CARE HOMES FOR OLDER PEOPLE
The Glen Private Nursing Home 224 Abbeydale Road South Dore Sheffield South Yorkshire S17 3LA Lead Inspector
Marina Warwicker Unannounced Inspection 7th February 2006 14:00h 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 Private Nursing Home DS0000021779.V275712.R01.S.doc Version 5.1 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 Private Nursing Home DS0000021779.V275712.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service The Glen Private Nursing Home Address 224 Abbeydale Road South Dore Sheffield South Yorkshire S17 3LA 0114 236 5580 01142363437 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Anthony Douglas Williams Mrs Sally 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 DS0000021779.V275712.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 30th June 2005 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 purpose built extention and conservatory. The home is situated within its own grounds within a residential 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 DS0000021779.V275712.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. An unannounced Inspection of The Glen Nursing home was carried out on 7th February between 2pm and 4pm. The inspector spoke with the residents who were present and the staff on duty and also checked the compliance of the last inspection requirements. Most requirements had been actioned by the manager. To obtain a full picture of the service it is recommended that this report is read in conjunction with the previous one. What the service does well:
The Glen is a small home, which is very homely and friendly. All residents looked comfortable and settled at the home. Two residents said that the staff treat them with respect and nothing is too much trouble for them. The home provides information to the prospective service users and their representatives so that they are able to make an informed choice. The residents are able to exercise their choice in relation to daily routines, meal times, leisure activities and the time they rise and retire. The home’s recruitment procedure and the staff training make sure that the residents and staff are safeguarded from abuse, self-harm, inhuman or degrading treatment. The staff numbers and skill mix of qualified nurses and health care support workers are allocated so that the service users are able to receive appropriate care. The manager and her team ensure that their approach creates an open and positive atmosphere at the home. Systems are in place to supervise staff at regular intervals. The Glen Private Nursing Home DS0000021779.V275712.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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 DS0000021779.V275712.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection The Glen Private Nursing Home DS0000021779.V275712.R01.S.doc Version 5.1 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 the following standard(s): 1,2,3,4&5 Trial visits are encouraged by the home. Prior to moving into the home all residents have their needs assessed to ensure that the home is able to cater for them. The residents or their next of kin are provided with a statement of terms and conditions following admission to the home. The home does not provide intermediate care. EVIDENCE: The inspector spoke with residents and staff and established that the home provided information to the prospective service users and their representatives so that they were able to make an informed decision about the home. The provider held copies of the terms and conditions of each resident. The inspector did not check the written copies on this occasion.
The Glen Private Nursing Home DS0000021779.V275712.R01.S.doc Version 5.1 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 the following standard(s): 7,8,9,10&11 The residents’ health, social and personal care needs are documented in the care plans. A range of health care professionals visit the home to assist in maintaining the care needs of residents. Medication procedures need to be reviewed to provide protection to residents. Residents’ privacy and dignity is maintained. The staff are trained on how best to deal with death and dying of service users. EVIDENCE: Three care plans were checked and there were copies of the pre-admission assessments. The care plans were set out to ensure that all aspects of the residents needs were addressed and the action to be taken by the staff to meet those needs. The Glen Private Nursing Home DS0000021779.V275712.R01.S.doc Version 5.1 Page 10 Medication Administration sheets were checked and the following observations were made to the manager: • • • The gaps in the daily records must indicate the reason why the resident did not receive the medication. The staff have accepted telephone instruction from the GP to recommence medication. There was no policy/guidance on this practice. The staff receiving medication from the pharmacy had not dated and signed on the individual Medication Administration Sheets to acknowledge receipt. The manager said that they had changed the supplying pharmacist and that there had not been an audit as yet. However the previous pharmacy report on 26/09/05 was satisfactory and no recommendation were made. The residents said that the staff treated them with respect and offered help if they needed. During the afternoon the inspector observed good interaction between the residents and staff. Staff and the manager said that there has been training for staff on caring for the residents who were dying and dealing with relatives of those who are terminally ill. The Glen Private Nursing Home DS0000021779.V275712.R01.S.doc Version 5.1 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 the following standard(s): 12,13,14&15 The residents are able to exercise their choice in relation to daily routines, meal times, leisure activities and the time they rise and retire. EVIDENCE: Four resident were consulted. They said that the food was very good and that they can get up and go to bed when they wanted to. They also informed the inspector that due to the cold weather they prefer sitting in the warm and comfort of the home and watch TV rather than going out in the cold. The staff were seen serving tea and cake and helping those residents who needed assistance. The Glen Private Nursing Home DS0000021779.V275712.R01.S.doc Version 5.1 Page 12 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): 17&18 The residents rights are protected by their advocates and the placing authorities. The home’s recruitment procedure and staff training ensures that the residents and staff are safeguarded from abuse, self-harm, inhuman or degrading treatment. EVIDENCE: The majority of residents are self-funders who have their own advocates who take care of their legal rights. All staff have received training on adult protection and dealing with abuse. The staff interviews confirmed this. The Glen Private Nursing Home DS0000021779.V275712.R01.S.doc Version 5.1 Page 13 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): x EVIDENCE: The home was clean and welcoming. The Glen Private Nursing Home DS0000021779.V275712.R01.S.doc Version 5.1 Page 14 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): The Glen has a thorough recruitment procedure to protect the service users and the staff at the home. The staff numbers and skill mix of qualified nurses and health care support workers are allocated so that the service users are able to receive appropriate care. More than 50 of the health care support workers are trained in NVQ level2. EVIDENCE: The inspector spoke with the residents and interviewed staff and checked the staff files with the help of the manager. It was established that the care staff were supervised by the qualified nurses and that there were sufficient numbers of staff on duty over 24 hour period. The staff have attended mandatory study sessions and all qualified nurses have up to date registration with the NMC. The Glen Private Nursing Home DS0000021779.V275712.R01.S.doc Version 5.1 Page 15 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): The manager and her team ensure that their approach creates an open and positive atmosphere at the home. Systems are in place to supervise staff at regular intervals. The owner supervises maintenance and service of equipment and the manager ensures as far as possible health, safety and welfare of the staff and residents. EVIDENCE: The manager is in the process of completing the Registered Managers Award. The qualified staff and the manager have attended training on clinical nursing topics to keep up to date. The staff said that the senior staff at the home supported them. The staff have had regular supervision. The Glen Private Nursing Home DS0000021779.V275712.R01.S.doc Version 5.1 Page 16 There had been an Environmental Health audit and some improvement has been made in the kitchen and laundry areas. All staff have had training on fire safety procedures and instructions on Fire drills, this included the permanent night staff. The Glen Private Nursing Home DS0000021779.V275712.R01.S.doc Version 5.1 Page 17 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 3 X X X X X X X X 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 2 3 3 X X 3 3 3 The Glen Private Nursing Home DS0000021779.V275712.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? Yes 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 OP9 Regulation 13 Requirement The manager must ensure that all medication received at the home is recorded and handled correctly. There must be a policy and guidance for the nursing staff when receiving instructions from the GP to recommence or prescribe medication for the residents at the home. Timescale for action 29/08/05 2 OP9 12,13 14/03/06 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 OP31 Good Practice Recommendations He manager should complete the RMA. The Glen Private Nursing Home DS0000021779.V275712.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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