glen lee care home report

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| Inspection Report |Glen Lee|January 2013 www.cqc.org.uk 1

Inspection Report

We are the regulator:Our job is to check whether hospitals, care homes and careservices are meeting essential standards.

Glen Lee

Wavell Road, Bitterne, Southampton, SO18 4SB Tel: 02380473696

Date of Inspection: 01 November 2012 Date of Publication: January2013

We inspected the following standards as part of a routine inspection. This is what wefound:

Respecting and involving people who useservices

Met this standard

Care and welfare of people who use services Action needed

Meeting nutritional needs Met this standard

Safeguarding people who use services fromabuse

Met this standard

Cleanliness and infection control Met this standard

Management of medicines Enforcement actiontaken

Staffing Action needed

Assessing and monitoring the quality of serviceprovision

Met this standard


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Details about this location

Registered Provider Southampton City Council

Registered Manager Mrs. Theresa Dyer

Overview of theservice

Glen Lee is registered to provide accommodation and careto a maximum of 34 people. There is no nursing provided atthis home. There is a registered manager responsible for theservice.

Type of service Care home service without nursing

Regulated activity Accommodation for persons who require nursing or personal

care


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Contents

When you read this report, you may find it useful to read the sections towards the backcalled 'About CQC inspections' and 'How we define our judgements'.

Page

Summary of this inspection:

Why we carried out this inspection 4

How we carried out this inspection 4

What people told us and what we found 4

What we have told the provider to do 4

More information about the provider 5

Our judgements for each standard inspected:

Respecting and involving people who use services 6

Care and welfare of people who use services 7

Meeting nutritional needs 9

Safeguarding people who use services from abuse 10

Cleanliness and infection control 11

Management of medicines 12

Staffing 14

Assessing and monitoring the quality of service provision 16

Information primarily for the provider:

Action we have told the provider to take 17

Enforcement action we have taken 18

About CQC Inspections 19

How we define our judgements 20

Glossary of terms we use in this report 22

Contact us 24


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Summary of this inspection

Why we carried out this inspection

This was a routine inspection to check that essential standards of quality and safety

referred to on the front page were being met. We sometimes describe this as a scheduledinspection.

This was an unannounced inspection.

How we carried out this inspection

We looked at the personal care or treatment records of people who use the service,carried out a visit on 1 November 2012, observed how people were being cared for andchecked how people were cared for at each stage of their treatment and care. We talked

with people who use the service, talked with carers and / or family members and talkedwith staff.

What people told us and what we found

We spoke with 11 people, six visitors and the staff who were on duty at the time of ourvisit. To help us to understand the experiences of people, we observed how people spenttheir time, the support they received from staff and whether they had positive outcomes.People told us that they were treated with respect when receiving care and they liked livingat the home. Relatives told us that their relatives were "very well looked after". They toldus that the staff were "very good". People said that the staff were very busy and therewere not always enough staff. People and relatives said the food was very good andchoices were available.

Care plans and risk assessments were in place although these did not always reflect thecurrent needs of people. People were provided a choice of meals that met their needs,although support with meals were at times lacking. Relatives were confident that anyconcerns they raised would be taken seriously and staff would help them to resolve theissue.

Medicines were not managed appropriately and may put people at risk to their health and

welfare. There were not always adequate staff and this may impact on the care that peoplereceived. The infection control procedures at the time of the inspection were inadequateand may put people at risk to their health. There was an audit system that looked at theservice delivery.

You can see our judgements on the front page of this report.

What we have told the provider to do

We have asked the provider to send us a report by 05 January 2013, setting out the actionthey will take to meet the standards. We will check to make sure that this action is taken.

We have taken enforcement action against Glen Lee to protect the health, safety and


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welfare of people using this service.

Where providers are not meeting essential standards, we have a range of enforcementpowers we can use to protect the health, safety and welfare of people who use this service(and others, where appropriate). When we propose to take enforcement action, ourdecision is open to challenge by the provider through a variety of internal and externalappeal processes. We will publish a further report on any action we take.

