Inspection on 25/10/05 for Glebe House

This inspection was carried out on 25th October 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Glebe House 22/09/08

Glebe House 23/06/08

Glebe House 28/09/07

Glebe House 10/04/07

Glebe House 03/10/06

Glebe House 23/11/04

Glebe House 19/07/04

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

CARE HOMES FOR OLDER PEOPLE Glebe House Glebe House The Broadway Laleham Middlesex TW17 0DU Lead Inspector Marianne Barham Unannounced Inspection 25th October 2005 10:50 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 DS0000049209.V261270.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 DS0000049209.V261270.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Glebe House Address Glebe House The Broadway Laleham Middlesex TW17 0DU 01784 465273 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) Dr Ajit Prasad Mrs Nishi Prasad To be confirmed Care Home 24 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (24), of places Sensory Impairment over 65 years of age (2) Glebe House DS0000049209.V261270.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Of the 24 residents accommodated, up to 3 may fall within the category of DE(E) The age/ age range of the persons to be accommodated will be OVER 65 YEARS OF AGE Of the 24 (twenty four) residents accommodated 2 (two) may have a sensory impairment. 28th June 2005 Date of last inspection Brief Description of the Service: Glebe house is a large detached property located in the village of Laleham, Middlesex. The home is owned by Surrey rest Homes Ltd and provides accommodation and care for up to 24 older people, 3 of whom may have dementia and two of whom may have a sensory impairment. The accommodation is arranged over three floors, with a passenger lift and a stair lift available to access the first floor. The second floor is reached by stairs. There are 22 single occupancy rooms, 19 of which have en-suite facilities, and a double room which is currently being used as a single room. Those rooms without en-suite facilities are located close to toilets and/or bathrooms. The communal areas include a large lounge leading onto a conservatory, a dining room and another conservatory at the far end of the building. There is a large, enclosed, well maintained garden with a patio to the rear of the property and parking for several cars to the front. The home has the use of a mini-bus to access activities and the local and wider community. Glebe House DS0000049209.V261270.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out at 10.50am by Marianne Barham, lead inspector for the service. The inspection was undertaken in response to a complaint made against the service and took place over a period of six hours. This was the second inspection in the Commission for Social Care Inspection (CSCI) year April 2005 to March 2006. The manager, Hannah Tapsell (not yet registered with CSCI) and the service manager, Kalem Choda were present during this inspection. A total of fifteen service users, one visiting relative and four members of staff were spoken with during this inspection and records relating to the management of the home and care of service users were examined. What the service does well: What has improved since the last inspection? The home has replaced carpets in some of the bedrooms, meeting a requirement made at the last inspection on 28th June 2005. The home has made changes to the management structure providing more support to the home manager. Contracts stating the terms and conditions of residence in the home are now signed by, the service user or a representative, meeting a recommendation made at the last inspection. Glebe House DS0000049209.V261270.R01.S.doc Version 5.0 Page 6 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 DS0000049209.V261270.R01.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 DS0000049209.V261270.R01.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): 1 Prospective service users do have enough information to make an informed choice about where they live, however the home does not supply a copy of the service users guide until they have moved into the home. EVIDENCE: The home has a combined statement of purpose and service users guide. This is comprehensive and gives clear information on the facilities and services offered by the home. The guide needs to be updated to reflect the change in manager and management structure in the home and a requirement has been made to address this. Prospective service users and their families are able to view the service users guide when they look around the home, with each service user being given a copy of the guide once they are admitted to the home. It was discussed with the manager that this does not give prospective service users time to read through all the information before making a choice. A recommendation has been made to supply prospective service users with a copy of the guide prior to moving into the home. Glebe House DS0000049209.V261270.R01.