Inspection on 05/11/08 for Glebe Cottage

This inspection was carried out on 5th November 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glebe Cottage 28/11/06

Glebe Cottage 19/01/06

Glebe Cottage 10/08/04

Glebe Cottage 20/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 29/01/2009.

Inspecting for better lives Key inspection report Care homes for adults (18-65 years) Name: Address: Glebe Cottage Glebe Cottage Sandhills Lane Virginia Water Surrey GU25 4DS     The quality rating for this care home is:   two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full assessment of the service. We call this a ‘key’ inspection. Lead inspector: Kenneth Dunn     Date: 0 5 1 1 2 0 0 8 This is a report of an inspection where we looked at how well this care home is meeting the needs of people who use it. There is a summary of what we think this service does well, what they have improved on and, where it applies, what they need to do better. We use the national minimum standards to describe the outcomes that people should experience. National minimum standards are written by the Department of Health for each type of care service. After the summary there is more detail about our findings. The following table explains what you will see under each outcome area. Outcome area (for example Choice of home) These are the outcomes that people staying in care homes should experience. the things that people have said are important to them: They reflect This box tells you the outcomes that we will always inspect against when we do a key inspection. This box tells you any additional outcomes that we may inspect against when we do a key inspection. This is what people staying in this care home experience: Judgement: This box tells you our opinion of what we have looked at in this outcome area. We will say whether it is excellent, good, adequate or poor. Evidence: This box describes the information we used to come to our judgement. Copies of the National Minimum Standards – Care Homes for Adults (18-65 years) can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop 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 Our duty to regulate social care services is set out in the Care Standards Act 2000. Care Homes for Adults (18-65 years) Page 2 of 28 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection report CSCI General public 0870 240 7535 (telephone order line) Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. www.csci.org.uk Internet address Care Homes for Adults (18-65 years) Page 3 of 28 Information about the care home Name of care home: Address: Glebe Cottage Sandhills Lane Glebe Cottage Virginia Water Surrey GU25 4DS 01344844144 Telephone number: Fax number: Email address: Provider web address: angela.brien@surreypct.nhs.uk Name of registered provider(s): Name of registered manager (if applicable) Mr Kuruppuage Upali Seela-Natha Type of registration: Number of places registered: Welmede Housing Association Ltd care home 6 Conditions of registration: Category(ies) : Number of places (if applicable): Under 65 learning disability Additional conditions: The maximum number of service users who can be accommodated is: 6 The registered person may provide the following category/ies of service only: Care home only - PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - LD Date of last inspection Brief description of the care home 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 Care Homes for Adults (18-65 years) Page 4 of 28 Over 65 0 6 Brief description of the care home on both floors. There is a small garden to the front of the property with car parking, and a larger garden to the rear. Care Homes for Adults (18-65 years) Page 5 of 28 Summary This is an overview of what we found during the inspection. The quality rating for this care home is: Our judgement for each outcome: two star good service Choice of home Individual needs and choices Lifestyle Personal and healthcare support Concerns, complaints and protection Environment Staffing Conduct and management of the home peterchart Poor Adequate Good Excellent How we did our inspection: The Commission has, since the 1st April 2006, developed the way it undertakes its inspection of care services. The inspection of this Care Home for Younger Adults was an unannounced Key Inspection. The inspector looked at how well the service is doing in respect to the National Minimum Standards for Care Home for Younger Adults. The site visit took into account detailed information provided by the registered provider and the manager, and any information that Commission for Social Care Inspection has received about the service since the last inspection. The inspector looked at how well the service was meeting the standards set by the Care Homes for Adults (18-65 years) Page 6 of 28 government and has in this report made judgements about the standard of the service. Documents sampled during the inspection included the care plans, daily records and risk assessments, medication procedures. The service has submitted the Annual Quality Assurance Assessment prior to the inspection, some details of which have been added to the report. No complainant has contacted the Commission for Social Care Inspection with information concerning a complaint made to the service since the last inspection. From the evidence seen by the inspector and comments received, the inspector considers that the service would be able to provide a service to meet the requirements of individuals who have diverse religious, racial or cultural needs. The inspector would like to thank the people who use the service and the staff for their time, assistance and hospitality during this inspection. The quality rating for this service is 2 star. This means the people who use this service continue to experience an good quality outcome. What the care home does well: What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details set out on page 4. The report of this inspection is available from our