Inspection on 25/01/06 for Glebe Gardens

This inspection was carried out on 25th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glebe Gardens 11/12/08

Glebe Gardens 14/02/07

Glebe Gardens 04/08/05

Glebe Gardens 17/02/05

Glebe Gardens 12/08/04

Glebe Gardens 08/12/03

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Glebe Gardens Reading Road Burghfield Reading Berkshire RG7 3BH Lead Inspector Amanda Longman Unannounced Inspection 25th January 2006 10:00 Glebe Gardens DS0000011146.V272478.R01.S.doc Version 5.0 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 Glebe Gardens DS0000011146.V272478.R01.S.doc Version 5.0 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 Adults 18-65. 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. Glebe Gardens DS0000011146.V272478.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Glebe Gardens Address Reading Road Burghfield Reading Berkshire RG7 3BH 0118 983 5476 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) Residential Community Care Limited Mrs Jennifer Carol Laing Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Glebe Gardens DS0000011146.V272478.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th February 2005 Brief Description of the Service: Glebe Gardens is a residential home, which provides people with a learning disability with accommodation and services in a communal setting. Our main aim is to live as safely, comfortably and as independently as possible and we hope that you will be very happy in the house and will come to regard it as your home. Glebe Gardens is a four bedroom detached house with four single bedrooms and a staff bedroom. All other rooms in the house are to be shared with the other residents. There is a large garden with a patio and garden furniture. (Extract from the service users guide)Glebe Gardens is one of three homes in the local area operated by Residential Community Care Limited. Glebe Gardens DS0000011146.V272478.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection during which the inspector spent several hours at the home, spoke in detail with the service users and with staff. Policies, procedures and service user files were reviewed. A tour of the home was undertaken which included two service users rooms. This was a very positive inspection. The home has a happy, homely atmosphere. It has good facilities and its close working relationship with the two other homes owned by the organisation benefits the people who live there. Individuals visit other homes in the group, forming friendships and sharing educational and social activities. Service users enjoy a good balance of educational and leisure activities supported by committed and caring staff. What the service does well: What has improved since the last inspection? What they could do better: Glebe Gardens has a new manager since the last inspection who needs to undertake her Registered Manager’s Award and to apply for registration with the Commission for Social Care Inspection. The home also needs to increase the number of staff studying to qualified to NVQ level 2 in care. They also need to ensure the lock on the cupboard containing substances hazardous to health is repaired and it is recommended that the home disposes of any chipped crockery. Glebe Gardens DS0000011146.V272478.R01.S.doc Version 5.0 Page 6 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. Glebe Gardens DS0000011146.V272478.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glebe Gardens DS0000011146.V272478.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Prospective users’ individual aspirations and needs are assessed. EVIDENCE: Records were examined relating to assessment and admissions. It was seen that pre-admission assessments are thorough and appropriate, involving others appropriately, such as care managers or family. Care plans are put together and were seen to include goals and agreements with service users on lifestyle and conduct, which are signed and dated. Glebe Gardens DS0000011146.V272478.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9 Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users are supported to take risks as part of an independent lifestyle. EVIDENCE: Service user files show detailed and regular reviews with goals clearly highlighted and agreed with service users. Likes and wishes are recorded in three priority levels and educational and personal profiles are recorded and regularly reviewed with service users covering strengths, needs and both short and long term goals. Risk assessments were seen to be in place for activities of daily living and for individual activities and behaviours. These showed ways of minimising risk, managing risk and appropriate intervention techniques and strategies. Glebe Gardens DS0000011146.V272478.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15, 16 and 17 Service users are able to take part in age, peer and culturally appropriate activities and have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and meal times. EVIDENCE: Service users’ needs in terms of education, employment and activities are regularly reviewed and this was seen to be documented on service user files. Two service users go regularly to college, one supported and one unsupported and one service user is about to commence vocational training at college and is being supported to find part time employment. This was confirmed by staff and service users. All the service users attend a new cay care programme which is shared with the two other homes owned by the group in the local area. This is a wide-ranging programme including arts, craft, exercise, relaxation classes and interest groups. These activities are greatly enjoyed by the majority of service users; this was confirmed in conversation with the service users. One service user who does not feel these sessions are meeting his needs is being enabled to commence additional training courses. Glebe Gardens DS0000011146.V272478.R01.S.doc Version 5.0 Page 11 The inspector discussed whether these group activities with the two other homes may become too insular and was satisfied by the manger’s response that these activities are combined with external activities such as bowling and swimming, shopping and visits to pubs and garden centres. This was confirmed by service users, file records and the fact that the service users went off bowling on the afternoon of the inspection. The inspector learnt through conversations with staff and service users that service users are enabled, were it is assessed and agreed as appropriate, to go out and pursue their own social live. Such activities were seen to be risk assessed and a signed agreement made covering, for example, return times. Service users are supported to pursue and maintain relationships with family and friends of their choosing. Evidence of this was gained through discussions with staff and service users. This includes visits home, communication through letters and phone calls, visits at Glebe Gardens, social outings and holiday where the venue and who to go with is chosen by service users. The home has in place a policy covering dignity and respect which was seen to be up to date (reviewed in November 2005) and appropriate. Service users have keys for their rooms and front door keys. The post arrived during the inspection and was seen to be opened by the appropriate service users without reference to staff. Service users may use the phone in the office for private telephone calls and two have their own mobiles. Service users plan the menus at a weekly meeting with staff and go shopping with staff. This was confirmed with service users in conversation who were happy with the meals. They all commented that one particular service user is a very good cook and cooks for them on occasions. The manager stated there is an emphasis on healthy eating and this was demonstrated in the menus seen. An inspection of the kitchen revealed it to be clean and tidy, with food stored appropriately. Fresh fruit and vegetables were seen. The crockery cupboard revealed a small number of chipped items and the inspector recommended to the manager that these be replaced. Glebe Gardens DS0000011146.V272478.