Inspection on 30/06/05 for The Glen Private Nursing Home

This inspection was carried out on 30th June 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

The Glen Private Nursing Home 06/06/07

The Glen Private Nursing Home 07/02/06

The Glen Private Nursing Home 14/09/04

The Glen Private Nursing Home 28/04/04

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE THE GLEN PRIVATE NURSING HOME 224 Abbeydale Road South Dore Sheffield, South Yorkshire S17 3LA Lead Inspector Rob Curr Unannounced 30 June 2005 08:50. 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 PRIVATE NURSING HOME 20050907 The Glen X00015 UN Stage 4 S21779 V219885.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Glen Private Nursing Home Address 224 Abbeydale Road South, Dore, Sheffield, South Yorkshire, S17 3LA 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) 0114 236 5580 01142363437 None Mr. A.D.Williams and Mrs. S Williams Mrs Christine Johnson Care Home 19 Category(ies) of Old age, not falling within any other category registration, with number (19) of places THE GLEN PRIVATE NURSING HOME 20050907 The Glen X00015 UN Stage 4 S21779 V219885.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 14-Sep-2004 Brief Description of the Service: The Glen, is a nursing home that provides care for up to 19 people. It is a converted house with a prupose built extention and conservatory. The home is situated within its own grounds within a residetnial area of Sheffield. The Glen is set within a woodland setting and is within easy access of the city centre and can be reached by bus, rail or car. THE GLEN PRIVATE NURSING HOME 20050907 The Glen X00015 UN Stage 4 S21779 V219885.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between the hours of 8.50 am and 3:00 pm. Kathryn Stringer was present during the inspection process and has been a nurse-in-charge for a number of years. The proprietors were also present for a period during the inspection and offered their support to the process. The inspector was escorted on a partial tour of the home. A variety of policies, procedures, and records were checked. The residents were very helpful during the inspection process, offering ample opportunity to talk about what life was like at the home. In all – 6 residents, 5 staff members, and 3 visiting relatives were spoken to. What the service does well: What has improved since the last inspection? There had been a number of environmental improvements. Disabled access to the front of the building had been improved. Further storage space had been created in the first floor level. All bedroom doors had been fitted with locks to ensure privacy and all the residents had been provided with lockable secure facilities within their bedroom. THE GLEN PRIVATE NURSING HOME 20050907 The Glen X00015 UN Stage 4 S21779 V219885.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. THE GLEN PRIVATE NURSING HOME 20050907 The Glen X00015 UN Stage 4 S21779 V219885.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection THE GLEN PRIVATE NURSING HOME 20050907 The Glen X00015 UN Stage 4 S21779 V219885.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 and 5. Standard 6 was not applicable. Resident’s records included a detailed assessment of their needs. EVIDENCE: Three care plans included assessments carried out by staff at the home, and information from the placing authority. Three relatives stated that they had been asked for information prior to their admission. THE GLEN PRIVATE NURSING HOME 20050907 The Glen X00015 UN Stage 4 S21779 V219885.doc Version 1.40 Page 9 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) 7,8,9,10 and 11. Health care was monitored and care plans were reviewed on a monthly basis, however, not all residents and or their representatives were involved in the care plan reviews. A range of health care professionals visited the home to assist in meeting the needs of the residents. Medication was in the main managed safely, however there were some difficulties around the recordings of the medication system, which could provide a risk to the residents’ health and welfare. Service users privacy and dignity was respected. EVIDENCE: Three care plans set out in detail the residents needs and the action to be taken by the qualified and care staff of the home to ensure all these could be met. Residents could see their GP in private so that their privacy and dignity was respected. THE GLEN PRIVATE NURSING HOME 20050907 The Glen X00015 UN Stage 4 S21779 V219885.doc Version 1.40 Page 10 There was a medication policy and the medication and records were stored in a secure room. When staff were questioned about the use of the MAR sheets, they were unclear about what to record when medication had not been administered. There were recordings on the medication sheets that had been marked with an ‘x’ without an explanation. Staff closed doors before assisting residents