Inspection on 20/09/06 for The Glen Nursing & Residential Home

This inspection was carried out on 20th September 2006.

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

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

Other inspections for this house

The Glen Nursing & Residential... 21/10/08

The Glen Nursing & Residential... 24/10/07

The Glen Nursing & Residential... 01/02/06

The Glen Nursing & Residential... 14/09/05

The Glen Nursing & Residential... 02/02/05

The Glen Nursing & Residential... 13/07/04

The Glen Nursing & Residential... 22/01/04

The Glen Nursing & Residential... 09/10/02

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE The Glen Nursing & Residential Home Shapway Lane Evercreech Shepton Mallett Somerset BA4 6JS Lead Inspector Justine Button Unannounced Inspection 20th September 2006 09:00 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 The Glen Nursing & Residential Home DS0000003298.V312622.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. The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Glen Nursing & Residential Home Address Shapway Lane Evercreech Shepton Mallett Somerset BA4 6JS 01749 830369 01749 831390 smithgaupa.com www.bupa.co.uk BUPA Care Homes (CFCHomes) Limited 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) Ms Gale Lesley Smith Care Home 58 Category(ies) of Old age, not falling within any other category registration, with number (58) of places The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. Number of persons for whom nursing care is provided shall not exceed 35. Up to 26 places for personal care, 23 of which must be sited within the original building. Up to three persons of either sex, in the age range 18-64, who require general nursing care. Maximum overall number 58. Date of last inspection Brief Description of the Service: The Glen is a service that supports up to 60 older people. The Glen is part of the BUPA Care Homes group. The service is situated in the village of Evercreech, which is a few miles from the town of Shepton Mallet. The home is situated within pleasant grounds in a country setting. The service is split into two wings with those service users who require nursing support in one and those who require personal care only in the other. There is a common kitchen and offices in the centre of the two wings. The bedrooms are distributed over three floors and there are two passenger lifts that allow easy access to all floors. Service users are able to visit all areas of the service even if their bedroom is on the opposite wing. The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key Inspection was unannounced and took place over one day and was conducted by two inspectors, which amounted to 14 inspector hours. During the inspection a number of the key standards were assessed. A number of tools were used during the inspection to assist the inspector make judgements for each outcome group. These tools included information received from the service prior to the inspection in the form of a pre-inspection questionnaire, feedback forms received from service users, relatives and healthcare professionals. During the inspection care plans and documentation was reviewed. Discussions took place through out the inspection with people living at the service, staff, relatives and the management team. The care and support offered to people living at the service was observed. The inspectors would like to thank the residents, deputy manager and staff for their time during the inspection process. What the service does well: The Glen is in a very pleasant rural setting and the grounds are well managed providing a very pleasant outlook for service users and level access for those service users wishing to go outside. The home is well managed; the Manager is approachable and is an experienced professional nurse. There is a good level of administrative support. This home offers both nursing and residential (personal care) care; this is in separate areas of the home but with integrated services and no restrictions on access across the communal areas. Service users were seen to be treated kindly and respectfully by staff. The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 6 The communal areas of the home are very well and comfortably appointed. The dining rooms are attractively presented and add to the social occasion of meal times. Bedrooms are comfortable and can be personalised to make them homely. A system is currently being developed to document people’s requests and wishes at the end stages of life. The staff are currently debating some legal and ethical issues such as how frequently the plans should be reviewed before fully implementing the plans. A system for auditing the care plans has been developed. This in turn has lead to training for some individual staff. The audit system has improved the care plans seen however this area needs additional development. What has improved since the last inspection? What they could do better: The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 7 A number of areas were highlighted to the deputy manager at the end of the inspection and to the manager via telephone on her return from leave. Although the care planning system had improved from the last inspection this area needs to be developed further. The plans need to reflect the needs of the individual A number of people who are frail and had lost weight were having their dietary intake monitored by staff by the use of food and fluid charts. It was difficult to assess how these charts were influencing the care that staff delivered. Medication was well managed however one area with regard to stock control was identified. The home has COSHH (control of Substances Hazardous to Health) data sheets. These need to positioned in the areas where the substances are held. Three minor environmental maintenance issues were identified. The programme for the purchase of adjustable beds, for people who have nursing needs, continues. The management need to ensure however that the people with the highest need have the beds that are currently available. People living at the home stated that the food was of a good standard and this has been confirmed at previous inspections. On the day of the inspection the meal provided at lunchtime was not of the usual high standard. The home has a number of sluices. Consideration should be given to updating these areas to incorporate mechanical sluice machines. 