Inspection on 19/01/06 for Glebe Cottage

This inspection was carried out on 19th 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 no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glebe Cottage 05/11/08

Glebe Cottage 28/11/06

Glebe Cottage 10/08/04

Glebe Cottage 20/04/04

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

CARE HOME ADULTS 18-65 Glebe Cottage Glebe Cottage Sandhills Lane Virginia Water Surrey GU25 4DS Lead Inspector Helen Dickens Unannounced Inspection 19th January 2006 10:35 Glebe Cottage DS0000013650.V260746.R01.S.doc Version 5.1 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 Cottage DS0000013650.V260746.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 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 Cottage DS0000013650.V260746.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Glebe Cottage Address Glebe Cottage Sandhills Lane Virginia Water Surrey GU25 4DS 01344 844144 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) Welmede Housing Association Ltd Mr Kuruppuage Upali Seela-Natha Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Glebe Cottage DS0000013650.V260746.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: UNDER 65 YEARS OF AGE 29th June 2005 Date of last inspection Brief Description of the Service: Glebe Cottage is a large two-storey Victorian house situated in a residential area in the village of Virginia Water, Surrey. It is within walking distance of local shops and amenities. The home offers accommodation and care to six residents, all under the age of 65, and is owned and managed by Welmede Housing Association. Residents have their own bedrooms and there are communal facilities on the ground floor including a lounge, activities room, dining room and kitchen. There are toilet and bathing facilities on both floors. There is a small garden to the front of the property with car parking, and a larger garden to the rear. Glebe Cottage DS0000013650.V260746.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over four and a half hours and was the second inspection to be undertaken in the Commission for Social Care Inspection year April 2005 to March 2006. The inspection was carried out by Helen Dickens, Regulation Inspector. Julie Dunn and Alan Ross, Senior Care Workers, assisted with the first part of the inspection, and the Registered Manager, Paul Seela-Natha, joined later. A partial tour of the premises took place. The inspector met and spoke with all the residents either during the inspection, or later in the day when a short return visit was made to meet resident’s who had returned from their daytime activities. A number of documents and files were also examined as part of the inspection process. This report covers fewer Standards than the previous one as all the Key Standards were covered at the last inspection. This was a positive inspection. The inspector would like to thank the residents, staff and manager for their time, assistance and hospitality. What the service does well: What has improved since the last inspection? The acting manager has now registered with CSCI as per the requirement made at the previous inspection. The manager said that an occupational therapist’s assessment had been carried out on the property (this is being forwarded to CSCI). More staff had been recruited and some staff had started NVQ training. The Manager gave the inspector an up-date on the requirement to bring this property up to an acceptable standard. He said the housing association had started to make arrangements for a large-scale refurbishment of the property due to start in the spring. Residents had already been involved in choosing colours (for decoration and furnishings) and furniture for the newly refurbished Glebe Cottage DS0000013650.V260746.R01.S.doc Version 5.1 Page 6 home. The updating of electrical wiring in the property has already been carried out. 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. Glebe Cottage DS0000013650.V260746.R01.S.doc Version 5.1 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 Cottage DS0000013650.V260746.R01.S.doc Version 5.1 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): EVIDENCE: For an assessment of these Standards, please see the previous report. Glebe Cottage DS0000013650.V260746.R01.S.doc Version 5.1 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 Resident’s care plans contain sufficient information to ensure social and health care needs will be met. EVIDENCE: Care plans at this home are well done giving staff a good deal of information about resident’s needs. The manager has also prepared some very clear guidance for staff to help them to up-date the individual life plans on each resident. Information on health, personal care requirements, activities and individual likes, dislike and goals were all recorded. Copies of resident’s risk assessments were also on their files. It was not possible to confirm verbally with residents if their needs were being met but observation of staff-resident interaction showed staff were sensitive to residents needs and frequently anticipated these needs. Glebe Cottage DS0000013650.V260746.R01.S.doc Version 5.1 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 and 14 Residents are provided with opportunities to take part in appropriate activities. EVIDENCE: There was a timetable of resident’s weekly activities posted on the board in the office (and outlined on each resident’s care plan), which showed a variety of interesting pursuits, mainly via the day care facility. Residents have one day at home per week. Local activities involve going to the shops and a pub. Annual holidays are arranged for all residents (the New Forest and Devon last year) who divide into two groups; staff said