Inspection on 10/01/06 for Glebe House

This inspection was carried out on 10th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Glebe House 05/06/09

Glebe House 03/12/08

Glebe House 05/02/07

Glebe House 27/07/05

Glebe House 15/02/05

Glebe House 28/07/04

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

CARE HOMES FOR OLDER PEOPLE Glebe House 5 Sundays Hill Lower Almondsbury South Glos BS32 4DS Lead Inspector Melanie Edwards Unannounced Inspection 10th January 2006 09:30 X10015.doc Version 1.40 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 House DS0000020277.V273687.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 Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Glebe House DS0000020277.V273687.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Glebe House Address 5 Sundays Hill Lower Almondsbury South Glos BS32 4DS 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) 01454 616116 01454 616118 janehand@glebehouse75.fsnet.co.uk www.bristolcarehomes.co.uk Avonedge Limited Ms Jacqueline Brown Care Home 53 Category(ies) of Old age, not falling within any other category registration, with number (53), Physical disability (5) of places Glebe House DS0000020277.V273687.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. May accommodate up to 53 persons aged 65 and over, who are receiving nursing care. Of the total 53 persons, the home may accommodate up to 3 persons (who must be 65 years or over) requiring personal care only. Staffing notice dated 19/3/1998 applies Manager must be a RN on parts 1 or 12 of the NMC register. May accommodate up to 5 persons between 50 and 65 years of age. Date of last inspection 27th July 2005 Brief Description of the Service: Glebe House was first registered as a Care Home providing nursing in 1996. It is one of three homes in the same ownership. The other homes are Field House in Horfield and Beech House in Thornbury. Glebe House is in part a converted older building with a purpose built annexe. The home is situated in wooded grounds that are well maintained and accessible to residents and visitors. Accommodation is of a high standard and is arranged on three floors providing forty one single bedrooms and six rooms for double occupancy. The majority of rooms have en-suite facilities and others have a washbasin and a toilet within a short walking distance and there are two large lounge areas and two smaller ones for quiet occupation if wished. There is access to all parts of the building provided by a passenger lift. Glebe House DS0000020277.V273687.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Twenty of the forty-seven residents currently living at the Home were consulted to find out their views of the service. A number of visitors including several relatives were also consulted. The registered manager, the administration manager, two registered nurses and a chef, were also consulted about their roles and responsibilities, their training needs, and how they assist and support residents and carry out their duties. Staff were observed assisting residents with their needs. A range of records relating to the day-to-day running and management of the Home were inspected. A selection of resident’s care records and care plans were also reviewed. The majority of the environment was seen with the only areas not viewed being a small number of bedrooms. What the service does well: What has improved since the last inspection? What they could do better: It would be beneficial for all residents if all care plans demonstrated how staff are meeting their needs. Residents would benefit if a suitable system of storing accident records was in place, to ensure records are easily auditable and causes of resident’s accident can be monitored and reviewed. The health and safety systems in the kitchen would be further enhanced if cleaning products were stored away from food preparation areas. Glebe House DS0000020277.V273687.R01.S.doc Version 5.1 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 House DS0000020277.V273687.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glebe House DS0000020277.V273687.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4 Residents’ needs are assessed and are met by the Home. EVIDENCE: There were many comments of satisfaction expressed by residents about the care and overall service that the Home provides. Examples of comments made by residents included, ‘life here is very nice the staff are very good they are very considerate, and I’m very critical’, also ‘everyone of the staff has been good to me, you feel like you’re an individual’, and, ‘I think its a wonderful place everybody does everything well’. These comments were reflective of the majority of comments made by residents. There were several comments made by residents around how busy staff seem to be on occasions and they said this meant call bells taking a longer time to be answered. However Ms. Brown said there is a call bell monitoring system to monitor the time calls bells take to be answered, and she regularly reviews waiting times. Five residents care records were also reviewed to find out how residents care needs are assessed. The majority of assessment records were informative and Glebe House DS0000020277.V273687.R01.S.doc Version 5.1 Page 9 showed the Home had consulted with residents and representatives to ascertain the range of physical, mental and social needs the person had. One resident’s assessment record and accompanying care plan required completion, so that an up to date risk assessment was in place to maintain their safety and to assist and support staff. This was discussed with Ms. Brown at the inspection and she confirmed this was going to be completed as a priority. There was an assessment of residents skin vulnerability, and their risk of developing pressure sores had also been completed. There was also a moving and handling assessment in place for each resident to assess how best to support residents with reduced mobility. The assessments had been reviewed and updated on a regular basis. The assessments demonstrated how the Home intends to meet each residents needs. A physiotherapy assessment is also carried out, (funded by the Home) for all new residents. Glebe House DS0000020277.V273687.