More information about the provider

Please see our website www.cqc.org.uk for more information, including our most recentjudgements against the essential standards. You can contact us using the telephonenumber on the back of the report if you have additional questions.

There is a glossary at the back of this report which has definitions for words and phraseswe use in the report.


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Our judgements for each standard inspected

Respecting and involving people who use services Met this standard

People should be treated with respect, involved in discussions about their careand treatment and able to influence how the service is run

Our judgement

The provider was meeting this standard.

People's privacy, dignity and independence were respected. People's views andexperiences were taken into account in the way the service was provided and delivered in

relation to their care.

Reasons for our judgement

People told us that they were very happy living at the home. Relatives told us that theirrelatives were "very well looked after". They told us that their privacy and dignity wasrespected when receiving care. Relatives were complimentary about the care that theservice provided.

We observed care across all areas of the home and saw that people's privacy and dignity

were respected. We saw that personal preferences were taken into account whenproviding support and people's choices were respected. Staff interacted with peopleappropriately, using their preferred names and explaining what was happening and askingwhat people wanted to do. From the interactions observed, this showed that the staff andpeople who use the service had developed good relationships with each other.

We looked at nine care records and found that the information relating to people's lifehistory was detailed. A staff member told us that this helped them to talk to people andfound this useful as most people suffered from varying degrees of dementia. We did notfind appropriate information concerning people's end-of-life care, nor was there sufficientevidence of next-of-kin involvement in the care records. The provider may wish to note that

this may impact on people's care due to their cognitive difficulties as they were unable toparticipate in their care planning. The staff told us that they tried to get people's relativesinvolved and more work was needed.

Relatives told us that they were encouraged to bring into the home items of people'spersonal belongings. Some of the bedrooms were personalised with a variety of familyphotos, pictures and other personal items. We saw that other bedrooms were sparse andnot individualised. The manager told us that the bedrooms had been redecorated and thepictures had been taken down, this was being addressed.


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Care and welfare of people who use services Action needed

People should get safe and appropriate care that meets their needs and supportstheir rights

Our judgement

The provider was not meeting this standard.

People experienced care, treatment and support that mostly met their needs and protectedtheir rights. There was at times a lack of detailed care plans to show how identified riskswould be managed and to reflect the current needs of people.

We have judged that this has a moderate impact on people who use the service, and havetold the provider to take action. Please see the 'Action' section within this report.


People told us that they were treated with respect when receiving care. Two relatives toldus that they "know she's being looked after". People said that the staff were" very good."People's needs were assessed and some care and treatment plans had been developed.Three of the care plans contained detailed information about people's needs and supportthey needed. We saw that one person had been identified as high risk of falling and theywere receiving one to one support on the day of our visit. Their relatives told us that theyfelt that staff supported this person well and they were "well looked after". We observed

staff supporting people in a calm and respectful way. Staff were knowledgeable aboutpeople's needs and interacted appropriately with them.

People who had been identified as at risk to their pressure areas had "profiling beds" inplace. We found that the care plans were variable and did not contain adequateinformation when risks had been identified. A person had a sensor mat in place; howeverwe could not see a risk assessment to show how the level of risk was assessed anddecision reached. This mat was to monitor this person's movements when they were intheir rooms as it would alert the staff they were up and about. There was no informationabout how the level of risk and what staff needed to do to monitor this person at othertimes when they were not in their rooms.

Another person was newly admitted and their records contained basic information andwere not adequate as it did not reflect this person's current needs. Their record showedthat they had three falls and a pressure mat was in place. This meant that staff would bealerted when this person was up and about. There was no other information about thesupport this person's needed to manage their risk of falls. This person care recordsshowed that they had difficulty following instructions and it was unclear what support theyneeded. The manager told us that care plans should have been developed as this personhad been at the home for a week. This meant that they may be at risk of their needs notbeing met in a consistent way.

The record for another person showed that they were at risk if they left the home andneeded one to one supervision. We found this person asleep in a spare room. We spoke


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to the staff and they were not aware of this person's whereabout. The manager told us thatstaff should have been monitoring this person to ensure their safety. This meant thatpeople may be put at risk to their welfare.

