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Inspection on 20/06/05 for The Glen Residential Home

Also see our care home review for The Glen Residential Home for more information

This inspection was carried out on 20th 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

What has improved since the last inspection?

There has been number of training courses provided for the staff members since the last inspection. All policies and procedures have been reviewed in light of the owner/manager undertaking her National Vocational Qualification level 4. The registered owner/manager has successfully completed her NVQ level 4 and her Managers Award, she is congratulated on this.

What the care home could do better:

The owner/manager and her staff should use their guidance on safe handling and recording of controlled drugs. This will reduce the margin serious error. Care plans should be reviewed more regularly, at least as and when the care needs of residents change.

CARE HOMES FOR OLDER PEOPLE The Glen 20 Groby Road Glenfield Leicester LE3 8GJ Lead Inspector Bhavna Keane Rao Unannounced 20 June 2005 11:15am 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 D C51 C01 S1665 The Glen V233803 200605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Glen Address 20 Groby Road Glenfield Leicester LE3 8GJ 0116 2871165 0116 2871165 None Mrs Jennie Neale 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) Mrs Jennie Neale Care Home 4 Category(ies) of OP Old Age (4) registration, with number of places The Glen D C51 C01 S1665 The Glen V233803 200605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 12/01/05 Brief Description of the Service: The Glen is a large, detached house, situated on a slip road off a busy thoroughfare in Glenfield, on the outskirts of Leicester. The home can accommodate four older people and is also home to the registered person. The home does not stand out from its’ neighbours and is commended for the very homely environment which it creates for its’ residents. All areas of the home are extremely well decorated and furnished to a high standard. The home has four single bedrooms, three of which are en suite, a comfortable lounge, dining room and pleasant conservatory and a very large, easily accessed, secluded rear garden with patio area. The front driveway of the home provides off road car parking space for several cars. The Glen D C51 C01 S1665 The Glen V233803 200605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place during Monday morning and early afternoon. The inspection took three and half-hours. The home is registered to provide care for four older people. One resident is in hospital. All three residents, at the home, were spoken with, however detailed discussions were only held with two. A tour of the premises was undertaken and opportunity was taken to view residents daily records, menus of meals, fire records, a staff rota and staff records. The primary method for this inspection used was ‘case tracking’ which involved all four residents and tracking the care they received through looking at their records, discussion with them, and their relatives, care staff and observation of care practices. The pre inspection questionnaire was also viewed. The registered owner/manager spent time discussing many issues that arise in the running of a residential home, facilitated this inspection. What the service does well: What has improved since the last inspection? There has been number of training courses provided for the staff members since the last inspection. All policies and procedures have been reviewed in light of the owner/manager undertaking her National Vocational Qualification level 4. The registered owner/manager has successfully completed her NVQ level 4 and her Managers Award, she is congratulated on this. The Glen D C51 C01 S1665 The Glen V233803 200605 Stage 4.doc Version 1.30 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 D C51 C01 S1665 The Glen V233803 200605 Stage 4.doc Version 1.30 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 D C51 C01 S1665 The Glen V233803 200605 Stage 4.doc Version 1.30 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 6 The admission process is flexible and well managed, which ensures care needs are met at the home. EVIDENCE: There have been no admissions since the last inspection. Procedures are in place to ensure that residents entering the home are given all relevant information to enable them and their relatives to make an informed choice. The newest resident was able to confirm that at the last inspection. The home does not provide intermediate care. The Glen D C51 C01 S1665 The Glen V233803 200605 Stage 4.doc Version 1.30 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 and 10 The current approach to care planning and medication is unsafe and may lead to individual health care needs not being met. Residents’ privacy is upheld and they are treated with respect. EVIDENCE: Four residents files were viewed. The initial recording in the residents’ plans of care was detailed setting out clearly preferences and assistance required for residents to continue living as independent as possible, depending on care needs. However there after care plans are reviewed by an entry of date and ‘no change’. Discussion was held with the manager to ensure that care plans are regularly reviewed, at least annually. This is particularly important where care needs of residents change, as is case in with one particular resident. Also risk assessments must be carried out where areas of concerns are identified. This was not the case in one particular file. Residents who were spoken with said they were involved in the provision of care. The Glen D C51 C01 S1665 The Glen V233803 200605 Stage 4.doc Version 1.30 Page 10 Medication is stored in a locked cupboard and administered by staff that are trained. Administration of medication and recording was seen and is considered to be