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Residents’ care needs are met; and generally care plans support how to meet the needs, and they are treated with respect and sensitivity. Also the system for handling storage and administration and disposal of medication is safe. EVIDENCE: Five resident’s care plans were inspected to monitor how residents are supported to meet their health care needs. Care plans addressed the physical and psychological health care needs of the person. There was detailed information stating how best to assist the residents with their needs. Care plans had been reviewed and updated on a regular basis by registered nurses, demonstrating that residents’ health care needs were being monitored and kept under review. However one residents’ care plan was incomplete and required a care plan for meeting their psychological needs and to be completed to ensure the residents and staff safety could be best maintained when they are assisting the person. As already referred to in the report there were moving and handling assessments completed for each resident to assist staff in safe working practices. There was an assessment for each resident around their vulnerability Glebe House DS0000020277.V273687.R01.S.doc Version 5.1 Page 11 to pressure sores, and risk from falls. The completion of such assessments help demonstrate residents range of needs have been identified and addressed. Many residents spoke very positively about how they feel staff help them to meet their needs examples of comments made by residents included, `the staff are very good they help you out’, `it’s an excellent service’, and, `I think its an excellent service they are so patient and caring’. Medication procedures and practices were also inspected with the assistance of one of the senior registered nurses. The Home is operating a safe system of administration, and disposal of resident’s medication. Glebe House DS0000020277.V273687.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 The Home is meeting residents’, social and recreational interests, and they are supported to maintain contact with their families, friends and community, also a varied and well balanced diet is provided. EVIDENCE: A new full time activities organiser has just been employed, due to the departure of the previous organiser. The new activities organiser is currently on leave, and in their absence a group of residents and relatives (supported by staff) have started their own activities sessions. This demonstrates residents feel empowered living at the Home. On the afternoon of the inspection there was a residents group playing scrabble, cards, and other activities. There are regular exercise groups, as well as trips out into the community, in the Home’s minibus. There is a hairdresser and manicurist who works part time, residents were having their hair attended to during the inspection, which they looked to be enjoying. There is also a mobile shop, which offers residents the opportunity to purchase a range of day-to-day items such as toiletries, and chocolates. The inspector was also able to meet a number of visitors who said that they are able to visit at any time they so wish. Glebe House DS0000020277.V273687.R01.S.doc Version 5.1 Page 13 The menu of resident’s meal choices was inspected and the meal options were nutritionally well balanced. Residents were asked their views of the quality and variety of meals provided at the Home, and many residents said they thought the food was satisfactory and very good. The inspector ate lunch with a group of residents. The meal choices were lamb chops cooked in red wine, or freshly made cheese and tomato quiche, accompanied by creamed leeks, cabbage, and creamed potato, followed by a desert of freshly made apple pie with custard, or fresh fruits, or ice cream. The meals were very tasty and well presented. At lunchtime the tables were laid with linen tablecloths and flower table settings, helping to make the lunchtime meal a relaxed and social experience for residents Every resident who the inspector met commented very positively about the quality, and variety of food that is offered. Residents said that both chefs regularly walk around the Home and ask them what food they like and what they think of the menu. Glebe House DS0000020277.V273687.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 There are systems and procedures in place to help protect residents from abuse or harm and to ensure complaints can be taken seriously and acted upon. EVIDENCE: A copy of the complaints procedure is on display on a wall in a well-frequented part of the Home. The procedure includes the contact details for who runs the Home, as well as the area office of the Commission for Social Care Inspection, if someone is not happy with the outcome of a complaint investigated by the Home. Also, all residents are provided with a copy of the complaints procedure and the contact details of the registered provider of the Home. The complaints record book was viewed to see how complaints are responded to. There had been no new complaints received since prior to the last inspection. The record included details of how complaints were to be dealt with. There is a policy in place relating to the issue of protection of vulnerable adults from abuse. Since the last inspection all staff have now been provided with training by Ms. Brown to ensure they are up to date in their understanding of the principle of the protection of vulnerable adults from abuse. Glebe House DS0000020277.V273687.