website www.csci.org.uk. You can get printed copies from enquiries@csci.gsi.gov.uk or by telephoning our order line –0870 Care Homes for Adults (18-65 years) Page 8 of 28 240 7535. Care Homes for Adults (18-65 years) Page 9 of 28 Details of our 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) Outstanding statutory requirements Requirements and recommendations from this inspection Care Homes for Adults (18-65 years) Page 10 of 28 Choice of home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People are confident that the care home can support them. This is because there is an accurate assessment of their needs that they, or people close to them, have been involved in. This tells the home all about them, what they hope for and want to achieve, and the support they need. People can decide whether the care home can meet their support and accommodation needs. This is because they, and people close to them, can visit the home and get full, clear, accurate and up to date information. If they decide to stay in the home they know about their rights and responsibilities because there is an easy to understand contract or statement of terms and conditions between the person and the care home that includes how much they will pay and what the home provides for the money. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The arrangements for assessing the needs of potential residents are strong. The procedures employed by the service ensures that individuals need are fully assessed and identified prior to admission to the home. Evidence: There has been no new individuals admitted into the home since the previous inspection by the CSCI. The policy in operation for potential new residents fully reflects the prescribes procedures established by the National Minimum Standards which requires all of the individuals needs to be assessed by a trained member of staff to ensure that the home can meet their individual needs and aspirations. Care Homes for Adults (18-65 years) Page 11 of 28 Individual needs and choices These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People’s needs and goals are met. The home has a plan of care that the person, or someone close to them, has been involved in making. People are able to make decisions about their life, including their finances, with support if they need it. This is because the staff promote their rights and choices. People are supported to take risks to enable them to stay independent. This is because the staff have appropriate information on which to base decisions. People are asked about, and are involved in, all aspects of life in the home. This is because the manager and staff offer them opportunities to participate in the day to day running of the home and enable them to influence key decisions. People are confident that the home handles information about them appropriately. This is because the home has clear policies and procedures that staff follow. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use this service have comprehensive care plan, which records their individual needs and goals. They are supported to make decisions about their lives with assistance. The people who live at the service are fully supported by staff. Evidence: A review of individual Person Centred Plans provided detailed information that the people how use this service are fully supported and enabled to have appropriate control over their lives. The care plans sampled during the site visit contain the personal goals of the people who use this service. The plans detail regular reviews being undertaken by the service in order to ensure that the changing needs and personal goals are fully reflective of individual resident. The information has been clearly developed in consultation with the person living in the home their families and other stake holders/professionals. One care plan clearly outlined the changing needs of one individual who because of Care Homes for Adults (18-65 years) Page 12 of 28 Evidence: ongoing health issues uses a wheelchair and has additional mobility problems. This care plan was clear and offered detailed guidance for the care and support of the individual concerned. Detailed reviews had been undertaken by staff to reflect the changes to this persons health needs and support requirements. The returned Annual Quality Assurance Assessment stated that each individual and key worker were encouraged to be involved in formulating their own Person Centred Plan, in addition the documents are live documents and are reviewed at least 6 monthly or more as required. The plans highlighted likes and dislikes, and the level of support required by that person to engage in as independent a life as possible. Each individual has risk assessments in place these are pertinent to their needs, they are read and signed by all staff to ensure continuity of care and to provide a safe environment. The Annual Quality Assurance Assessment states, when risk assessments are put in place every effort is made to not restrict an individuals choice but to ensure they are safe. It was noted that the people who use the service do not hold any keys to either their bedroom or the front door, it is recommended that the service develop risk assessments and record why people hold keys or not. Care Homes for Adults (18-65 years) Page 13 of 28 Lifestyle These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: Each person is treated as an individual and the care home is responsive to his or her race, culture, religion, age, disability, gender and sexual orientation. They can take part in activities that are appropriate to their age and culture and are part of their local community. The care home supports people to follow personal interests and activities. People are able to keep in touch with family, friends and representatives and the home supports them to have appropriate personal, family and sexual relationships. People are as independent as they can be, lead their chosen lifestyle