Inspection on 20/07/05 for Glen, The

This inspection was carried out on 20th July 2005.

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

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

Other inspections for this house

Glen, The 07/06/07

Glen, The 22/11/05

Glen, The 02/12/04

Glen, The 21/04/04

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

CARE HOMES FOR OLDER PEOPLE The Glen 57 Part Street Southport Merseyside PR8 1JB Lead Inspector Elaine White Unannounced 20th July 2005 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 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. The Glen F53 F03 S5323 THE GLEN V240488 210705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Glen Address 57 Part Street Southport Merseyside PR8 1JB 01704 544332 01704 544332 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Miss Carol Lynn Marshall Miss Carol Lynn Marshall Care Home 10 Category(ies) of Dementia over 65 - 1 registration, with number Old age - 10 of places The Glen F53 F03 S5323 THE GLEN V240488 210705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 10 old age. 2. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 3. The service is registered to provide personal care to one named service user in the category of Dementia. This variation will cease when the service user is no longer resident. Date of last inspection 2nd December 2004 Brief Description of the Service: The Glen is a private family run residential care home which provides personal care and support for up to 10 elderly residents and one named resident in the category of dementia. The home is owned and managed by Ms. Carol Marshall who provides hands on care and support to the residents and staff. Nursing care is provided by the nursing services when required. The home is located close to the town centre of Southport. Amenities provided within the town include cinema, shops, restaurants, pubs and parks. These can be accessed by local transport or within walking distance of the home. The Glen is a large detached property, within its own grounds. The owner purchased the property as an existing care home. The accommodation is located on two floors. There is no lift access provided. The home provides a dining room, which caters for all residents. A large comfortable lounge is located on the ground floor. Parking is available at the front entrance. Disabled access is provided via a portable ramp to the front garden. A call system is available throughout and assisted bathing facilities. All residents are registered with a GP. Positive comments were received from the residents on the service provided. The Glen F53 F03 S5323 THE GLEN V240488 210705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced visit and conducted as part of the regulatory requirement for care homes to be inspected at least twice a year. A tour of the building was conducted. The home provides a warm, friendly, clean and comfortable environment for the residents to live. Case tracking was conducted on 3 residents to assess the care and support provided. A selection of care, staff and home records was also viewed. The manager, 3 staff and 5 of the 10 residents were spoken with and their views obtained of the home. 1 new resident was being admitted during the inspection and was being settled into the home by care staff and her relative. Comments received have been favourable regarding the home and the very caring nature of the staff and the standard of the environment and atmosphere in the home. What the service does well: The home provides a very clean, pleasant, homely, relaxed and comfortable atmosphere. The home is registered for 10 residents, 4 male and 6 female. Those spoken to said they “feel part of the family”. “I love it here”. The home is resident focused and relatives and friends are encouraged to call in as often as they wish. Visitors are made welcome and invited to stay for lunch with their relative. Vacancies are few and the home is usually fully occupied. An ongoing training programme is in place, which provides the staff employed with the necessary skills to enable them to deliver care and support to the residents. The home is committed to providing NVQ (National Vocational Qualifications) for their employees. There is a low turnover of staff, which ensures continuity of care to the residents. No agency staff are employed. 1 resident commented, “The carers are super. They always come in with a smile on their face”. Discussion with staff and viewing of records confirmed that supervision is in place. “I get lots of support and training and handovers take place so I know what is going on”. The Glen F53 F03 S5323 THE GLEN V240488 210705 Stage 4.doc Version 1.40 Page 6 The recording systems are well organised and staff spoken with commented “All the information is there so I know what I need to do”. A varied menu is available and alternatives are offered. Residents commented, “The food is good”, “If I fancy something Carol (manager) will do it for me. I like creamed mushrooms and they do them for me when I fancy them”. What has improved since the last inspection? What they could do better: Radiator covers are not in place, however the manager conducts risk assessments to assess this risk. A portable ramp is in place at the front entrance and this requires a risk assessment for its use. The home is yet to be assessed by a qualified occupational therapist who has a specialist knowledge of the needs of the client group. The manager has agreed to have this completed. An activity programme is not in place. The manager, staff and residents commented that as it is a small, friendly, family run home they provide activities on a more personal basis i.e. accompanied walks, trip to the shops, dominoes and video afternoons. 