The records of three people showed that they were at risk of weight loss and had lostweight in the last three months. One person was to be weighed weekly and the otherfortnightly, there was no record that this had been done. A staff member told us that this

had been missed and it would be looked into. This meant that people may not alwaysreceive care as planned.

People were supported to access external health care support and advice. Staff confirmedthat the healthcare teams were consulted for advice and support. The manager said thatpeople were supported to attend appointments in the community as needed. We saw thata referral had been made for a dentist as a person had lost their dentures. This meant thatpeople's healthcare needs were met and people were supported to access these.

An external entertainer was visiting the home to provide some activities in the afternoon ofour inspection. We observed a large group of people took part and people told us that they

enjoyed the activity. Staff told us that there were few organised activities as thecoordinator left a couple of months ago. We noted activity sheets had not been filled in forthe last three months. This meant that people were not supported to take part in activitiesto meet their needs.

The Deprivation of Liberty Safeguards was only used when it was considered to be in theperson's best interest. Staff received training in the Mental Capacity Act 2005 andDeprivation of Liberty Safeguards (DoLS). The staff said that they would involve people'sfamily and healthcare professionals to ensure that they acted in the best interests ofpeople who use services. The manager told us that there was no one currently at thehome who was subject to a DoLS authorisation. We saw that this had been in effect forone person which had recently expired.


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Meeting nutritional needs Met this standard

Food and drink should meet people's individual dietary needs

Our judgement


People were protected from the risks of inadequate nutrition and dehydration. They weresupported to eat and drink and they had choices available to them to meet their needs.


People spoken with were complimentary about the food. They commented that the food

was very good and they were offered plenty to eat and drink. Relatives told us that theyfelt the meals were good and choices were offered to people.

People were supported to be able to eat and drink sufficient amounts to meet their needs.We observed the lunchtime meal in different areas of the home and found that this waswell presented. There was a choice for the main course and desserts were available topeople. We observed that the staff assisted people with their food and drinks in a sensitivemanner. Throughout the day we observed that hot and cold drinks were available topeople. The chef told us that snacks were available to people at bed times. The dietaryrecords contained details about people's likes and dislikes. We saw a list was in thekitchen that identified the types of meals such as puree or diabetic meals as needed.

We observed that a person was prescribed and needed a thickening powder to be addedto their drinks as they were at risk of aspiration due to their swallowing difficulties. A staffmember was seen serving drinks and they were aware of that person's need and anappropriate drink was served to that person. People were offered choices and staff usedvisual prompts for meals and drinks. This meant that people were informed and supportedto make choices regarding their meals and drinks.

Some people were having their food and fluids monitored. The provider may wish to notethat records of food and fluids were inadequate as we were told the staff were failing torecord what people had eaten and drank. The staff in charge told us that staff had beenreminded to complete the food records and this would be addressed.


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Safeguarding people who use services from abuse Met this standard

People should be protected from abuse and staff should respect their humanrights

Our judgement


People who use the service were protected from the risk of abuse, because the providerhad taken reasonable steps to identify the possibility of abuse and prevent abuse fromhappening. Training in safeguarding was available to the staff.


People who use the service were protected from the risk of abuse, because the providerhad taken reasonable steps to identify the possibility of abuse and prevent abuse fromhappening. The home had in place a safeguarding policy and procedure which includedthe local authority safeguarding procedures that they used. The manager described theprocedure that they would follow and alert the safeguarding team as needed.

Three staff spoken with were able to tell us of the types of abuse that could occur and theaction they would take if abuse was suspected. They were confident that they couldapproach the manager or the provider and actions would be taken to protect people. Theysaid that they were aware that they could raise an alert with the local safeguarding team.

They knew about the whistle-blowing policy and felt they would have managementsupport. A staff told us that would also be prepared to go outside of the organisation if theirconcerns were not dealt with.

The staff told us that they had completed training in safeguarding adults. We saw recordsshowing this training also formed part of the induction process for all staff. This meant thatpeople could be assured that staff had the necessary skills to report any allegation asrequired.


