the specifics were discussed with the acting manager. The sheets had not been fitted properly on the mattress and the bed contained many crumbs. The bedding was stained and looked old. The relative claimed the room often smelt of faeces and stated was unable to go into the room as it made him feel sick. On the day the inspection the room had an unpleasant smell. The acting manager advised us the room was having a new carpet fitted during the following week. When entering another bedroom it was noted the light in the room and in the en-suite did not work. We were advised they were having problems with the electrics, which had been reported. A member of staff changed a fuse and the lights worked. It was noted in all the bedrooms except one where the bedding had been provided by the family the sheets and blankets were of a poor quality. Some beds had very little blankets on them to keep residents warm at night. Two beds had a sheet and just a cover no blankets. One blanket on one bed was ripped and had a hole in it. The training manager stated new sheets were on order and the residents get very warm at night. It was noted out of the seven, two bedroom doors were wedged open. In one room it was noted the washbasins had been placed in the rim of the commode. In another room the windowpane was cracked. As already stated prescribed creams were found in bedrooms. We were advised over the next six months there are plans to re-decorate all the hallway and corridors to lay new carpets in these areas and in two bedrooms. Bedroom furniture will be replaced in twelve bedrooms. Glen Rose DS0000069891.V357182.R01.S.doc Version 5.2 Page 19 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 adequate. This judgement has been made using available evidence including a visit to this service Staffing levels mostly meet the needs of people but breaks and lunchtime need to be better organised to ensure residents needs can be met at all times. People are supported by a group of staff that would benefit from further training. Recruitment procedures offer protection for residents. EVIDENCE: We were advised the home always ensures there are two RGN nurses on duty throughout the day with eight carers on duty in the morning and six carers on duty in the afternoon until 8.00pm. At night time there is one trained nurse on duty with three carers, all work a waking night duty. The home has a laundress who works five days a week working six hours each day. Two cleaners work in the home covering all seven days, one works upstairs and one works downstairs. Two cooks cover the seven-day week working from 7.00am until 5.00pm with kitchen assistants working from 7.00am until 7.00pm. All relatives spoken to were full of praise for the care staff stating they work very hard and have very good caring skills. Care staff spoken felt there was adequate numbers of staff on duty but they were concerned about the number of shifts covered by agency staff. They felt the agency staff were competent but did not know the residents, which had a negative effect on the residents. One relative, carer survey stated “some of the agency staff are not always up Glen Rose DS0000069891.V357182.R01.S.doc Version 5.2 Page 20 to the same standard as permanent staff”. Another relative /carer survey stated, “There have been a few staff changes. Senior staff should make sure all staff know what their duties are and carry out those duties”. Two of the three care staff also stated they felt morale was low, as many permanent staff had recently left. The AQAA document stated 17 members of staff had left in the last twelve months and in the last three months agency staff had covered 373 care shifts. It was noted two care staff took the same lunch break leaving two members of staff to feed 15 resident. On one occasion it was noted three members of staff came in from outside after being on a break. On this occasion the door leading to outside was left wide open giving residents the potential to wander outside on a very cold day without appropriate clothing or supervision. Whilst walking around the home it was noted several residents called out but no staff went to them. One relative/carer survey stated, “ staff should spend more time communicating with residents, I have had some who have said ‘talk to me’ ‘please talk to me’ and I have gone and had a chat”. From three staff surveys two had ticked there is usually enough staff to meet the individual needs of all people and one had ticked never. We were advised nine per cent of the staff have achieved a National Vocational Qualification (N.V.Q.) level 2 in care or above. Two members of staff who were undertaking this qualification had just dropped out. We advised the home is just about to undertake a huge recruitment drive and is considering asking staff if they will undertake training and a N.V.Q Level 2 if they are employed. The staffing records of the last two members of staff to be employed were looked at, one being a registered nurse. It was noted all the relevant information had been recorded and collected, including application forms identification, qualifications, references and checks with the criminal reference bureau (CRB). One member of staffs file who had not started in the home due to all her checks not being completed was looked at. It was noted all the information except the CRB had been completed but we were advised she would not start in the home until this check was received. The home has it’s own training officer, which it shares with the other homes belonging to the same proprietor. Individual training records could not be found and the acting manager and training manager were unable to detail what training each member of staff had undertaken. Records demonstrated three staff had completed training in first aid in 2006, twelve had in date training in food hygiene, four had in date training in infection control, 21 staff members had in date training in manual handling. Six members of staff had received a two-hour session on dementia, we were advised the community psychiatric nurse had also given staff a talk, but no details were available on this. Three staff surveys received stated they were given training, which is relevant to their role. We were advised the acting manager is going to undertake training, which will equip her to train staff in the areas of infection control and movement and handling. Glen Rose DS0000069891.V357182.R01.S.doc Version 5.2 Page 21 Glen Rose DS0000069891.V357182.