with personal care. Staff knocked on residents does and waited before being invited in. Residents and relatives said that said that staff were ‘polite’ and ‘helpful’. Although some of residents had communication difficulties, some residents said that they were happy in the home and said, “the staff are nice and kind” and ”I’m happy here”. Relatives said they were “very satisfied” with the care delivered by staff. THE GLEN PRIVATE NURSING HOME 20050907 The Glen X00015 UN Stage 4 S21779 V219885.doc Version 1.40 Page 11 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) 12,13,14 and 15. Residents and relatives were happy with the activities, but there were no outings planned. Mealtimes were well managed with dining areas to accommodate all service users. The home had clear visiting policies and procedures to ensure that residents could maintain contact with their family and friends. Residents are encouraged to bring in personal items of furniture and ornaments to help them settle into their own bedroom. The cook had reviewed the menu, to improve choice and reflect the resident’s preferences. The cook/catering team would benefit from some formal training in ‘special diets’. EVIDENCE: Some residents said that they had not been on an outing for a long time. Others said that they had been out with the proprietors – and that if they requested an outing, the proprietor would arrange one. THE GLEN PRIVATE NURSING HOME 20050907 The Glen X00015 UN Stage 4 S21779 V219885.doc Version 1.40 Page 12 Visitors to the home praised the staff. Visitors confirmed that they liked to visit their relative in the main lounge, while others preferred to see their relative in their own bedroom. Residents receive support from other people visiting the home, e.g. hairdresser, optician, chiropodist, and representatives from the local church, maintaining contact with the local community. A partial tour of the building provided evidence that residents were able to personalise their bedrooms, many had brought in small items of furniture and pictures of their family. The mealtime was well organised and the inspector was able to observe residents being assisted with their meal where required. Staff were unhurried and there were sufficient numbers to ensure those residents who were being cared for in their bedroom were taken a meal that looked appetising. The cook had worked hard to develop the menus. This had resulted in a clear choice at mealtimes. The catering team had gained food hygiene certificates. THE GLEN PRIVATE NURSING HOME 20050907 The Glen X00015 UN Stage 4 S21779 V219885.doc Version 1.40 Page 13 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 and 18. Relatives and staff were aware of how to make a complaint and were confident that they would be listened to. An adult protection procedure was in place to ensure that residents safety was promoted. Staff needed to undertake formal training in adult protection. EVIDENCE: The complaints procedure was on display in the foyer, which contained relevant information and provided the reader with details of who to contact outside the home, to ensure complaints were taken seriously. The home kept a record of complaints. Staff spoken to were unaware of the local Adult Protection Procedures. The residents, relatives, and staff all stated that they had confidence in the homes manager. They said that she would listen and respond to any concerns they raised. All the residents spoken to said they felt safe at the home. THE GLEN PRIVATE NURSING HOME 20050907 The Glen X00015 UN Stage 4 S21779 V219885.doc Version 1.40 Page 14 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) 19,20,21,22,24,25 and 26. The proprietors continue to improve the décor and furnishings at the home creating a comfortable and safe environment for the residents. The home was clean and generally well maintained. Communal areas were homely and comfortable. The bedrooms seen were personalised by residents and their relatives. The home was free of any offensive odours. Systems for the control of infection were in place. A call system was available in all rooms used by the residents so that they could summon assistance at all times. EVIDENCE: The inspector carried out at tour of the home. All of the residents spoken with were happy with their bedrooms and the furniture to provide a comfortable environment. THE GLEN PRIVATE NURSING HOME 20050907 The Glen X00015 UN Stage 4 S21779 V219885.doc Version 1.40 Page 15 The hot water temperature in one bathroom measured in excess of the safe temperature of 43ºC. THE GLEN PRIVATE NURSING HOME 20050907 The Glen X00015 UN Stage 4 S21779 V219885.doc Version 1.40 Page 16 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) 27,28,29 and 30. Sufficient staff were provided to meet the needs of the residents. The majority of staff undertook NVQ training. Recommended levels of NVQ trained staff had been achieved