generally safe. However it was noted with concern that on occasions where mistakes are made then correcting fluid is used. The owner/manager was informed that this was unsafe. There are issues also with regards to Controlled Drugs. The safe handling of medication procedure is not followed. Last month one page is used to record controlled drugs being given out for two different residents. Also correcting fluid is used where errors have occurred. All the residents are on electoral register and had received their voting cards for the last elections. The Glen D C51 C01 S1665 The Glen V233803 200605 Stage 4.doc Version 1.30 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 staff working together meet the physical, emotional and health care needs of residents. EVIDENCE: Staff undertake activities with residents both individually and in groups. The owner/manager stated that there are activities planned everyday. Residents spoken with said that they did ‘things’ in the daytime and also watched television. A resident who spoken with in detail stated, when asked about activities at the home, that “At my age I want to be pampered and not doing exercise!!” Therefore the staff provide manicure and pedicure to the residents along with gentle massage. A number of comment cards were received from both the residents and their relatives. All these were positive about the service provided by the home. Menus were viewed and demonstrated that meals provided are nutritionally balanced and appealing. One resident will only eat cheese on toast for tea. This is accommodated. Residents spoken with said the meals were generous and good. Records showed the residents particular preferences and dietary needs. Residents’ religious/spiritual needs are catered for. The Glen D C51 C01 S1665 The Glen V233803 200605 Stage 4.doc Version 1.30 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 standard(s) 16 and 18 Residents are safe and protected from abuse. EVIDENCE: Residents and Comment Cards showed that people feel very comfortable discussing any concerns with the home’s manager. The complaints procedure is available for residents and visitors. There have not been any complaints received by the home or CSCI since the last inspection. Residents spoken with felt they were safe and protected. The adult protection procedure has been given to all the staff. The Glen D C51 C01 S1665 The Glen V233803 200605 Stage 4.doc Version 1.30 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 standard(s) 19 and 26 A comfortable, well-maintained, pleasant, clean and safe standard of accommodation is provided for the residents. EVIDENCE: The home is well maintained and suited to residents needs. There is ample natural light throughout the home. It is decorated and furnished to a high standard that creates a comfortable homely atmosphere. There is a lounge/dining leading to the conservatory. Entry to the home and to the garden is wheelchair friendly. The garden area is flat with climbing plants, pot plants, trees, seating area and a very large lawn. The Glen D C51 C01 S1665 The Glen V233803 200605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 and 30 Training and supervision is in place to ensure staff are able to carry out their work safely and competently. EVIDENCE: On the day of this unannounced inspection, there were two members of staff on duty to provide care for the residents, this includes the owner/manager. At present there are four residents for whom care is provided. One of whom is in hospital. All staff have undertaken all mandatory training. All the care staff have either completed their NVQ level 2 training or are about to complete. One person has successfully completed her NVQ level 3. The registered owner/manager has also completed her NVQ level 4 and Care Managers Award, she is congratulated on this achievement. Residents who were spoken with were positive about the staff employed at the home. One particular resident stated that she could not thank the staff enough for the care provided for her. The observed interaction between the staff and residents was relaxed and friendly. The Glen D C51 C01 S1665 The Glen V233803 200605 Stage 4.doc Version 1.30 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 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) 33,35 and 38 Residents and staff benefit from clear leadership. EVIDENCE: Staff and the residents who were spoken with felt that they could go to the owner/manager at any time with any concern. This is positive working practice. Records of residents’ valuables and cash are accurately detailed and up to date. Residents said that their monies are looked after by their relatives, the home deals with nominal amounts to cover hairdressing etc. Records are kept of these transactions. The Glen D C51 C01 S1665 The Glen V233803 200605 Stage 4.doc Version 1.30 Page 16 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 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 x x 3 The Glen D C51 C01 S1665 The Glen V233803 200605 Stage 4.doc Version 1.30 Page 17 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 7,8 Regulation 13 Requirement Timescale for action 30/06/05 2. 9 13 It is required that care plans and risk assessments are reviewed and up dated as and when the care needs of residents changed. It is required that the Safe 30/06/05 Handling of Medication procedure is followed when dealing with medication such as controlled drugs. 3. 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 None Good Practice Recommendations The Glen D C51 C01 S1665 The Glen V233803 200605 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection The Pavilions 5 Smith Way, Grove Park Enderby, Leicester LE19 1SX 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 D C51 C01 S1665 The Glen V233803 200605 Stage 4.doc Version 1.30 Page 19 - 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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