CARE HOMES FOR OLDER PEOPLE
Glebe House 8 Mill Street Kidlington Oxfordshire OX5 2EF Lead Inspector
Carole Moore Unannounced Inspection 14th December 2005 10:00 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 DS0000013155.V272350.R02.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 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 DS0000013155.V272350.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Glebe House Address 8 Mill Street Kidlington Oxfordshire OX5 2EF 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) 01865 841859 01865 841194 The Orders Of St John Care Trust Elaine Ratcliffe Care Home 40 Category(ies) of Past or present alcohol dependence over 65 registration, with number years of age (3), Dementia - over 65 years of of places age (18), Learning disability over 65 years of age (3), Old age, not falling within any other category (40), Physical disability over 65 years of age (10) Glebe House DS0000013155.V272350.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The total number of persons that may be accommodated at any one time must not exceed 40. 26th May 2005 Date of last inspection Brief Description of the Service: Glebe House is a purpose built care home providing personal care and accommodation for 40 older people. The single storey building provides single rooms with shared bathroom facilities and the care home is divided into five wings. Each wing has a small lounge/dining area and there is also a large communal dining area. The home is set in its own grounds within a quiet residential area of Kidlington, although local facilities are within walking distance, and the home has transport available to enable the residents to access the wider community. The home is very much part of life in the local community of Kidlington, and the majority of residents have family or other links with the area. Glebe House DS0000013155.V272350.R02.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 that took place on the morning of the 14th December 2005. The inspector was made to feel very welcome by both staff and residents and was very appreciative of the cooperation of all the staff that were on duty that day. Most of the key standards had been assessed and met at the announced inspection in May 2005. However Standard 7 in relation to the care records was reassessed at this inspection, along with those standards that had not as yet been assessed. The inspector toured the building looking at all of the communal areas of the home as well as individual bedrooms with the permission of the residents. Most of the morning was spent talking to residents and some time was spent with staff, the office administrator and the registered manager. The registered manager spent time talking about the changes that have been made since the last inspection and about her plans for further improvements in the future. Residents’ care records were reassessed. There was a festive feel within the home and the home was decorated in readiness for the Christmas celebrations. The residents made positive comments to the inspector:” Its so Homely,” “Never go hungry”.” Rooms just right” “Staff are so good”. What the service does well:
The home is well managed and the manager is keen to raise morale within the staff team and has worked hard to achieve this by having regular meetings with staff, residents and relatives. Residents spoken to during the inspection visit were very positive about their overall care. They spoke highly of the home, the catering arrangements, the activities, staff and the manager. The activities programme continues to improve and works well for all residents. Glebe House DS0000013155.V272350.R02.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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 House DS0000013155.V272350.R02.S.doc Version 5.0 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 DS0000013155.V272350.R02.S.doc Version 5.0 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): These key standards were assessed at the announced inspection in May 2005. EVIDENCE: Glebe House DS0000013155.V272350.R02.S.doc Version 5.0 Page 9 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 The home meets the health, personal and social care needs of their residents. EVIDENCE: Three residents’ care notes were examined and it was apparent that there had been much improvement in the overall record keeping and writing in the care notes. Reviews are now being carried out as appropriate and being documented. There has been training in the writing of care plans and carers are much clearer on what to write in the daily care notes. There is also a monitoring of the written daily records by the seniors to ensure a consistent approach. In the records seen there was little evidence of the emotional needs of the residents and this could be an area for further improvement. However it was pleasing to see what steps have been put in place to change current working practices and that the manager sees this as an area of ongoing monitoring and further improvement. Glebe House DS0000013155.V272350.R02.S.doc Version 5.0 Page 10 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): 13 & 14. Residents are encouraged to remain independent and are encouraged to maintain contact with their family and friends. EVIDENCE: There was a variety of visitors to the home on the day of the inspection and residents confirmed that their visitors were always made to feel very welcome. Residents are also encouraged to be active in the community and the residents were being taken out to participate in a Christmas activity that afternoon. Residents also confirmed that they were able to exercise choice over how they spent their day. Some residents were happy to spend time in their rooms and others chose to sit with other residents in the communal areas of the home. The residents were all looking forward to the Christmas celebrations and felt that they had plenty to do if they wished. The notice board was full of events leading up to Christmas. That morning a church service was taking place for those residents who wished to take part. Glebe House DS0000013155.V272350.R02.S.doc Version 5.0 Page 11 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): The key standards were assessed at the announced inspection in May 2005. EVIDENCE: Glebe House DS0000013155.V272350.R02.S.doc Version 5.0 Page 12 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 clean, safe and well maintained but bedroom doors must not be wedged open. EVIDENCE: The environment was assessed at the last inspection but there has been some redecoration and refurbishment, which has further improved the outlook of the home. The inspector looked around the home and visited residents in their rooms and all expressed satisfaction with the standard of cleanliness and decoration. One bedroom door was wedged open with a box of tissues and this practice must cease. A requirement has been made in relation to this issue of health and safety. Glebe House DS0000013155.V272350.R02.S.doc Version 5.0 Page 13 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): These key standards were assessed at the announced inspection in May 2005. There were sufficient staff on duty on the day of the inspection to meet the overall needs of residents. EVIDENCE: Glebe House DS0000013155.V272350.R02.S.doc Version 5.0 Page 14 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): 31,35 & 38. The home is well managed and residents’ financial interests are safeguarded. The health and safety of residents are a high priority for Glebe House but residents’ doors must not be wedged open. EVIDENCE: The registered manager is keen to improve all systems within the home and to ensure that staff work together as a team to provide the best possible care for the residents. The home administrator manages the residents’ petty cash and she is responsible for all the receipts and records of all transactions. The inspector had sight of the computerised programme of accounts and had access to individual’s records and it was clear that records are well maintained. Glebe House DS0000013155.V272350.R02.S.doc Version 5.0 Page 15 There is also a property file for those residents who wish their valuables to be kept safe. The health and safety of residents was assessed and met at the announced inspection in May 2005, but care needs to be taken that residents’ doors are not wedged open. If residents wish to have their doors open, a suitable device needs to be installed to protect their overall health and safety and one that meets with the fire officer’s approval. Glebe House DS0000013155.V272350.R02.S.doc Version 5.0 Page 16 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 2 Glebe House DS0000013155.V272350.R02.S.doc Version 5.0 Page 17 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 OP38 Regulation 23 Requirement The home must ensure that bedroom doors are not wedged open. A suitable device must be installed to protect the health and safety of residents. Timescale for action 01/02/06 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. Refer to Standard OP7 Good Practice Recommendations It is recommended that further monitoring take place to ensure consistency and quality of care records. Glebe House DS0000013155.V272350.R02.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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