for some time. The home did not have appropriate recruitment systems in place, improvements to this system need to take place in order to promote the safety of residents and meet standards. A staff-training programme for the year had been organised and planned, in order that staff had the skills to meet the residents needs. The cook on duty had undertaken training in food hygiene. EVIDENCE: The manager was fully aware of the training needs of the staff group. The manager had developed a staff-training plan. On examination of the staff recruitment procedures the following issues were noted: • Staff had Criminal Records Bureau (CRB) disclosure and POVA first checks that did not correlate with the start of employment. • Staff members had been employed without references from their previous or current employers. • Gaps in employment histories were not explained • Not all references had confirmation of dates of previous employment. • No evidence that ID had been checked. THE GLEN PRIVATE NURSING HOME 20050907 The Glen X00015 UN Stage 4 S21779 V219885.doc Version 1.40 Page 17 These practices could compromise the safety of the residents. The proprietor was instructed that the identified staff member that does not have a current ‘PIN’ must not be allocated any duties until the appropriate checks have been made Staff said that they received a minimum of 3 days paid training each year. THE GLEN PRIVATE NURSING HOME 20050907 The Glen X00015 UN Stage 4 S21779 V219885.doc Version 1.40 Page 18 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) 31,32,33,36,37 and 38. The registered manager has the required skills and competencies to ensure the safety and protection of the residents and is on target for completing the management qualification recommended to carry out her role and responsibilities. During the inspection – the nurse in charge demonstrated a clear commitment to the residents and staff in her care. Staff were provided with formal supervision. Health and Safety policies are in place for the health, safety, and welfare of those individuals who work and live at the home and accident records were monitored. There were issues around staff that had not undertaken a fire drill. THE GLEN PRIVATE NURSING HOME 20050907 The Glen X00015 UN Stage 4 S21779 V219885.doc Version 1.40 Page 19 EVIDENCE: From records checked, it appeared that a number of staff had not undertaken a fire drill nor had nurses left in charge during the night conducted a fire drill. Debris was found on the floor behind laundry equipment. These actions clearly compromise the health and safety of everyone in the building. THE GLEN PRIVATE NURSING HOME 20050907 The Glen X00015 UN Stage 4 S21779 V219885.doc Version 1.40 Page 20 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 x x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 2 3 3 x 3 3 3 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 3 x x 3 2 2 THE GLEN PRIVATE NURSING HOME 20050907 The Glen X00015 UN Stage 4 S21779 V219885.doc Version 1.40 Page 21 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. 1. Standard 7 Regulation 15 Requirement Residents or their reprsentatives must be involved the review of care planning. Timescale for action 26.9.05 2. 9 13 All staff administering medication 29.8.05 must be aware of what to record when medication is not administered. Residents must be consulted over their recreational and social needs. Staff must have awareness of the local Adult Protection Procedures. The registered persons must operate a thorough recruitment procedure. All of the required checks must be completed before staff commence working at the home. The identified member of staff that had no PIN must not be offered any duties until all the required checks have been completed. 26.9.05 3. 12 16 4. 18 13 26.9.05 5. 29 Sch 2 30.6.05 6. 29 Sch 2 30.6.05 THE GLEN PRIVATE NURSING HOME 20050907 The Glen X00015 UN Stage 4 S21779 V219885.doc Version 1.40 Page 22 7. 8. 38 38 13 13 Staff who have not taken part in a fire drill must do so. Staff that are left in charge during the night must conduct a fire drill. The debris must be removed from behind the laundry equipment. The water temperature in the bathroom must be kept close to 43C. 30.6.05 30.6.05 9. 38 13 30.6.05 10. 20,38 13 30.6.05 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 31 Good Practice Recommendations The registered manager should hold a recognised management qualification. THE GLEN PRIVATE NURSING HOME 20050907 The Glen X00015 UN Stage 4 S21779 V219885.doc Version 1.40 Page 23 Commission for Social Care Inspection Ground Floor Unit 3 Waterside, Bold Street Sheffield, South Yorkshire S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI THE GLEN PRIVATE NURSING HOME 20050907 The Glen X00015 UN Stage 4 S21779 V219885.doc Version 1.40 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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