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 Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. Standard 6 is not applicable. Quality in this outcome group was good. Residents are able to make an informed choice of whether to stay at The Glen from the information available to them. Residents were assessed prior to admission to ensure the home can meet their needs. Residents have a contract of terms and conditions, which informs them of what to expect including the fees and what is not included. EVIDENCE: The home displays the Statement of Purpose for the home including the last CSCI inspection report in the reception area. A copy of the Service User Guide, which reflects the homes Statement of Purpose, was seen by the inspectors. The guide portrays the running structure of the home exactly, which enables The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 10 prospective residents and /or their representatives to make an informed choice on any decision of living at the home. Four care plans were sampled as part of the case tracking process. Evidence of the home assessing residents before admission was seen. This enables the home to ensure it can meet the residents’ needs prior to admission. Recently admitted residents spoken to confirmed that a representative of the home, had seen them prior to admission. The inspectors assessed individual contracts of the residents’ case tracked. Each had a contract either from Social Services or the home. The contracts indicate the fees to be paid and what is included. There is a trial period of 4 weeks. Surveys received from service users indicated that the majority of residents had a contract that they were aware of and had received enough information about the home prior to admission. Fees currently range from £588 for personal care and £695 for people who require nursing care. The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11. Quality in this outcome group was adequate. Care planning practice was good however some areas in regard to residents’ records of hydration and nutritional needs needed improving. Evidence was not seen of input from the resident and/or their representative. The management of medication within the home was generally very good. Residents are able to have privacy in their own rooms. Personal support was offered in a way to promote the privacy and dignity of residents. Service users were treated with respect and looked well cared for. EVIDENCE: Seven care plans were viewed during the inspection. Four of these were included in the case tracking tool. The plans showed a significant improvement The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 12 from the previous inspection however some additional development is required. The plans contained the all necessary assessments and subsequent plans of care. The plans however were not person centred and did not necessarily reflect the individual preferences and likes of the individual. Examples of this include does the individual have a preferred brand of soap or bubble bath. Do they have dry or sensitive skin which precludes the use perfumed products. What activities can they do for themselves or what level of support do they require. This aspect of the care planning process may be met if people and or their representative was involved in the development and review of the plans and if there was a move away from the current “core” care plans. Discussion with the manager following the inspection highlighted that action had already begun to implement this. In one of the plans information in the moving and handling assessment did not reflect the information in other parts of the care plan. This had however been identified by the management team via the newly implemented auditing system. Surveys from Health Care Professionals and GP’s indicated that they were satisfied overall with the level of care provision at the home. Visitors spoken to were satisfied with the provision of care. Residents consulted with told inspectors that the staff were kind and caring and the majority indicated that the home meets their needs. Residents seen looked well cared. Health care needs were generally well addressed. A number of people living at the home are frail and as such weight loss can become an issue. A system of identifying people who are loosing weight is in place. Individuals who had lost weight were having their dietary intake monitored by staff by the use of food and fluid charts. It was difficult to assess how these charts were influencing the care that staff delivered. For example if chart showed that an individuals appetite had been low on a particular day there was no formal system to ensure that the meals the following day were of a higher calorific value or that supplements were given. The medication records of one of the nursing floors were assessed and best practice was noted throughout. Controlled Drugs (CD’s) were stored appropriately and those checked reconciled with the CD register. Drugs were stored safely. It was noted however that one individual had an excessive stock of one drug. This was because this medication is taken on a PRN (as required) basis. The drug had been ordered monthly despite the individual taking the drug infrequently. This issue was highlighted to the deputy manager who agreed to rectify the situation immediately. Staff demonstrated a good understanding of how to promote privacy and dignity and examples of how they do this were seen. Health and social care professionals, through surveys received, confirmed that they see their The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 13 residents in private. Staff were seen interacting kindly to residents and were seen knocking on doors before entering. Residents spoken to confirmed that staff treated them with respect and helped to maintain their privacy when delivering personal care. Feedback received from residents indicated that the majority felt that they always got the care and support they needed. The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15. The outcome for this area is good Activities are well advertised and well managed. There is a good range of social events and for the less able there are opportunities for one to one social contact. Comment cards indicated service users found the activities suitable Families were seen to be welcomed and to be part of the home life. The menu is varied. The food on the day of the inspection was of a poorer standard than is usually served at the home. EVIDENCE: All activities and event at the home are well advertised; service users were seen to have an activities sheet and a newsletter, which is issued monthly. This was seen in service users