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): 8 and 9 The home meets the health needs of service users, however a risk assessment for falls needs to be introduced for one service user. The policies and procedures for dealing with medicines protect the service users, however the temperature of the medicines fridge needs to be taken and recorded. EVIDENCE: All service users are registered with a local GP practice and specialist healthcare professionals are accessed through these. The district nurses attached to the GP practices visit the home regularly as needed. A domiciliary NHS dentist and NHS optician visit the home every six months or as needed and a private chiropodist visits every six weeks. All service users have their health needs assessed and reviewed regularly and have risk assessments undertaken for daily activities of living. One service user who is prone to falls has a risk assessment in place for using the stairs but not for falls in general. A recommendation has been made to address this. The home has a policy and procedure in place for dealing with medicines that is in line with the guidance issued by the Royal Pharmaceutical Society. The Glebe House DS0000049209.V261270.R01.S.doc Version 5.0 Page 10 dispensing pharmacy to the home carries out medication audits every six months and provides guidance and training to the staff. All medications were seen to be stored securely and appropriately, however no records are kept of the temperature for the medication fridge and no thermometer was available to take the temperature. A requirement has been made to address this. Medication administration charts are maintained accurately and profiles detailing the medication, indications and possible side effects are in place for each service user. Glebe House DS0000049209.V261270.R01.S.doc Version 5.0 Page 11 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): 15 Service users receive a wholesome, balanced diet that reflects their individual needs and preferences, however the kitchen requires refurbishments/repairs in order to ensure the safety of the food prepared. EVIDENCE: The home has four weekly menus that offer a good variety of balanced meals. The menus are produced in consultation with service users and are reviewed according to the season. The home employs a cook and she is currently updating the menus to provide more choice to the service users. Service users spoken with said that they enjoyed the food at the home and that it is always nice. Members of staff were observed to support service users to eat their meals in a caring and dignified manner, allowing plenty of time for service users to finish their meals. The kitchen was viewed and food storage areas seen to be well stocked with a range of fresh produce and groceries. The kitchen was generally clean and well equipped, however the wall tiles are broken in some places and do not meet the work surfaces, posing a risk of contamination. A requirement has been made to address this. Glebe House DS0000049209.V261270.R01.S.doc Version 5.0 Page 12 It was also disappointing to see that the floor cover by the external door of the kitchen had not been repaired or replaced as required at the last inspection on 28th June 2005. A further requirement has been made for this to be done. Glebe House DS0000049209.V261270.R01.S.doc Version 5.0 Page 13 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 and 18 Service users are protected from abuse and they and their families can be sure that their complaints will be listened to and acted upon by the home. EVIDENCE: The home has a complaints procedure that has been placed in the service users guide. This document gives information to service users and their families on how to make a complaint in the home and also to the commission. Records are maintained of complaints and actions taken by the home to resolve them. The home has received one complaint since the last inspection on 28th June 2005, and appropriate responses and actions concerning this have been recorded. The home has a policy and procedure on the prevention of abuse and a whistle blowing policy. Staff members are made aware of these at induction and through training sessions carried out at the home by an external trainer. The last training session was in August 2005. The home also has a copy of the Surrey Multi-Agency Procedures and all staff members have signed to show they have read and understood the procedures. Members of staff spoken with said that they had received training on adult protection and were able to demonstrate an awareness of their responsibilities in this area. Glebe House DS0000049209.V261270.R01.S.doc Version 5.0 Page 14 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, 21 and 26 The home is generally safe and well maintained however some areas of the home require attention. There are sufficient toilet and washing facilities, however there are insufficient bathing facilities. The home is clean and tidy throughout. EVIDENCE: The home is clean, comfortably furnished and pleasantly decorated throughout. At the last inspection on 28th June 2005 a requirement was made that an extra bath/shower room be provided by 28th December 2005, however works have not yet commenced. This was discussed with the manager and service manager Kalem Choda and the inspector has asked to be informed when the works commence. Service users bedrooms are pleasantly decorated and are personalised with their own belongings. The bedding provided was seen to be clean, comfortable and appropriate to their needs. Service users spoken with said they were happy with their rooms and find them comfortable and suitable for their needs. Glebe House DS0000049209.V261270.R01.S.doc Version 5.0 Page 15 Three chairs in