and have the opportunity to make the most of their abilities. Their dignity and rights are respected in their daily life. People have healthy, well-presented meals and snacks, at a time and place to suit them. People have opportunities to develop their social, emotional, communication and independent living skills. This is because the staff support their personal development. People choose and participate in suitable leisure activities. This is what people staying in this care home experience: Judgement: People using this service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. In General the people who use the service are supported to participate in activities that they choose and that match their interests. The majority of individuals living at Glebe Cottage are supported to access services and facilities in their local community. Individuals are supported to develop and maintain appropriate relationships inside and outside the service. Meals appeared to be well balanced and nutritious. Evidence: The service offers the people who live there a wide range of activities. There is sufficient evidence within individual Person Centred Plans, that activities were tailored to suit individual needs and preferences. A detailed activity plan was available for each individual. Care Homes for Adults (18-65 years) Page 14 of 28 Evidence: The Annual Quality Assurance Assessment provided evidence that all individuals at the home attended a day centre where they participate in activities. There is comprehensive evidence that individuals are asked if they wish to go to specific activities and clear records are maintained if they decline. A sample of daily notes demonstrated that individuals are encouraged to participate in at home activities. However one individual living at the service is not in a position to engage in regular and consistent activities out side the home. The transport used by the service does not have appropriate wheelchair access. It was stated that as a result this person has to depend upon the availability of suitable transport from another source, which is not always guaranteed at the time this person requires. The staff on duty stated that they always attempt to met this individuals needs but this is not always possible. Meal are offered three times a day with snacks in between. Meal times are morning lunch and evening, the meal is offered at regular, although it was stated that this is not rigid, if individuals choose to eat then they do, if not they are offered something later and a log is maintained to ensure that the person is safe. The policy of the home is that if an individual dislikes what is offered an alternative is offered. A sample of individual records demonstrated that the service has sought the assistance of a dietitian, to ensure that one of the people who use the service with a eating disorder nutrition requirements are fully met. Care Homes for Adults (18-65 years) Page 15 of 28 Personal and healthcare support These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People receive personal support from staff in the way they prefer and want. Their physical and emotional health needs are met because the home has procedures in place that staff follow. If people take medicine, they manage it themselves if they can. If they cannot manage their medicine, the care home supports them with it in a safe way. If people are approaching the end of their life, the care home will respect their choices and help them to feel comfortable and secure. They, and people close to them, are reassured that their death will be handled with sensitivity, dignity and respect, and take account of their spiritual and cultural wishes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home has consistent recording and documentation to evidence that the people who use the service health care, wellbeing and welfare are fully supported. The homes medication procedures are robust to ensure the safety and wellbeing of the people living in the home. Evidence: The care plans demonstrated that the personal support needs were well documented and had been agreed with the resident, families, advocate and care professionals. The manager stated that the time for getting up and going to bed in the home is flexible. A review of individual Person Centred Plans indicated that all residents are registered with a local general practitioner (GP). It was documented in the individual Person Centred Plans that the people who use the service have access to a dentist, chiropodist and optician. The staff on duty during the site visit stated that it is the good observation of the staff that helps in the quick identification of the changing needs of the individuals, this enables us to request Care Homes for Adults (18-65 years) Page 16 of 28 Evidence: specialist in-put and assessments. All medication is stored in a locked cupboard and there is documentation to indicate that the medication is reviewed and audited regularly. The homes Medication administration practises were examined. Protocols were in place for service users receiving As required medication. The service however did not record stocks of medication being carried over each month, as a result there was a quantity of medication held be the service that was not reflected on the medication administration record sheet. A review of the individual files of the people who live in the service identified that their wishes regarding ageing and dieing has been discussed and fully documented. Care Homes for Adults (18-65 years) Page 17 of 28 Concerns, complaints and protection These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: If people have concerns with their care, they or people close to them, know how to complain. Their concern is looked into and action taken to put things right. The care home safeguards people from abuse, neglect and self-harm and takes action to follow up any allegations. There are no additional outcomes. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use this service benefit from the knowledge that any complaints or concerns will be listened to. There are robust procedures in place to ensure that individuals are protected from abuse. Evidence: The complaint procedure had been produced in a pictorial format. There is a pictorial poster available to keep people aware of what is abuse and where and how it may occur. Records sampled indicated that there have been no complaints made since the last inspection. The Commission for Social Care Inspection have been informed of one complaint and one adult safeguarding investigation since the previous inspection visit 28/11/2006. There is evidence of both events being effectively completed and the issues raised being resolved. There is a clearly written safeguarding adults procedure and a copy of the local authority safeguarding adults from abuse policy was available. The contact details for the local authority Social Care Team was also displayed. All staff have attended in the Safe guarding adults training. Care Homes for Adults (18-65 years) Page 18 of 28 Environment These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People stay in a safe and well-maintained home that is homely, clean, comfortable, pleasant and hygienic. People stay in a home that has enough space and facilities for them to lead the life they choose and to meet their needs. The home makes sure they have the right specialist equipment that encourages and promotes their independence. Their room feels like their own, it is comfortable and they feel safe when they use it. People have enough privacy when using toilets and bathrooms. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The layout of the home enables the people who use the service to live in a safe environment. The home is clean, pleasant and hygienic throughout. Evidence: A full tour of the building was undertaken as part of the site visit. The building is a large detached propriety sitting in its own private grounds. The service is light and well maintained and offerers the people who live there a pleasant, homely and comfortable home. The communal areas are large and spacious affording very flexible areas to undertake a series of activities. Individuals have their own bedrooms the rooms have been furnished and personalised to a high standard to meet their individual needs with their own furniture and pictures. The carpets throughout the service however were heavily stained and a requirement was made to have them professionally cleaned or replaced. Apart from the carpets the service was very clean and hygienic with adequate hand washing facilities being available throughout the service. Care Homes for Adults (18-65 years) Page 19 of 28 Staffing These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have safe and appropriate support as there are enough competent, qualified staff on duty at all times. They have confidence in the staff at the home because checks have been done to make sure that they are suitable. People’s needs are met and they are supported because staff get the right training, supervision and support they need from their managers. People are supported by an effective staff team who understand and do what is expected of them. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff group are skilled and in sufficient numbers to provide 24 hour care within the home. The systems for recruitment and training are designed to be robust and therefore should protect the people who use the service. Evidence: The service employees sufficient numbers of skilled staff to provide 24-hour care within the home. The staff on duty have a variety of skills and experience that allow them to support the people who live there professionally and with dignity. The deputy manager stated that all staff at the home have undertaken a full induction programme and the records sampled during the site visit confirmed this. During the site visit the deputy manager provided copies of staff duty rotas. The rotas indicated that adequate staffing levels are maintained in the service at all times. Each member of staff has their own training record in place and it was evident that staff have received mandatory training in safeguarding adults, fire, food handling, food hygiene manual handling, health and safety, first aid and managing medication. During Care Homes for Adults (18-65 years) Page 20 of 28 Evidence: the sample of training records it was evident that one member of staff employed in medication administration and handling did not have appropriate training. This was discussed with the deputy manager and it was agreed that this person would not be involved in medication administration until they completed all relevant training. The deputy manager stated that three Support Workers have gained their National Vocational Qualification Level 3 in care, two member of staff have gained their National Vocational Qualification Level 2 and a further two members of staff are in the process of completing National Vocational Qualification level 2. Four employment folders were sampled and contained all the relevant documents as detailed in Schedule 2 of The Care Homes Regulations. All staff has had a criminal record bureau (CRB) check and Protection of Vulnerable Adult (POVA) check prior to starting work in the home. Care Homes for Adults (18-65 years) Page 21 of 28 Conduct and management of the home These are the outcomes that people staying in care homes should experience. They reflect the things that people have said are important to them: People have confidence in the care home because it is run and managed appropriately. People’s opinions are central to how the home develops and reviews their practice, as the home has appropriate ways of making sure they continue to get things right. The environment is safe for people and staff because health and safety practices are carried out. People get the right support from the care home because the manager runs it