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 20 Service users’ physical and health needs are met and service users are protected by the home’s policies and procedures for dealing with medication. EVIDENCE: Records showed that service users physical and health needs are regularly and fully reviewed. Service users are supported to attend regular dentist appointments and other specialist appointments as necessary, such as chiropody. The manager informed the inspector that GP visits are accompanied/supported by staff but that the service user will see the GP in private unless they wish the member of staff to be present. Records showed that service users in need of psychiatric support receive this regularly. Service users spoken with were happy with the amount of support for their physical and health needs. The home’s medication policies and procedures were examined and found to be appropriate. Medication is appropriately stored. Records held in the home showed that training for medication issues is up to date for staff. Glebe Gardens DS0000011146.V272478.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Service users feel their views are listened to and acted on and service users are protected from abuse, neglect and self-harm. EVIDENCE: Regular service user meetings are held and the minutes of these provided clear evidence of one way in which service user views are sought and acted upon. Service users were all spoken with and confirmed that their views are sought on all aspects of the running of the home and their lives, for example, meals, staff appointments, the home’s policies and procedures, and holidays. The policies and procedures relating to the protection of vulnerable adults were seen to be appropriate and included the local interagency guidelines. Staff spoken with had received training and were competent in this area. Glebe Gardens DS0000011146.V272478.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 and 27 Service users bedrooms promote their independence and service users toilets and bathrooms provide sufficient privacy and meet their individual needs. EVIDENCE: Two service users showed the inspector their bedrooms which were seen to be clean, well equipped and comfortable. One service user is having a new socket fitted to enable him to use his computer, this was confirmed by the staff in the home. The home has a down stairs cloakroom and two bathrooms on the first floor – one with a bath and one with a shower, all of these were seen to be pleasantly decorated and clean. Glebe Gardens DS0000011146.V272478.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 and 35 Service users are supported by competent staff but the home falls short of the required number holding an NVQ qualification. Service users’ needs are met by appropriately trained staff. EVIDENCE: Records were seen to show appropriate training is in place for staff, including appropriate induction training and this was confirmed by staff spoken with. All service users were spoken with and felt that staff were supportive and well trained. In addition to the manager there are currently three staff, with a new member due to start in February. The current vacancy is being covered from within the organisation and so the use of agency staff is not generally required. This is appreciated by service users as they therefore know all the staff well. Staff have appropriate qualifications, such as social care or psychology but only one member of staff is currently undertaking a level 2 NVQ and the home needs to address this. The manager does hold an NVQ level 4 in care. Glebe Gardens DS0000011146.V272478.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The experience of service users is that they benefit from a well run home, but the manager needs to be registered with the CSCI and to undertake the registered managers award. Service users views do underpin self-monitoring, review and development of the home and their health, safety and welfare are promoted and protected. EVIDENCE: The current manager has been in post since 31 October 2005, but has worked for the organisation since 2002. She holds an NVQ level 4 in care but has yet to commence the registered managers award. She also has not yet applied to be registered with the CSCI. Service users spoken with were of the opinion that the home is well run and they are able to input to this process. The quality assurance policy and procedures were seen to have been updated in April 2005 and states that the home will have an annual development plan for quality improvement drawn up as part of its business plan and based upon feedback from service users, staff and relatives. Detailed six monthly client review questionnaires were completed in October 2005 and this has informed the development plan for 2006 which was seen in draft form. It includes an Glebe Gardens DS0000011146.V272478.R01.S.doc Version 5.0 Page 17 evaluation of last year (the development plan for 2005 was seen), issues form the above service user questionnaires, service user forums, section 26 reports and other feedback. The Health and Safety policies and procedures were examined. All have been reviewed within the last twelve months and were seen to be appropriate. Fire policies and procedures, risk assessments, evacuation plans and equipment testing and servicing were all seen to be up to date. All food hygiene procedures and temperature monitorings were up to date. First aid training and risk assessments were up to date. Accident reporting procedures were seen to be appropriate. The lock on the COSHH cupboard was broken. The cupboard was within the office which staff informed the inspector was locked when not occupied, however this does need to be repaired urgently. Glebe Gardens DS0000011146.V272478.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X 3 3 X X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Glebe Gardens Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score 2 X 3 X X 2 X DS0000011146.V272478.R01.S.doc Version 5.0 Page 19 Yes 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 YA32 Regulation 19 (5b) Requirement Timescale for action 31/05/06 2. YA37 19 (2) (i) 3 YA42 13 (4) The registered person must ensure that 50 of staff working at the home have NVQ level 2 or above in social care or are studying to achieve this. This is a requirement from the previous inspection. The manager of the home must 31/05/06 have NVQ level 4 in management and must apply to the CSCI to be registered. So as to protect the health and 07/03/06 safety of service users, the manager must arrange for the lock on the COSHH cupboard to be repaired. 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 YA17 Good Practice Recommendations It is recommended that the manager disposes of any chipped crockery. Glebe Gardens DS0000011146.V272478.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Berkshire Office 2nd Floor 1015 Arlington Business Park Theale, Berks RG7 4SA 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 Glebe Gardens DS0000011146.V272478.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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