this was decided according to advice from key workers about which residents get on best together. At weekends some residents visit or receive visits from relatives. Glebe Cottage DS0000013650.V260746.R01.S.doc Version 5.1 Page 11 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): 18,19 and 21. Resident’s social and healthcare needs are well documented and this makes it more likely that their wishes will be met. The home needs to review their information regarding the ageing and death of residents to ensure their wishes, and those of their families, will be taken into account. EVIDENCE: The home has a key worker system in place, and care plans contain a good overview of the personal support residents need. Residents were observed to be individual in their appearance and dress. The inspector noted that one bathroom did not afford privacy, as there was no lock on the door; a two way lock or other method of protecting privacy during supported bathing for example, should be sought. In addition, residents privacy needs to be protected when they use the toilet facility in this same bathroom and this was discussed the manager. Healthcare needs of residents had been assessed and this was noted on their files; records of healthcare interventions were also noted. Resident’s health is monitored and they are registered with the local GP surgery. The home has a policy containing information on the practical aspects of dealing with the death of a resident including what actions to take, who to contact etc. However, there did not seem to be a policy on ageing, and no Glebe Cottage DS0000013650.V260746.R01.S.doc Version 5.1 Page 12 record of resident’s wishes at the time of their death could be found. The home must review this Standard and devise policies and practices to ensure that the ageing, illness and death of a resident would be handled as the individual would wish. Glebe Cottage DS0000013650.V260746.R01.S.doc Version 5.1 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 The complaints procedure and vulnerable adults policies at this home should protect residents. EVIDENCE: The home has a complaints procedure in place and keeps a loose-leaf file of comments and complaints received; no complaints have been received since the last inspection. The manager was asked to keep a complaints ‘log’ which would identify any complaints made, and the response and actions taken by the home. This should show any investigation carried out and what the outcome was. This should be monitored as per Standard 22.7. The home has a copy of the Surrey multi-agency procedures for the protection of vulnerable adults and this is mentioned in their own local policy on this issue. Staff questioned knew what their response should be if there was an allegation of abuse. A protection of vulnerable adults issue had been raised since the last inspection had been dealt with according to the countywide procedures. The manager mentioned that not all staff had relatives to advocate for them and that independent advocacy had been considered but was not available at the moment. This should be pursued in order to ensure transparency and appropriate support for residents. Glebe Cottage DS0000013650.V260746.R01.S.doc Version 5.1 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): 24 Though staff try hard to provide a homely environment, the standard of repair and maintenance at this home remains poor. EVIDENCE: Some parts of the home look particularly homely; for example the spacious activities room with matching curtains and sofas, a well cared for aquarium and games and activities for residents to enjoy. However, throughout the home there are many instances of poor decoration (torn wall paper, large areas needing repainting, and the recent rewiring work has been re-plastered but not painted). Furnishings and fittings are worn and either need refurbishing or replacing (e.g. rusting radiator cover in the bathroom; damaged sealant around the basin; and stained and worn carpets). The manager said this work will start around March but no definite arrangements have been made. A previous requirement to send an action plan relating to the refurbishment/redecoration of Glebe House has been outstanding since August 2005 and a further requirement will be made in this regard. Glebe Cottage DS0000013650.V260746.R01.S.doc Version 5.1 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 Resident’s needs are currently being met but the home has not reached the target for training set down in the National Minimum Standards (NMS). EVIDENCE: This Standard was assessed at the previous inspection but reviewed here as the home has not yet met one aspect of this Standard; the target set in the NMS (32.6) regarding 50 of care staff achieving NVQ2 or above by the end of 2005. The manager said that there has been a high turnover of staff and, whilst more staff are now enrolled on NVQ training courses, currently only one member of the care staff has completed an NVQ course. The home should send an action plan to CSCI regarding when then are likely to meet this Standard and how they will ensure residents continue to be properly supported. Glebe Cottage DS0000013650.V260746.R01.S.doc Version 5.1 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 and 42 Residents benefit from a well run home but further work needs to be done on health and safety matters to fully protect residents. EVIDENCE: The new manager is qualified and competent to run the home and has fifteen years experience in management. He is a trained mental health nurse and currently studying for the Registered Manager’s Award. He continues to update his training by joining other staff on in-house training courses; he has recently completed the medication