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Cleanliness and infection control Met this standard

People should be cared for in a clean environment and protected from the risk ofinfection

Our judgement


The provider failed in the maintenance of appropriate standards of cleanliness andhygiene in relation to the premises. This had been rectified when we checked again at alater time.


People were not protected from the risk of infection because appropriate guidance hadbeen followed. At 09:45 on the morning of the visit we found that four of the communaltoilets and a bathroom had offensive odours, were dirty and toilets seats were smearedwith faeces. In the communal bath we saw that a soiled incontinence pad had beendiscarded. In one of the bedrooms the flooring had brown residue that a staff memberconfirmed had been caused by another person. The staff in charge told us that one of thedomestic staff was serving breakfast and was not able to clean the home. This meant thatpeople were exposed to infection control risks as the toilets and their seats were not clean.We asked to see the risk assessments and infection control procedures. Staff said thatthey should be carrying out spot checks of the communal facilities but these had not taken

place as they were very busy. We checked the home again at lunchtime and found thatthese areas had been cleaned and there was no offensive odour present.

Relatives we spoke with said that they found the home was clean including their relativesbedrooms. Laundry arrangements for used and infected linen were in place.


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Management of medicines Enforcement actiontaken

People should be given the medicines they need when they need them, and in asafe way

Our judgement


People were not protected against the risks associated with medicines because theprovider had inappropriate arrangements in place to manage medicines. People were putart risk of not receiving their medicines safely.

We have judged that this has a major impact on people who use the service and have

taken enforcement action against this provider. Please see the 'Enforcement action'section within this report.


People could not tell us about their medicines 'management due to their cognitivedifficulties. We looked at the process the home had in place to ensure that people receivedtheir medication as prescribed. The home used the monitored dosage system (MDS) anda staff member said that this worked well. The MDS ran over a 28 days cycle. There weredesignated staff responsible for ordering medications for people who used the service.

Staff confirmed that only those who had completed training in medicines' managementwere responsible for people's medications.

Medicines were prescribed however they were not given to people appropriately. Thearrangements at the time of the inspection in relation to dispensing and administeringpeople's medicines were unsafe and put them at risk of harm. We found that staff had lefta pot containing the morning medications labelled for one person in another person'sbedroom. These medicines were within the reach of this vulnerable person with cognitiveproblems and putting put them at risk. A staff member confirmed that these tablets did notbelong to that person. We found these tablets were completely different to thoseprescribed for this person. The staff in charge told us that they had been "potting" up

secondary dispensing up to six people's medications at a time and taking them upstairs.This was due to the lift being out of order. The "potting "of medicines contradicted thehome's procedure and good practice guidance. The staff were dispensing people'smedicines and writing the person's name on a piece on paper placing this in the pot. Thiscarried the risk of them getting mixed up or placed in the wrong pot and given to the wrongperson. The guidance document from the Royal Pharmaceutical Society, 'handlingmedicines in social care setting' recommends that medicines must be given from thecontainer they are supplied in. We also found that a person was having their medicinescrushed. There were no records of which medicines were being crushed. There was norisk assessment, care plan and evidence that their GP or pharmacist had been consultedand consented to these medicines being crushed. This may put this person at risk ascrushing tablets and opening capsules can change the way that medicines work. Followingthe inspection the provider wrote to us and sent us information to show that they had


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consulted the GP and pharmacist regarding management of crushed medicines for thesepeople.

A random sample of 16 medicine administration record (MAR) charts was also looked at. Astock check showed that staff did not record medicines that were carried forward whichmeant that these could not be audited. We found that the MAR records were maintained;however there were gaps on the MAR charts that staff could not tell us if people had

received their medicines. We also found that for three people whose medication we wereable to audit, there were extra or missing tablets that could not be accounted for. Thismeant that people were at risk of not receiving their medicines as prescribed.


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Staffing Action needed

There should be enough members of staff to keep people safe and meet theirhealth and welfare needs

Our judgement


People were cared for by staff who were skilled and experienced to deliver care andtreatment. There were not always adequate numbers of staff to support people and delivercare to an appropriate standard.

We have judged that this has a moderate impact on people who use the service, and havetold the provider to take action. Please see the 'Action' section within this report.