4 of the 10 residents access the local community independently and go out daily. The home should continually review the activities provided with the residents to demonstrate that their needs are being met and to obtain feedback on the service provided. The laundry room in the basement requires repainting and hand washing equipment provided. The manager agreed this during the inspection. The Glen F53 F03 S5323 THE GLEN V240488 210705 Stage 4.doc Version 1.40 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 Glen F53 F03 S5323 THE GLEN V240488 210705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Glen F53 F03 S5323 THE GLEN V240488 210705 Stage 4.doc Version 1.40 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 standard(s) 1,2,3,4,5,6. Information is available for all prospective residents and relatives on the services provided and conditions of residency. Prospective residents are encouraged to visit the home and assessments are completed prior to admission to ensure their needs can be met. EVIDENCE: Records viewed showed an up to date statement of purpose is in place, which outlines the services provided, residents charter and residents contract. A leaflet provides information for prospective service users/relatives and a service user guide is available for all residents. Contracts are in place, which include a statement of terms and conditions. These include fees to be charged for the services provided, charges for extras, the rights of service users and terms and conditions of occupancy. 3 care plans were viewed and were found to contain up to date information on the needs of the residents. Records showed that care plans are reviewed monthly and changing needs are addressed. The home provides access to health care services, were required and records of all visits are made. 2 service users receive a diabetic nurse visit twice daily to monitor their progress. Staff The Glen F53 F03 S5323 THE GLEN V240488 210705 Stage 4.doc Version 1.40 Page 10 training programmes ensure that they are able to meet the needs of the residents. During the inspection 1 new admission was observed to be settled into her new accommodation by the manager, care staff and her accompanying relative. The resident was made comfortable and sat chatting to the staff who were very pleasant and friendly. The Glen F53 F03 S5323 THE GLEN V240488 210705 Stage 4.doc Version 1.40 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 standard(s) 7,9,10,11. Care plans identify and record the health care needs of the residents. Access is available to health care services. Medication policies and procedures are in place. Residents are treated with dignity and respect and are assured at their time of death their wishes will be addressed. EVIDENCE: 3 care plans were viewed and were found to contain up to date information on the needs of the residents and their wishes at the time of their death. All care plans are reviewed monthly with the residents to monitor changing needs. Daily records are maintained of all care needs, visits to and by health care services and relatives and visitors. Changes in need, action taken and outcomes are recorded. Discussion took place with the service users to confirm that the care provided reflected their care plans. Residents spoken to provided positive comments on the care and support provided and the pleasant attitude of the staff. “If I want anything I just ring the bell”. “They often give me a hug when I am down”. “They always come in with a smile on their face”. “When I need personal care they do it nicely and I don’t feel embarrassed”. The Glen F53 F03 S5323 THE GLEN V240488 210705 Stage 4.doc Version 1.40 Page 12 Medication policies and procedures are in place and all administrations are recorded. Medication is securely stored and a separate fridge is provided for insulin. The Glen F53 F03 S5323 THE GLEN V240488 210705 Stage 4.doc Version 1.40 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 standard(s) 13,15 The home encourages community contact and welcomes visitors. A wholesome, appealing diet is provided with alternatives for the residents. EVIDENCE: Observation and discussion with residents and staff confirmed that visitors are made welcome at the home, offered tea and snacks and encouraged to stay for lunch with their relatives who live at the home. 1 resident said her husband stays for his lunch every Friday when he visits her. The home’s statement of purpose outlines the policy on visitors and an information leaflet is available to all visitors to outline the services provided. A number of residents access community facilities independently. Although the home does not provide a weekly activity programme discussion with residents and staff confirmed that activities are provided on a more personal basis i.e. walks, DVD’s and trips to the shops. The manager hopes to arrange an exercise class in the near future. The residents spoken to said they are satisfied with this as it helps them to choose what they wish to do. The home should continually to review this to demonstrate that they are meeting individual changing needs. Meals are served in a pleasant dining room and residents have the choice of eating in their own rooms should they wish. Menus are in place and alternatives are available. Residents spoken to provided positive comments on The Glen F53 F03 S5323 THE GLEN V240488 210705 Stage 4.doc Version 1.40 Page 14 the food provided. “The food is good”. “If I fancy anything Carol (manager) will get it for me”. The Glen F53 F03 S5323 THE GLEN V240488 210705 Stage 4.doc Version 1.40 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18. Policies and procedures are in place to protect residents form abuse. Residents are aware of how to make a complaint. A robust recruitment and selection procedure is in place. EVIDENCE: All staff are recruited and selection through the correct procedure, which involves POVA checks (protection of vulnerable adults) and 2 written references obtained. Staff and residents interviewed said they are aware of the complaints procedure, which is contained in the service user guide available to all residents and relatives. No complaints have been recorded since the last inspection. 1 resident commented, “If I wasn’t happy I wouldn’t hesitate to tell Carol”. Policies and procedures are in place for abuse. Staff spoken to confirmed they have access to them and are aware of the procedure. The Glen F53 F03 S5323 THE GLEN V240488 210705 Stage 4.doc Version 1.40 Page 16 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 standard(s) 19,20,22,23,24,26. The home provides a homely, comfortable and clean environment for the residents to live. The home is yet to be assessed by a qualified occupational therapist with knowledge of the client group. The use of the portable ramp requires a risk assessment to ensure its safe usage. EVIDENCE: A number of private rooms were viewed and all the communal areas. These were found to be comfortably furnished, clean and homely. A programme of planned maintenance is in place. Repairs, decoration and improvements are undertaken when needed to maintain the standard. The grounds are attractive, kept tidy and safe and provide a pleasant outlook from the accommodation. Residents commented on their satisfaction with the homely, comfortable environment. Individual rooms are personalised with their own possessions and residents said they are very satisfied with their accommodation. 