the small conservatory require repairing or replacing, the manager removed them from the conservatory in the presence of the inspector, therefore no requirement has been made. The door sensors on the first floor level of the passenger lift are faulty causing the doors to close before the person is able to fully leave the lift. A requirement has been made to address this. The doormat by the main door to the home is at a lower level than the carpet posing a risk of service users and staff members tripping. This was seen to be made level with the carpet during this inspection therefore a requirement has not been made. As stated previously in this report some areas of the kitchen are in need of refurbishment or repair. Glebe House DS0000049209.V261270.R01.S.doc Version 5.0 Page 16 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): 29 and 30 Service users are supported and protected by the home’s recruitment policy and practices and staff are trained and competent to do their jobs. EVIDENCE: The home has a policy and procedure in place for the recruitment of new members of staff. Recruitment files were examined for several members of staff. These were found to be in good order with all necessary checks and documentation in place for each member of staff. The manager is currently in the process of updating the staff training records to a more individualised format. Members of staff spoken with confirmed that receive mandatory and developmental training and also regular formal supervision sessions. There was no programme of planned training available during the inspection. The service manager Kalem Choda stated that this is currently being produced and the inspector has asked that a copy be forwarded to the commission at the earliest opportunity. Glebe House DS0000049209.V261270.R01.S.doc Version 5.0 Page 17 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): 33 and 38 The health, welfare and safety of service users and staff is generally promoted and protected by the home, however some parts of the home require attention. The home is run in the best interests of the service users. EVIDENCE: The home has a quality assurance plan in place, comprising of a quality audit carried out annually that covers management, staffing, training, environment and care of service users. Feedback forms are sent to service users and their relatives every six months with responses recorded and acted upon as required. The home also holds meetings for service users quarterly with records kept of issues or concerns raised and any actions taken to address them. Service users spoken with said that they are able to air their views and that members of staff listened to them. Glebe House DS0000049209.V261270.R01.S.doc Version 5.0 Page 18 The home carries out regular health and safety audits and related risk assessments are in place. The staffs training programme incorporates training in all aspects of health and safety and equipment and appliances are tested and maintained regularly. Surrey Care Homes Ltd employ a maintenance worker between the three care homes in the group who is responsible for routine maintenance and repairs in the home. As stated previously in this report there are areas in the kitchen in need of repair and also the door closure sensors on the passenger lift are faulty. Requirements have been made to address these. Glebe House DS0000049209.V261270.R01.S.doc Version 5.0 Page 19 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 3 X X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 1 X X X X 3 STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X 2 Glebe House DS0000049209.V261270.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? YES 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 9 Regulation 13 (2) Requirement The registered person must ensure that the temperature of the medication fridge is taken and recorded. The floor cover by the external door in the kitchen must be repaired or replaced. The broken tiles in the kitchen must be replaced and the exposed bare walls tiled and sealant applied around work surfaces to prevent build up of food debris behind and under the units. The door sensors on the passenger lift must be repaired and a notice placed on the lift informing users that the sensors are faulty in the meantime. The registered person must install a further bath/shower room. Timescale for action 08/11/05 2 3 15/19/38 15/19/38 23 (2) (b) 23 (2) (b) 01/11/05 28/11/05 4 19/38 23 (2) (c) 01/11/05 5 21 23 (2) (j) 28/12/05 Glebe House DS0000049209.V261270.R01.S.doc Version 5.0 Page 21 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 1 Good Practice Recommendations It is strongly recommended that prospective service users and their families are supplied with a copy of the homes service users guide prior to moving into the home so that they may make an informed choice about whether to move into the home. It is strongly recommended that a falls risk assessment is carried out for a named service user who is prone to falling. 2 8 Glebe House DS0000049209.V261270.R01.S.doc Version 5.0 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. Extracts may not be used or reproduced without the express permission of CSCI Glebe House DS0000049209.V261270.R01.S.doc Version 5.0 Page 23 - 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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