appropriately, with an open approach that makes them feel valued and respected. They are safeguarded because the home follows clear financial and accounting procedures, keeps records appropriately and makes sure staff understand the way things should be done. This is what people staying in this care home experience: Judgement: People using this service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people who use the service benefit from a well run home and can be confident their views are taken into account. The health, safety and welfare of individual within the home are promoted and there are appropriate risk assessments in place. Evidence: This Key Inspection site visit was brought forward as a result of information received by Commission for Social Care Inspection regarding management issues at Glebe Cottage. The conclusion of this key inspection site visit is that the organisation has managed the areas of concern successfully and appropriately and that the service is now being effectively managed for the benefit of the people who live there. The registered manager has considerable experience and appropriate qualification to manage a care home. The manager was described as being open and approachable to both the staff and the people who live at the service. Care Homes for Adults (18-65 years) Page 22 of 28 Evidence: The manager stated in the completed Annual Quality Assurance Assessment that The home management encompasses the principles of the Social Care Code of conduct, treating people as individuals, respecting and promoting views of individuals, acknowledge rights and choice, respect privacy and dignity, promote equal opportunities and to respect diversity and different cultures. A random review of documents upheld this statement. The service holds monthly meetings for the people who live there and the minutes are documented and action plans drawn up if necessary. Regulation 26 visits take place every month by the Responsible Individual and these are saved in the home and available during inspection. The health and welfare of the people who live and work in the home are seen is a priority in the service and records observed on the day of the inspection were found to be well documented and kept up to date. This included certificates for the testing of Legionella, electrical, fire prevention records, fridge and water temperatures. The Annual Quality Assurance Assessment demonstrated the health and safety checks had taken place also. Care Homes for Adults (18-65 years) Page 23 of 28 Are there any outstanding requirements from the last inspection? Yes £ No R Outstanding statutory requirements These are requirements that were set at the previous inspection, but have still not been met. They say what the registered person had to do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards No. Standard Regulation Requirement Timescale for action Care Homes for Adults (18-65 years) Page 24 of 28 Requirements and recommendations from this inspection: Immediate requirements: These are immediate requirements that were set on the day we visited this care home. The registered person had to meet these within 48 hours. No. Standard Regulation Requirement Timescale for action Statutory requirements These requirements set out what the registered person must do to meet the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The registered person(s) must do this within the timescales we have set. No. Standard Regulation Requirement Timescale for action 1 13 16 The registered provider 12/12/2008 must ensure that the service has appropriate transport, which meets the needs of all residents of the home. It is essential that a person assessed to live at the service has the facilities in place to allow them to participate in community based activities. 2 13 16 The registered provider must ensure that appropriate risk assessments are completed for individuals with physical disabilities accessing the community. The people who use the service must be safeguarded when accessing the community. 12/12/2008 3 20 13 The registered provider must ensure that all medication stored on site are fully documented on the 12/12/2008 Care Homes for Adults (18-65 years) Page 25 of 28 current medication administration record sheets. The people who use the service and the staff must be safeguarded by an appropriate auditing system for all medication retained within the home. 4 30 23 The registered provider must ensure that the carpets are professionally cleaned or if the stains are to heavy the carpets must be replaced. The people who live at the service should be able to live in an environment which is homely, fresh and clean. 5 35 18 The registered provider 13/12/2008 must ensure that appropriate training must be provided to staff for the purpose of medication administration. The people who live in this service must be protected by staff that are trained to support their assessed needs. 12/12/2008 Recommendations These recommendations are taken from the best practice described in the National Minimum Standards and the registered person(s) should consider them as a way of improving their service. No. Refer to Standard Good Practice Recommendations 1 9 It is recommended that the service develop a series of risk assessment giving details why individual who use the service hold or do not hold keys to either their bedrooms or the front door. Care Homes for Adults (18-65 years) Page 26 of 28 2 35 It is recommended that the registered manager undertakes regular audits of the staff training matrixs. Care Homes for Adults (18-65 years) Page 27 of 28 Helpline: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Commission for Social Care Inspection (CSCI). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CSCI copyright, with the title and date of publication of the document specified. Care Homes for Adults (18-65 years) Page 28 of 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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