1 resident had recently purchased some new furniture and commented that the staff “have been very helpful helping me sort it all out”. The Glen F53 F03 S5323 THE GLEN V240488 210705 Stage 4.doc Version 1.40 Page 17 The home is a smoke free area. A large comfortably furnished lounge and dining area available to seat all residents. There was a pleasant, relaxed atmosphere throughout the inspection. Residents commented, “We are all one big happy family”. Residents were observed to relax in the lounge and chatted freely to the staff. The garden is accessed via a portable ramp, which requires a risk assessment. The home must be assessed by a qualified occupational therapist who is aware of the needs of the client group. This was agreed by the manager during the inspection. Radiator covers are not in place, however the manager conducts a risk assessment for all residents. The laundry was found to be in need of repainting due to the flaking walls. Hand washing equipment i.e. towels and soap must be in place to avoid cross infection. These were brought to the attention of the manager during the inspection and action is to be taken to improve this. The Glen F53 F03 S5323 THE GLEN V240488 210705 Stage 4.doc Version 1.40 Page 18 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30. Sufficient staff are on duty to meet the needs of the residents. Training for staff is in place to ensure competency of their role. The procedures for the recruitment of staff are robust and include necessary Protection of Vulnerable Adult (POVA) checks prior to employment on all staff, which are needed to help ensure protection to people living in the home. EVIDENCE: Records viewed, observation during the inspection and discussion with staff and residents demonstrated that sufficient staff are on duty to meet the needs of the residents. The home has a low staff turnover, which ensures continuity of care. Residents commented positively on the staff employed. “I love it here”. “They always come in with a smile on their face”. “If I want anything I just ring the bell”. Staff spoken to and records viewed confirmed that a training plan is in place and they are encouraged to take qualifications in NVQ. Staff commented, “I get lots of supervision and support”. “We all get on so well”. “We all work together”. Staff meetings take place every 6 – 8 weeks. A robust recruitment and selection process is in place and records showed that all staff are employed following a satisfactory CRB (criminal record bureau check) and 2 written references. 1 new member of staff confirmed that an The Glen F53 F03 S5323 THE GLEN V240488 210705 Stage 4.doc Version 1.40 Page 19 induction process is in place to ensure staff are aware of their roles and responsibilities. The Glen F53 F03 S5323 THE GLEN V240488 210705 Stage 4.doc Version 1.40 Page 20 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36,38. General records of the home viewed including fire prevention and accident records were up to date to promote and protect the health, safety and welfare of the residents. The home is run in the interest of the residents, well managed by an experienced manager, who provides leadership and support to the staff. EVIDENCE: The registered manager is experienced in the care of older people and has recently achieved a qualification in NVQ Level 4, Registered Managers Award. Staff and residents spoken to gave positive comments regarding the care, support and direction the manager provides. “Carol makes me feel like part of the family”. (Resident). “We all work together”. (Staff). Residents commented that the manager is always approachable and available to discuss any issues that arise. A positive, open atmosphere was witnessed during the inspection. . The manager is in day-to-day control of the home and has developed wellorganised systems, procedures and records. The manager is due to take The Glen F53 F03 S5323 THE GLEN V240488 210705 Stage 4.doc Version 1.40 Page 21 maternity leave and will leave the home in the charge of her deputy who is experienced and has almost completed her NVQ Level 3. Staff and residents expressed their confidence in the deputy manager and commented, “I have no concerns when carol goes off”. (Resident). “Carol will be there if we need her”. (Staff). Records are up to date on all certificates required. Fire safety and water temperatures are recorded. Risk assessments are in place for residents, however the inspector recommends that a risk assessment is completed for the portable ramp. The manager to continue to provide risk assessments for all residents in the absence of radiator covers. The Glen F53 F03 S5323 THE GLEN V240488 210705 Stage 4.doc Version 1.40 Page 22 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 3 3 2 3 3 x 2 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 3 x x 3 x 3 The Glen F53 F03 S5323 THE GLEN V240488 210705 Stage 4.doc Version 1.40 Page 23 none Are there any outstanding requirements from the last inspection? 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 19,22 Regulation 23 Requirement The registered person shall obtain an assessment of the building by a qualified occupational therapist to ensure the home is suitable for the client group. The registered person shall provide hand washing facilites in the laundry and redecorate the laundry walls. Timescale for action 31st December 2005. 2. 26 23 31st December 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard 15 38 19 Good Practice Recommendations Regular surveys of the activity programme should take place to demonstrate residents needs and interests are being met. The manager should continue to provide risk assessments for all residents in the absence of radiator covers. The manager should provide a risk assessment for the use of the portable ramp. The Glen F53 F03 S5323 THE GLEN V240488 210705 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Burlington House, South Wing 2nd Floor, Crosby Road North Waterloo, Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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