rooms at this inspection. This newsletter contains activity information, notice of forthcoming events, welcomes new service users and informs of staff news. A copy of the September newsletter was seen. This showed activities that had or were due to take place include a charity bridge night, which raised £225 that was donated to the local children’s hospice appeal. Lunch at a local pub, trip to Wells, Harvest festival service, and three outside entertainers. The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 15 Photos in the newsletter showed a recent cream tea in the garden and entries (flower arrangements) for a local show. The hairdresser visits weekly and Holy Communion is held monthly. On the inspection day, activities included stroke club. The inspectors found this activity to be well attended, it had been well prepared and service users seemed to be enjoying the social occasion. The Glen hosts the community stroke club to enable service users to access the club and participate if they wish. The Art group is a popular activity and pictures are displayed at the home. Service users from the BUPA home, Clare Hall, are invited and attend. Two people spoken to during the inspection stated that they would like the opportunity to go outside more frequently. Lunch was observed in the dining rooms, the dining rooms are well presented with linen tablecloths and napkins. The inspector has visited the service several times and has always found the food to be of an excellent standard. This was confirmed by feedback form people living at the home. On this inspection however the food did not meet the usual high standard. Soup or fruit juice was initially served. This was followed by Fish fingers or pork chops. This was served with chips and peas. At least two of the people served stated that they did not like chips however no other potatoes were available. No second or alternative vegetable was served. The meal served was in line with the menu supplied by the home prior to the inspection. People living at the home and staff stated that it was unusual for a wider choice of potatoes and vegetables not to be available. Staff were observed assisting service users in a manner which was relaxed, unhurried and respectful. The evening meal is the lighter meal of the day. Homemade soup is available and sandwiches or light snack. A folder is available which provides information on providing meals and the customs of people who have differing ethnic or cultural backgrounds not all the staff who work in the kitchens appeared to be aware of this. It is recommended that staff are made aware of this system. The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17, 18. Quality in this outcome group was good. Residents and visitors to the home have the information to enable them to make a complaint or raise concerns. Arrangements for protecting residents from harm or abuse were good. EVIDENCE: The home had a complaints procedure, which was available to service users, staff, and visitors. It forms part of the Service User Guide and is detailed in the Statement of Purpose. Service users who were able and staff spoken with informed the inspectors that they would not hesitate in raising concerns if they had any. Five complaints had been received by the home since the last inspection. These were handled in accordance with the homes complaints procedure. The CSCI had not received any against the home since the last inspection. Staff spoken to understand the lines of communication should they suspect any form of abuse. Abuse training is provided during new staff induction. The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 17 Five staff recruitment files were viewed. These showed that robust pre employment checks are carried out. The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26. The quality for this outcome group is good. The Glen is well maintained and provides a comfortable well-adapted and well maintained environment for service users. Some minor repair works are required. Risk assessments need to reflect the equipment provided. EVIDENCE: The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 19 The Glen is suitable for its stated purpose with well-maintained buildings and attractive well kept gardens. The service is split into two wings with those service users who require nursing support in one and those with personal care needs in the other. The bedrooms are distributed over three floors and there are two passenger lifts that allow easy access to all floors. Service users are able to visit all communal areas of the home, even if their bedroom is on the opposite wing. Redecoration was in progress on the top floor of the residential wing. In addition to the 49 bedrooms with en-suite facilities the Glen has a further 11 toilets and 4 bathroom facilities. There are gardens, which are accessible by wheelchair and provide pleasant places to sit or walk, in warmer weather. All communal areas are nicely furnished and decorated. The Glen has in place a range of equipment and adaptations. A nurse call bell is available in all areas. Various hoists and moving and handling equipment are provided to meet the needs of service users. There are grab rails and specialist bathing hoists. The Glen provides aids used for pressure relief and the prevention and treatment of pressure ulcers, equipment was seen in use. The sluice rooms are small some contain disinfection cycle machines and others do not. Consideration should be given to updating the rooms without a disinfection cycle. The laundry room is small for the size of the home. A number of areas require some minor remedial work. In one bathroom the light did not work, in another the toilet seat was missing and in a third there was an odour. There are separate toilet facilities for visitors. The tiles in this area were loose in parts. These issues were feedback at the end of the inspection and the deputy manager stated that they would be rectified as soon as possible. The purchasing of adjustable beds for all people receiving nursing care is on going. Several have been purchased since the last inspection. Risk assessments are in place for people who have not got these beds. It was noted however that one person who was nursed in bed for the period of the inspection did not have such a bed. It is the inspector view that the lack of an adjustable bed for this individual would pose a high risk for such things as The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 20 back injuries to staff. The management need to ensure that the risk assessments are