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. 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. People have confidence the acting manager will bring good outcomes for residents. Finances are well managed and run in the best interests of resident’s. Health and safety practices could be improved to ensure residents are safe at all times. EVIDENCE: The acting manager has achieved the Registered Managers Award and has over five years management experience. During the inspection the manager showed an awareness of the shortfalls identified and demonstrated an awareness of how these should be corrected. Staff and visitors spoken to on Glen Rose DS0000069891.V357182.R01.S.doc Version 5.2 Page 23 the day made positive comments about the manager, one care staff stating, “she will be really good for the home”. The acting manager was unaware of any quality monitoring system in the home. The AQAA received makes no mention of any formal quality assurance taking place. One visitor spoken to stated he had never formally been asked his views on the home, but did say if he ever was it would only praise the home and staff. The home manages the personal allowance for several residents. The finances of two residents were viewed. Accounts and monies held were kept on an individual basis. All monies were recorded in and out, with receipts being held. The home is the appointee for two residents. We were shown details of their accounts and advised the resident’s money is held in individual accounts in the resident’s name. One resident had asked for specific Christmas decorations in her room. Evidence was seen these had been purchased on her behalf and placed in her room. Deficiencies in health and safety in the home have already been identified in this report and include concerns over portable heaters, the electrics in one room, prescribed creams being left in residents rooms, substances which could be harmful to health being left in reach of residents, communal hair brushes being used. The number of staff who have in date training in first aid, food hygiene and infection control could not be established. Further deficiencies identified were in house checks on fire equipment had not been kept up to date. Staff since the registration have received one session in fire training. The fire alarm had been serviced but deficiencies had been noted with regard to the batteries. We were advised the concerns over the fire alarm were already being addressed. In the kitchen the temperature of the fridge and freezer were being maintained daily. A probe thermometer was being used and the temperature recorded each mealtime. The laundry was well equipped and organised; the washing machines had the necessary programmes for dealing with soiled linen. All windows had been risk assessed and restrictors fitted. The accident book was seen, which had been filled out appropriately. Glen Rose DS0000069891.V357182.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 X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X X X 2 X 2 STAFFING Standard No Score 27 2 28 1 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Glen Rose DS0000069891.V357182.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 OP3 Regulation 14 Requirement Timescale for action 01/03/08 2 OP7 15 (1) (c) 3 OP9 13 (2) 4 OP19 24 Assessments must demonstrate all a residents needs when they enter the home, ensuring staff have adequate information to meet all their needs including mental health needs and social needs. Care plans must show how 01/03/08 individual needs are to be met. Plans must include mental health needs and strategies to ensure the home works with residents in a consistent way. Medication procedures must be 01/03/08 followed ensuring the dispensing, administration and recording of medication is correct to keep residents safe. All prescribed creams must be kept in a locked cabinet. Protocols need to be drawn up to indicate when PRN medication should be administered. Deficiencies in the environment 20/03/08 including bedrooms, bed linen, portable heaters and the carpet identified must be made safe and the windowpane replaced or repaired. DS0000069891.V357182.R01.S.doc Version 5.2 Glen Rose Page 26 5 OP27 18 (1) (a) (b) 6 OP27 18 (1) (c) (i) (ii) 7 OP38 17 Staffing levels and the deployment and the mix of agency staff must ensure all the residents needs can be met at all times. Training in first aid, infection control, basic food hygiene, dementia and adult protection must be provided for all staff, who do not have in date training in these areas. The provider must have a plan as to how they reach 50 of staff achieving a National Vocational Qualification Level 2. Records must be kept up to date and maintained of all checks on fire fighting equipment in the home. 20/03/08 01/06/08 20/03/08 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 OP33 Good Practice Recommendations A system for involving residents and seeking their feedback about the quality of care provided must be put in place. Any system must also include seeking views from other interested parties All hazardous objects and fluids must be stored out of the reach of residents. 2 OP19 Glen Rose DS0000069891.V357182.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Rose DS0000069891.V357182.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!