We looked at the staffing structure and arrangements that were in place in order to ensurethat people were supported by an adequate staffing compliment to meet their needs. Wesaw staff supporting people in a sensitive manner, listened to people's requests andhelping them as needed. Care was provided at a pace that suited people and we observedstaff and people interacted well.

Relatives told us that the staff were very good and helpful. However people said they felt

that there were at times staff were rushed. They said that the staff did their very best andwere very busy. We talked with the six staff and a number of them had been working at theservice for a number of years. All the staff told us that staffing was inadequate and thishad been compounded by the passenger lift being out of order. They told us that theyneeded extra staff as people were unable to go downstairs and need to be supervised onthe first floor. There was a training plan and the staff were supported to undertake furthertraining and development. The permanent staff were knowledgeable about people's needsand we observed that they interacted well with the people living at the home and theirrelatives.

The home accommodated a large number of people with complex and sometimes

challenging needs. We observed on various occasions where people were leftunsupervised as the staff were busy attending to other people particularly on the first floor.Two staff told us that they were unable to supervise people such as the person foundasleep in an empty room, as they were busy helping people with personal care throughoutthe morning. This meant that people were not always monitored and received the supportthey needed.

The lack of an activity coordinator we were told also impacted on the care that peoplereceived; as this support with activities was not available. We observed people whoneeded help and encouragement to eat were not given this as much as they should havebeen. As a result of low staffing, there was not enough support, where necessary, for thepurpose of enabling people to eat and drink in a timely way. Staff told us that they relied onagency staff for support and felt they needed extra staff in order to be able to do their job


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effectively. On the day of the visit following the incident with the medicines; a staff memberhad contacted senior management and was told they would not be able to have extra staffat that time. It was unclear what system was in place to look at the people's dependencyand staffing levels to ensure there were adequate numbers of staff on duty. We were alsotold that the domestic staff were not able to carry out their duties as they were helping totake trays of breakfast to the first floor. This meant that people may not always receive thecare and support they needed and in a timely way.


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Assessing and monitoring the quality of serviceprovision

Met this standard

The service should have quality checking systems to manage risks and assurethe health, welfare and safety of people who receive care

Our judgement


The provider regularly assessed and monitored the quality of the service provided. Riskshad been assessed relating to the health, welfare and safety or service users. Theprovider regularly sought the views of people using the service.


People who used the service, their representatives and staff were asked for their viewsabout their care and treatment and they were acted on. The provider undertook a yearlysurvey and sent out questionnaires to people, their relatives and care professionals. Theresult was sent to us after the inspection and this showed that people were positive aboutthe care and treatment they received. People felt that they were involved in the care andstaff treated their relatives well. The manager held quarterly meetings with people andtheir relatives to keep them informed about the service and any developments and to seektheir views.

The passenger lift had been out of order when we visited the home. There was a riskassessment in place however this was not robust. According to the risk assessment extrastaff would be in place to assist people who were unable to access the ground floor andwould be remaining upstairs. The five staff we spoke with told us that staffing had not beenincreased. Following the inspection we received an updated risk assessment dated 7November 2012 to inform us about risk assessments and staffing arrangements had beenput in place.

We saw that there was a system in place where a senior member of staff from thecompany carried out a care audit of the home and reported to the registered manager andprovider. The manager told us that an action was developed to address any issues asidentified. Health and safety audits of the environment were in place. Checks were carriedout in relation to fire equipments and the staff told us that they carried out regular firealarm checks. The manager told us that they carried out a falls' audit and action wastaken as appropriate such as referral to GP and falls' clinic.The manager took account of complaints and comments to improve the service. Therelatives were confident to report any concerns to the manager. There was a complaintslog in place. Concerns raised were looked into and responded appropriately as per thehome's policy.


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This section is primarily information for the provider


Action we have told the provider to take

Compliance actions

The table below shows the essential standards of quality and safety that were not beingmet. The provider must send CQC a report that says what action they are going to take tomeet these essential standards.