reflected in the equipment provided. The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28, 29, 30. The quality in this outcome group is good. Staffing levels and skill mix are appropriate to the numbers and needs of current service users. The home follows appropriate staff recruitment procedures. EVIDENCE: Staffing levels are currently adequate to meet the numbers and assessed needs of the service users at the home. The deputy manager informed the inspectors that staffing levels would be increased to reflect any increase in service user numbers or any increase in assessed needs. Copies of a four-week staffing rota were made available to the inspector. These demonstrated that the staffing levels were in line with the previous agreed staffing notice Staff spoken with during the inspection did not raise any concerns about staffing levels. A number of the feedback forms received and comments from people living at the home on the day of the inspection stated, “ you sometimes have to wait to receive help and support” and “staff tell me they are short staffed”. In view of this it is advised that the staffing levels are reviewed to ensure that people living at the home receive care and support promptly. The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 22 The home also employs kitchen staff, domestics, laundry staff and a maintenance person. The registered manager provided the inspectors with information indicating that of the are staff employed, 6 had achieved a minimum of an NVQ level 2 in care. This gives an overall percentage of 32 . three staff were currently undertaking this award. Four staff recruitment files were examined. These contained all appropriate information as required in Schedule 2 of the Care Homes Regulations 2001. Enhanced CRB checks and POVA checks were also in place. Newly appointed staff follow a BUPA induction programme. This covers the initial induction programme and on-going training for staff. Staff spoken with during the inspection were positive about the training opportunities available to them. Staff also indicated that they had received appropriate training to enable them to meet service users’ assessed needs. Training conducted recently included First aid training; fire training; Oral hygiene. The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37, 38. The quality in this outcome group is good. The home is well managed in an open management style. The home is run with the service users best interests safeguarded by policy, practice and procedures. Attention to the health and safety of service users and staff is of a good standard. Staff supervision requires development. EVIDENCE: The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 24 The home Manager is supported by an experienced Deputy Manager and an Administrator. The management style of the home is appreciated by staff and service users. The company, BUPA Care Homes (CFCHomes) Limited undertake quality assurance assessment of the home, surveys have been made to assess service user satisfaction. All records seen were stored appropriately and safely. Accident forms are completed and these are audited on a monthly basis to ascertain any patterns or commonalities. Financial accounts were seen where small amounts of money are held on behalf of service users. This was well managed and is held in one bank account for named individuals each with their own personal account details and each being individually interest bearing. This was satisfactory. Records are held on the homes accounts computer system that has restricted access. Staff supervision was discussed with the deputy manager and staff during the inspection. This area requires additional development. Clinical supervision is conducted for some staff. This appears to be when there has been an incident of poor practise or in response to a complaint. Discussions took place with the management with regard to developing a more formal, meeting style system for all staff including ancillary staff. Clinical supervision may form part of this system. Annual appraisals are conducted for all staff. Servicing and maintenance records were sampled these were found to be in good order. COSHH (Control of Substances Hazardous to Health) advisory sheets are held at the home. These are held in a central location. It is recommended that these be held in the area in which the chemical is stored or used. This will ensure a quick response if an accident should occur. The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 2 The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 26 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. 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 OP7 Good Practice Recommendations It is recommended that the care plans continue to be developed to ensure that they are person centred. The plans should be developed and reviewed with the service users and/or their representative. It is recommended that the excess stock of the identified drug are destroyed in line with the homes procedures. It is recommended that the risk assessments reflect the equipment provided for service users. It is recommended that some of the sluices are upgraded to include mechanical washers. It is recommended that the minor repairs identified during the inspection are carried out. These include • The missing toilet seat • The loose tiles in the visitors toilet • The broken light • The odour in one of the bathrooms. It is recommended that the management audit the meals DS0000003298.V312622.R01.S.doc Version 5.2 Page 27 2 3 4 5 OP9 OP22 OP26 OP19 6 OP15 The Glen Nursing & Residential Home at regular intervals to ensure that they are consistently of a high standard and a choice is readily available. All staff should be made aware of the whereabouts of the information held in regard to providing meals to people of a different ethnic or cultural background. It is recommended that the system of staff supervision is developed so that all staff benefit from this system. Staff supervision should be completed on a regular basis. It is recommended that COSHH data sheets are held where the chemical is used or stored. It is recommended that a system is developed to ensure that the information gained from the diet sheets of people who have lost weight effect the care given. The care plans should give clear guidance to the staff of action to be taken in response to weight loss. 7 8 9 OP36 OP38 OP8 The Glen Nursing & Residential Home DS0000003298.V312622.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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