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19-26 The Home is safe well maintained, and suitable for meeting the needs of residents. EVIDENCE: The Home is set in landscaped gardens in a quiet area, next door to a church and village pub. The property is located a short car ride away from the village of Thornbury, where there are shops, services and amenities. The Home is also a short drive away from nearby motorway access, and a large shopping mall. The building is an older spacious converted property, built over three floors, with a range of suitable adaptations in place throughout the Home, to assist people who may have limited mobility. There is lift access to each floor of the Home. The inspector walked around the inside of the Home, and viewed all of the communal living areas and the majority of bedrooms. Rooms are generally spacious and fixtures and fittings are of a very high standard. This helps to enhance the quality of life for residents who live at the Home. Glebe House DS0000020277.V273687.R01.S.doc Version 5.1 Page 16 The environment was very clean, tidy and well maintained. All residents are provided with their own television by the Home, as well as their own telephone and external line, they are also informed of the manager’s office extension number if they wish to contact her. A full time maintenance worker is employed to address general maintenance and they were observed carrying out their duties during the inspection. Service records were seen for the lift, the fire fighting equipment, and the hoists and manual handling aids. The records showed that external contractors had serviced the lift, and equipment in the last twelve months. Glebe House DS0000020277.V273687.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,30 The staff are competent and well trained to meet residents needs. EVIDENCE: The staff on duty said that there are regular training and development opportunities provided by the Home. Two registered nurses told the inspector about recent clinical training and update sessions that they had attended. The training records of staff were reviewed and demonstrated staff attended training and updating in subjects that are relevant to the Home and to the needs of residents. The inspector spent some time sitting in the communal areas, and with residents in bedrooms observing staff carrying out their duties. Staff assisted residents in a calm, very courteous way, and knocked on bedroom doors before entering rooms. Staff were observed communicating among each other, and were working well as a team. In discussion staff conveyed a good understanding and sensitivity to the needs of the residents in their care. As already referred to in the report all of the residents the inspector met spoke positively about the staff, and their `kindness’ and the way that staff support them to meet their needs. Glebe House DS0000020277.V273687.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,37,38 The Home is well run, with residents’ views actively taken into account by management , and the health and safety systems and procedures in place generally help protect the health and safety of residents, staff and visitors. EVIDENCE: Glebe House DS0000020277.V273687.R01.S.doc Version 5.1 Page 19 Generally records inspected were well maintained, up to date and in order. However residents’ accident records were not being audited or filed in a methodical or easily auditable way. It would be beneficial if the accident records were stored in this manner so that resident’s accidents can be more easily monitored and reviewed. Other records have been referred to elsewhere in this report, and demonstrate well-organised management in the Home. Ms Brown is supported in her role by a full time administration manager who overseas non-clinical management areas of the Home There are regular residents and relatives meetings held in the Home. A number of residents told the inspector that they attend the meetings and that Ms Brown and the administration manager will readily listen to their views and any concerns. As also previously referred to in the report each resident’s room has a telephone line installed by the Home, and residents are made aware of the extension number to Ms Brown’s office if they wish to speak to her. Also, as previously referred to catering staff walk around the Home on a daily basis to talk to residents and seek their views of the meals that are being provided. The kitchen was inspected to see if food is stored and prepared in a safe environment. The kitchen was clean, tidy, and organised. However, there were kitchen cleaning materials stored in an area of the kitchen in close proximity to a food preparation area. It was recommended that the materials be moved to a safer place. There are also health and safety procedures in place for staff and residents to follow to promote health and safety in the Home. The fire logbook record showed that the range of required fire safety checks were being carried out and were up to date helping to ensure the safety of people inside the building is maintained. Since the last inspection the Home has made sure that monthly checks of the fire fighting equipment are being carried out and an up to date record was maintained. Glebe House DS0000020277.V273687.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 4 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 4 3 3 3 4 3 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 4 X X X X 3 3 Glebe House DS0000020277.V273687.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? no 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 OP7 Regulation 15(1) Requirement The residents care plan identified at the inspection must be complete, and include an up to date risk assessment. Timescale for action 10/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 Refer to Standard OP38 OP38 Good Practice Recommendations Ensure residents’ accident records are filed methodically. Kitchen cleaning materials should be stored away from food preparation areas. Glebe House DS0000020277.V273687.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Bristol North LO 300 Aztec West Almondsbury South Glos BS32 4RG 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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