Regulated activity Regulation

Accommodation forpersons who requirenursing or personalcare

Regulation 9 HSCA 2008 (Regulated Activities) Regulations2010

Care and welfare of people who use services

How the regulation was not being met:

People experienced care, treatment and support that mostly mettheir needs and protected their rights. There was at times a lackof detailed support plans to show how identified risks would be

managed. Regulation 9(1) (a) (b).

Regulated activity Regulation



Staffing


People were cared for by staff who were skilled and experiencedto deliver care and treatment. There were not always adequatenumbers of staff to support people and deliver care to anappropriate standard. Regulation 22

This report is requested under regulation 10(3) of the Health and Social Care Act 2008(Regulated Activities) Regulations 2010.

CQC should be informed when compliance actions are complete.

We will check to make sure that action has been taken to meet the standards and willreport on our judgements.


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This section is primarily information for the provider


Enforcement action we have taken to protect the health, safety andwelfare of people using this service

Enforcement actions we have taken

The table below shows enforcement action we have taken because the provider was notmeeting the essential standards of quality and safety (or parts of the standards) as shownbelow.

We have served a warning notice to be met by 30 November 2012

This action has been taken in relation to:

Regulated activity Regulation or section of the Act



Management of medicines


People were not protected against the risks associated withmedicines because the provider had inappropriate arrangementsin place to manage medicines. Regulation13

For more information about the enforcement action we can take, please see ourEnforcement policyon our website.


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About CQC inspections

We are the regulator of health and social care in England.

All providers of regulated health and social care services have a legal responsibility to

make sure they are meeting essential standards of quality and safety. These are thestandards everyone should be able to expect when they receive care.

The essential standards are described in the Health and Social Care Act 2008 (RegulatedActivities) Regulations 2010 and the Care Quality Commission (Registration) Regulations2009. We regulate against these standards, which we sometimes describe as "governmentstandards".

We carry out unannounced inspections of all care homes, acute hospitals and domiciliarycare services in England at least once a year to judge whether or not the essentialstandards are being met. We carry out inspections of dentists and other services at least

once every two years. All of our inspections are unannounced unless there is a goodreason to let the provider know we are coming.

There are 16 essential standards that relate most directly to the quality and safety of careand these are grouped into five key areas. When we inspect we could check all or part ofany of the 16 standards at any time depending on the individual circumstances of theservice. Because of this we often check different standards at different times but wealways inspect at least one standard from each of the five key areas every year. We maycheck fewer key areas in the case of dentists and some other services.

When we inspect, we always visit and we do things like observe how people are cared for,

and we talk to people who use the service, to their carers and to staff. We also reviewinformation we have gathered about the provider, check the service's records and checkwhether the right systems and processes are in place.

We focus on whether or not the provider is meeting the standards and we are guided bywhether people are experiencing the outcomes they should be able to expect when thestandards are being met. By outcomes we mean the impact care has on the health, safetyand welfare of people who use the service, and the experience they have whilst receivingit.

Our inspectors judge if any action is required by the provider of the service to improve thestandard of care being provided. Where providers are non-compliant with the regulations,we take enforcement action against them. If we require a service to take action, or if wetake enforcement action, we re-inspect it before its next routine inspection was due. Thiscould mean we re-inspect a service several times in one year. We also might decide to re-inspect a service if new concerns emerge about it before the next routine inspection.

In between inspections we continually monitor information we have about providers. Theinformation comes from the public, the provider, other organisations, and from careworkers.

You can tell us about your experience of this provider on our website.


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How we define our judgements

The following pages show our findings and regulatory judgement for each essential

standard or part of the standard that we inspected. Our judgements are based on theongoing review and analysis of the information gathered by CQC about this provider andthe evidence collected during this inspection.

We reach one of the following judgements for each essential standard inspected.

Met this standard This means that the standard was being met in that theprovider was compliant with the regulation. If we find thatstandards were met, we take no regulatory action but wemay make comments that may be useful to the provider andto the public about minor improvements that could be made.

Action needed This means that the standard was not being met in that theprovider was non-compliant with the regulation.We may have set a compliance action requiring the providerto produce a report setting out how and by when changeswill be made to make sure they comply with the standard.We monitor the implementation of action plans in thesereports and, if necessary, take further action.We may have identified a breach of a regulation which ismore serious, and we will make sure action is taken. We willreport on this when it is complete.

