Inspection on 18/06/08 for Glenlyn

This inspection was carried out on 18th June 2008.

CSCI found this care home to be providing an Excellent 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

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Glenlyn Exminster Exeter Devon EX6 8AT Lead Inspector Michelle Oliver Unannounced Inspection 18th June 2008 09:15 Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 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 Glenlyn DS0000071087.V366282.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 Adults 18-65. 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. Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glenlyn Address Exminster Exeter Devon EX6 8AT 01392 824222 01392 824284 glenlyn@guinness.org.uk 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) Guinness Care and Support Ltd Miss Sarah Elizabeth Pyne Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered person may provide the following category of service only: Care home only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability (Code LD) The maximum number of service users who can be accommodated is 5. Date of last inspection 05/07/06 Brief Description of the Service: Glenlyn has recently changed ownership and is now under the ownership and organisation of Guinness Care and Support Ltd The home provides services for five people with learning disabilities and physical disabilities. The ages of the current residents range from 50 to 72 years old. The home has five single rooms, one of which has en-suite facilities, a lounge, dining room and pleasant garden area. The home is situated near to local facilities and shops and is a short car journey into Exeter City Centre. Glenlyn DS0000071087.V366282.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 3 stars. This means the people who use this service experience excellent quality outcomes. This unannounced inspection took place over 5 hours on Wednesday 18th June 2008. As part of this key inspection the manager completed an Annual Quality Assurance Assessment (AQAA), which contained general information about the home and the people living and working there. With the information provided, CSCI surveys were sent to people living at the home, their relatives, staff and outside professionals, in order to hear their confidential views of the service, prior to our unannounced site visit. Prior to this inspection we sent surveys to people living at the home and staff. We received completed surveys from 5 people living at Glenlyn, 4 staff, 4 health care professionals and 1 relative, expressing their views about the service provided at the home. Their comments and views have been included in this report and helped us to make a judgement about the service provided. We spent 5 hours at the home, speaking with people living there and staff. We also spent time observing the care and attention given to people by staff. To help us understand the experiences of people living at this home, we looked closely at the care planned and delivered to three people. Most people living at the home were seen or spoken with during the course of our visit and three people were spoken with in depth to hear about their experience of living at the home. We also spoke with 4 staff, including the registered manager, and ancillary staff, individually. A tour of the premises was made and we inspected a number of records including assessments and care plans and records relating to medication, recruitment and health and safety. Finally the outcome of the inspection was discussed with the registered manager. What the service does well: Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 6 People currently living at Glenlyn have done so for between 17-22 years. and have a stable and safe family based home and long standing relations together. Staff have an excellent knowledge of individual needs and how to meet them to a high standard on a individual basis and the core staff team have been employed at Glenlyn from 5-20years. There have been no new admissions to the home for 17 years, so the manager has had little experience of this at present, however she has supported her line manager in carrying out an initial needs assessment in a emergency situation, so is aware of her role and duties when needed. The manager has developed a comprehensive new admissions assessment, which care plans are based upon. Each person living at Glenlyn has a individual plan of care , which is developed in agreement with the them as well as family, advocates, professionals and specialists. The atmosphere at Glenlyn is homely, friendly, caring and fun. Staff were seen being kind, respectful and offering choices to people living at the home and the relationship between them was clearly trusting and caring. The staff team work hard to ensure peoples’ social needs are well met. Many attend groups outside the home for learning life and independent skills. Staff were very motivated in enabling people to have these opportunities. The food provided in the home is healthy and varied and a weekly menu is displayed with pictures of the prepared meals and recipes. Health and personal care needs of people living at Glenlyn are supported and well met, some people confirmed this and observations and records provided further evidence. People living at Glenlyn are listened to and fully protected from potential abuse or harm through good recruitment practices, good staff training, and clear complaint’s and financial procedures. Feedback from people living at the home, a relative, staff, and a community nurse, before and during the inspection indicated that the manager runs a good service. Staff said she was very supportive, worked hard and provided a clear sense of direction. Throughout the inspection the manager was observed being kind, caring, working hard and giving clear instructions to staff. What has improved since the last inspection? During the last inspection in July 2006 it was highlighted that windows to the rear of the building needed to be replaced. A requirement was made for this work to be undertaken. During this inspection we noted that all windows had been replaced within the set timescale. Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 5. Quality in this outcome area is good. People who may be considering making Glenlyn their home will benefit from being provided with good information about the home and the costs. The manager gathers enough information to ensure the home is able to meet peoples’ needs prior to admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Glenlyn has had no new admissions for 17 years, so the manager has had little experience of this at present. However she has supported her line manager in carrying out an initial needs assessment in an emergency situation, and is fully aware of her role and duties for when needed. The manager told us that the procedure for the admission of a person to the home would include a comprehensive assessment of health, welfare and social care needs to make sure that the home meets peoples needs and that staff have the experience and competency to meet individual assessed health and social care needs. Staff would seek information from parents, health care professionals and other sources before agreeing to offer the person Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 10 ‘transitional visits’ where they can get to know other people living at the home. Staff at Glenlyn then complete their own assessment which covers all areas of need, ranging from health, emotional, mobility, dietary, spiritual, likes and dislikes and much more. We looked in detail at three peoples’ files during this inspection and noted that all had been given contracts and details of their rights when they had moved to Glenlyn. Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. Staff are provided with good information to meet peoples’ needs and goals safely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person living at the home has a plan of care in which information is recorded about his or her individual needs and details of how to make sure individual needs / goals are met and monitored. Each person living at the home has a key worker, who is responsible for co-ordinating all aspects of their care and completing monthly reviews of the care plans. Since the last inspection people living at the home have been asked about their spiritual or religious needs. Those people who wished to share this information agreed to it being recorded in their plans of care. Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 12 Staff spoken to during this visit demonstrated an excellent knowledge and understanding of each person’s individual needs. Staff communicated with individuals appropriately and were kind and respectful to them during this visit. Regular meetings are held at the home when people living there discuss aspects of daily life and have a say in the running of the home. Most people said they are able to go shopping to choose their own clothes. People can get up and go to bed when they choose. The manager told us that if person wanted to stay out late arrangements would be made. One person spoken to during this visit said they are usually able to make decisions about what they do each day. Through discussions between people who use the service and staff individual goals have been set for each person and records of these are kept with the daily diaries. This ensures staff are aware of the goals and maintain a record of progress and achievements. Staff record the days events including times people chose to get up and go to bed, what they ate and whether a choice was offered, activities, daily living skills, interactions with others, methods of communication used, contact with relatives, appointments and other comments. The daily records always reflected if care plan goals had been met. Staff are provided with good information to meet peoples’ needs and goals safely. Individual risk assessments have been undertaken to reduce risks to an acceptable level but not to restrict or limit peoples’ lives. Any risks to people through general health, needs or activities are assessed and clear action to reduce any risks is recorded. Staff demonstrated a good understanding of such risks and were able to describe what they should do to reduce them. Methods of individual communication are identified in care plans to ensure people have every opportunity to make their views known and to make choices and decisions. We saw information about individuals choice of activities, communication methods and action to be taken in the event of aggression or behaviour which may be challenging. The purpose of these plans are to focus on positive aspects and included involvement from multi disciplinary team. Staff demonstrated an excellent knowledge of peoples’ needs, mainly through their years of working in the home and being involved in care planning and following peoples’ individual goals. This was also observed throughout the inspection. Throughout the inspection staff were seen taking time with people talking about what they would like to do and what they would like to eat. One person told us they were always consulted with and provided with choices in most aspects of their live. The manager and staff said any decision about peoples’ lives are always discussed with them, or if they are unable to communicate, Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 13 with relatives, care managers and other professionals. This is to ensure decisions are being made in the individuals’ best interests. Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17. Quality in this outcome area is excellent. People living at Glenlyn benefit from being cared for by respectful staff, accessing the local community, engaging in appropriate activities; and by being supported in maintaining good relationships with relatives. People also benefit from being provided with a varied and healthy diet. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff were seen and heard being kind and respectful to people living at Glenlyn throughout the inspection and those that were able confirmed that staff were “very kind”. Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 15 The staff spoken with were very motivated to make sure that people living at Glenlyn were given the opportunity to go out when they wished and experience activities and social events that met their needs and wishes. These ranged from trips out to clubs in the evenings, educational groups, art & craft sessions, shopping, lunches and picnics out and many more. At the time of this inspection one person spent the morning at an arts and crafts class and was looking forward to going out that afternoon. We were told about a day service recently started within Guinness Care and Support [GCS], called Parachute Club. This is coordinated by staff from Glenlyn with staff from another GCS home, which the registered manager also manages. The club runs 3 sessions each week, an outing once a month and regular parties and events. All adults with a learning disability who live in GCS accommodation have access to the club. The manager told us that they plan to convert a garage in to an activity room, and are currently obtaining a quote to link up a new fire alarm from the garage to the main fire alarm circuit/panel. The use of public transport is assessed on an individual need basis and recorded in individual plans. The home has a lease car, which can seat 7 people, and staff are flexible to ensure drivers are always available when required. Family and friends are encouraged to visit the home at any time and this is also achieved by holding special events throughout the year such as parties, barbecues, celebrations, inviting for tea, and encouragement to join in with activities within and outside of the home environment. People living at the home are provided with a very health, balanced and varied diet. A weekly menu is displayed in the kitchen together with pictures of the meals and recipes. The meal served during this inspection was attractively presented and healthy. Fresh fruit and yoghourts are available as well as healthy sweet alternatives. People confirmed they are offered a choice of foods and are supported to take part in the preparation of some meals. One person helped prepare vegetables for the meal served during this inspection. Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20. Quality in this outcome area is good. People living at Glenlyn benefit from staff respecting their dignity and privacy and having their individual health needs being well met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The ethos and atmosphere of Glenlyn is very much about giving people living there choice, having their rights respected and providing a relaxed and homely atmosphere. Staff had a gentle, caring and respectful manner when talking about and communicating with individuals during this inspection and people living at Glenlyn responded well to staff and appeared relaxed and happy. A relative spoke highly of the staff team and said they were always helpful, caring and patient and commented that the service does “everything” well and that the service was “ first class”. Care plans clearly described individuals’ health care needs and showed their needs were monitored and specialist health professionals have been regularly consulted. Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 17 People living at Glenlyn are supported and encouraged to be as independent as possible and to take an interest in their own appearance through positive approaches and praise. People are also encouraged to make choices about the daily lives such as choosing when they want to go to bed and get up, have baths and meals. People are supported to attend and maintain all health appointments regularly when they will be accompanied on a 1-1 basis, by their keyworker wherever possible or staff member of choice. Medication seen during this inspection was stored appropriately and medication administration sheets were recorded correctly. All staff have received training on the safe administration of medicines. The manager assesses staffs’ competencies regularly to ensure what they have learned continue to be put into practice, thereby protecting individuals’ welfare. All residents receive an annual medication and health review with their own GP, who will visit them at home if required. Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Quality in this outcome area is good. People who use the service are assured they are listened to and complaints are dealt with appropriately. People living at Glenlyn are fully protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a complaints policy in a variety of formats to ensure people living there, relatives and staff know how to make a complaint. The home has a Complaints register and the complaints procedure is available at all times and is displayed. People who were able said that they would talk to their key worker or the manager if they were unhappy. The manager has introduced Residents’ meetings where issues of concern can also be raised. The home has comprehensive procedures for protection against abuse and all members of staff receive Protection of Vulnerable Adults [POVA] training. Staff demonstrated an excellent knowledge and understanding of Adult Protection issues. They clearly described forms of abuse, including infringing on people’s rights and choices; and knew what to do should they suspect any abuse. The home also has policies and procedures and local guidance on abuse awareness and what to if it is suspected. Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 19 People living at Glenlyn have their own bank accounts and the home maintains small amounts of cash for peoples’ personal spending. Good records with receipts are kept which the manager audits. We looked at records of money held on behalf of people living at the home. The records were detailed, up to date and accurate. We checked balances shown with cash held and all were correct. We saw evidence that consultation takes place with peoples’ next of kin or advocates in relation to large purchases and spending. All people living at Glenlyn have known each other for a number of years and exchange small gifts on birthdays and at Christmas. We saw no evidence of the individuals agreeing to this. We discussed this with the manager agreed that these discussions and decisions need to be recorded. The manager has attended training recently and is implementing what they had learned about the Mental Capacity Act 2005 especially in relation to consent issues. The home’s recruitment process is robust and includes an in depth interview, carried out by the manager and another member of staff and CRB and police checks. All new staff has a 12-week induction process and are employed on a probationary period of 6 months, which includes a formal 3 and 6 month review. We looked at records during this inspection that were accurate and up to date and confirmed the process is carried out for all new staff. An annual quality assurance questionnaire is distributed to those living at the home, family, friends, advocates, professionals and specialists and staff for feedback on the service provided with any ideas for improvement. Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. People living at Glenlyn do so in a clean and homely environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Glenlyn is bright, clean and cheerful with a warm homely atmosphere. The home has a comfortably furnished lounge, separate dining room, a wellequipped separate laundry, an upstairs bathroom, a toilet downstairs, a separate office and individual personalised bedrooms. The lounge has a TV, video player and a music system and comfortable furniture. The home does not employ domestics and staff undertake all cleaning and laundry chores at the home. The home has an infection control policy and procedure and all staff have had training in infection control. Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 21 Glenlyn is run as a family home and as such people living there and staff undertake not only the daily cleaning and laundry chores but also the decorating of the home. People’s bedrooms are decorated and furnished to their personal tastes and preferences; the lounge has been re-decorated and had a new carpet and two bedrooms have been decorated since the last inspection. However, some areas of the home are looking tired and would benefit from redecorating. The manager told us that there are plans for this to be undertaken. The bathroom was looking very shabby and we were told that the manager has plans for it to be decorated and for the bathroom suite to be replaced. This will ensure that people live in a well-decorated, comfortable and personalised environment, which suits their needs and wishes. People living at Glenlyn get a lot of pleasure from the garden, which is easily accessible and is diverse to suit all people living there and their interests. We were told that they had recently had a strawberry tea using home grown strawberries. There are several different areas of the garden offering different themes. One person uses a summerhouse to relax and listen to music, there are several seating areas and several bird feeders, some made by the people living here and wind chimes. The environment is well maintained and is monitored through 3 monthly reviews and on going by staff and manager. The manager carries out monthly assessments of the building, reviews risk assessments, monitors standards, results and action plans. A programme is maintained on the renewal and decoration of the environment, furniture and furnishings. Records are kept of the daily cleaning of the premises. We spoke to the manager about the arrangements for routine maintenance at the home. We were told that a report would be made to the Company head office and a visit from a maintenance person would be arranged. During the last inspection we noted that windows to the rear of the property needed to be replaced. During this inspection we noted that all windows have been replaced within the set timescale. This ensures that people live in a well maintained house and are kept safe. On the day of the inspection the home was clean and free from offensive odours. Hand washing and drying facilities were available and gloves and aprons are used when necessary. Therefore protecting service users from the risk of cross infection. Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. Quality in this outcome area is good. People living at Glenlyn are protected by robust recruitment procedures and are supported by a trained, experienced and caring team of staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection three staff were spoken to and observed as they interacted with people at the home. It was clear they were experienced and skilled in their knowledge of each person’s needs, preferences and goals. People living at Glenlyn are encouraged to be involved and take part in the recruitment process. Two staff files were looked at in detail during this inspection. They were stored securely, were well organised and included the necessary checks required such as references and Criminal Records Bureau (CRB) checks. Ensuring the recruitment procedure is consistent and that all Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 23 required information is obtained for all employees will protects people, as only those who have undergone this robust procedure will be employed to work at the home. All staff have received a good range of training that helps them to understand and meet peoples’ needs. Training includes, mandatory health & safety training, protection of vulnerable adults, medication administration, epilepsy, safe holding techniques and many more. Newly recruited staff undertake probationary period of training, which is reviewed at 3 and 6 months. Staff training is also monitored and booked through the Company’s’ Human Resources department who have a rolling programme on a database. This ensures that all staff receive appropriate training and are kept up to date with any changes. Over 50 of care staff have obtained NVQ qualifications level 2 and above. This is a national recognised qualification where staff have reached the standards of care expected in care homes. Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is excellent. The home is being run in the best interests of people who live there Systems to review, develop and improve the home have been developed peoples’ safety and welfare are protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff and those people living at the home who were able to communicate spoke highly of the manager. Staff said she provided a clear sense of direction Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 25 and leadership. It was clear throughout the inspection that the manager was working hard to raise standards and have better and clearer recording systems in place, for example improving care plans and risk assessments. The manager has obtained the registered manager’s award and NVQ level 4 in care. We spoke to the manager about how the views of those living at the home are sought, and what quality assurance and monitoring systems are in place to measure success in achieving the aims and objectives of the home. The manager completes audits of the service through, for example care plan reviews, staff supervision and meetings, environmental and health and safety checks, audits of medication, accidents, complaints and finances. People living at the home and their relatives are consulted about their views on the home and services. This quality audit ensures the home is being run efficiently and effectively and in the best interests of those who use the service. We looked at records kept of accidents that have occurred at the home and all included good information of the accident and treatment given. Prior to the inspection the Manager was asked to complete an AQAA (annual quality assurance assessment), which requests information regarding maintenance records and policies and procedures. Information received before this inspection indicated that all equipment is well maintained regularly. The information also included conformation that all necessary policies and procedures are in place and are up to date. These are not inspected on the day but the information is used to help form a judgement as to whether the home has the correct policies to keep people living there and staff safe. In this instance policies and procedures were in place. The fire logbook confirmed that fire safety checks, risk assessments and staff training are up to date. People living at the home and staff said that they would all know what to do if the fire alarm went off and that they had practised fire drills. Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 4 X X 3 X Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 27 No 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. Standard Regulation Requirement Timescale for action 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 OP23 Good Practice Recommendations Records should be kept when people living at the home are consulted about whether they wish to buy gifts for others living there. A record should also be kept of their decision. Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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 Glenlyn DS0000071087.V366282.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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