refresher training and the protection of vulnerable adults training. The home operates a number of good practices with regard to health and safety. For example, risk assessments are in place for residents, the hazardous substances cupboard was securely locked, and a member of staff has been given responsibility for overseeing the health and safety of the home. A variety of safety certificates were seen and found to be satisfactory. The relevant policies and procedures have to be read by each staff member and then signed by them. Glebe Cottage DS0000013650.V260746.R01.S.doc Version 5.1 Page 17 However, the home’s legionella safety check was overdue and it was not clear whether local water outlets are controlled by local thermostats or by reducing the overall temperature of the boiler. This latter method increases the risk of legionella and the manager was advised to review the whole issue regarding the safety of water systems within the home. Policies and procedures available in the office were old; most of those sampled had not been reviewed since 1997. On a return visit later in the day to meet the three residents who had been out at daycare, the manager produced an up-dated folder of health and safety procedures. Staff now need to familiarise themselves with these. Other policies and procedures will also need up dating. A number of other safety checks were overdue including the gas safety check; the home must ensure that all safety checks are carried out in a timely fashion. The kitchen fridge was also a cause for concern. Items with a limited shelf life (bottles and jars) had been opened but not dated so it would be impossible to know when they were out of date. A packet of ham was opened, and again not labelled with the date of opening. A packet of sausage rolls and some raw chicken were out of date though the day staff thought these items may have been taken out of the freezer by other staff, but not labelled – these practices need to be reviewed as a matter of urgency and staff reminded of the importance of safe food handling and hygiene. Not all radiators have safety covers and on the day of the inspection at least one radiator was too hot and could have put residents at risk. The staff were asked to carry out risk assessments on those radiators without covers which could not be thermostatically controlled to a guaranteed safe temperature. Hand washing facilities in one toilet did not have disposable hand towels; cotton towels for communal use increases the chance of infection spreading and are therefore not recommended. Glebe Cottage DS0000013650.V260746.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X X X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 X 2 3 X X X X 1 x Glebe Cottage DS0000013650.V260746.R01.S.doc Version 5.1 Page 19 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 YA18 Regulation 12(4)(a) Requirement The Responsible Individual must review arrangements for the privacy and dignity of residents in relation to the downstairs bathroom (as discussed with staff and in the report). The Responsible Individual must ensure that resident’s wishes regarding their ageing and death are documented. This should include a review of Standard 21. The Responsible Individual must send an action plan to CSCI setting out the timescales, and extent of the work that is intended to be carried out, to bring the premises up to an acceptable standard. To ensure that at all times suitably qualified staff are working at the care home, the Responsible Individual must forward to CSCI an action plan setting out how and when the target of having 50 of staff trained to NVQ level 2 or above will be reached. The Responsible Individual must review arrangements for ensuring water safety as DS0000013650.V260746.R01.S.doc Timescale for action 20/01/06 2. YA21 12(2)(3) 19/03/06 3. YA24 23(2)(b) (d) 19/02/06 4. YA32 18(1)(a) 19/03/06 5. YA42 13(4)(c ) 26/01/06 Glebe Cottage Version 5.1 Page 20 6. YA42 13(4)(c ) 7. YA42 13(4)(c ) 8. YA42 13(4)(a) 9. YA42 13(3) discussed with the staff and manager, and as identified in the report. The home must arrange for the overdue legionella safety check to be carried out. The home should review its current arrangements to ensure that all safety checks are carried out in a timely fashion and documents confirming these checks should be available for inspection. The Responsible Individual must ensure that up-to-date policies and procedures (particularly on safe working practise) are available in the home and that staff are familiar with these documents. The Responsible Individual must ensure there is an urgent review of arrangements for the storage of perishable foods in the refrigerator as discussed in the report and with staff on the day of the inspection. For the safety of residents, the Responsible Individual must ensure risk assessments are carried out on all radiators which do not have covers, and take remedial action as necessary. The Responsible Individual must ensure that suitable hand washing and drying facilities are made available throughout the home, as discussed with staff and outlined in the report. 19/02/06 20/01/06 20/01/06 20/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Glebe Cottage DS0000013650.V260746.R01.S.doc Version 5.1 Page 21 1. 2. YA22 YA22 The home should compile a complaints log and record details of complaint, any investigation carried out, and the outcome. The home should pursue the option of independent advocacy for those residents who do not have relatives or friends to represent their interests. Glebe Cottage DS0000013650.V260746.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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. 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