Enforcementaction taken

If the breach of the regulation was more serious, or therehave been several or continual breaches, we have a range ofactions we take using the criminal and/or civil procedures inthe Health and Social Care Act 2008 and relevantregulations. These enforcement powers include issuing awarning notice; restricting or suspending the services aprovider can offer, or the number of people it can care for;issuing fines and formal cautions; in extreme cases,cancelling a provider or managers registration or prosecutinga manager or provider. These enforcement powers are setout in law and mean that we can take swift, targeted actionwhere services are failing people.


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How we define our judgements (continued)

Where we find non-compliance with a regulation (or part of a regulation), we state which

part of the regulation has been breached. We make a judgement about the level of impacton people who use the service (and others, if appropriate to the regulation) from thebreach. This could be a minor, moderate or major impact.

Minor impact people who use the service experienced poor care that had an impact ontheir health, safety or welfare or there was a risk of this happening. The impact was notsignificant and the matter could be managed or resolved quickly.

Moderate impact people who use the service experienced poor care that had a

significant effect on their health, safety or welfare or there was a risk of this happening.The matter may need to be resolved quickly.

Major impact people who use the service experienced poor care that had a seriouscurrent or long term impact on their health, safety and welfare, or there was a risk of thishappening. The matter needs to be resolved quickly

We decide the most appropriate action to take to ensure that the necessary changes aremade. We always follow up to check whether action has been taken to meet thestandards.


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Glossary of terms we use in this report

Essential standard

The essential standards of quality and safety are described in our Guidance aboutcompliance: Essential standards of quality and safety. They consist of a significant numberof the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and theCare Quality Commission (Registration) Regulations 2009. These regulations describe theessential standards of quality and safety that people who use health and adult social careservices have a right to expect. A full list of the standards can be found within theGuidance about compliance. The 16 essential standards are:

Respecting and involving people who use services - Outcome 1 (Regulation 17)

Consent to care and treatment - Outcome 2 (Regulation 18)

Care and welfare of people who use services - Outcome 4 (Regulation 9)

Meeting Nutritional Needs - Outcome 5 (Regulation 14)

Cooperating with other providers - Outcome 6 (Regulation 24)

Safeguarding people who use services from abuse - Outcome 7 (Regulation 11)

Cleanliness and infection control - Outcome 8 (Regulation 12)

Management of medicines - Outcome 9 (Regulation 13)

Safety and suitability of premises - Outcome 10 (Regulation 15)

Safety, availability and suitability of equipment - Outcome 11 (Regulation 16)

Requirements relating to workers - Outcome 12 (Regulation 21)

Staffing - Outcome 13 (Regulation 22)

Supporting Staff - Outcome 14 (Regulation 23)

Assessing and monitoring the quality of service provision - Outcome 16 (Regulation 10)

Complaints - Outcome 17 (Regulation 19)

Records - Outcome 21 (Regulation 20)

Regulated activity

These are prescribed activities related to care and treatment that require registration withCQC. These are set out in legislation, and reflect the services provided.


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Glossary of terms we use in this report (continued)

(Registered) Provider

There are several legal terms relating to the providers of services. These includeregistered person, service provider and registered manager. The term 'provider' meansanyone with a legal responsibility for ensuring that the requirements of the law are carriedout. On our website we often refer to providers as a 'service'.

Regulations

We regulate against the Health and Social Care Act 2008 (Regulated Activities)Regulations 2010 and the Care Quality Commission (Registration) Regulations 2009.

Responsive inspection

This is carried out at any time in relation to identified concerns.

Routine inspection

This is planned and could occur at any time. We sometimes describe this as a scheduledinspection.

Themed inspection

This is targeted to look at specific standards, sectors or types of care.


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Contact us

Phone: 03000 616161

Email: [email protected]

Write to usat:

Care Quality CommissionCitygateGallowgateNewcastle upon TyneNE1 4PA

Website: www.cqc.org.uk

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glen lee care home report

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