Inspection on 26/01/06 for Glebe House

This inspection was carried out on 26th January 2006.

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

The inspector found 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 10/10/05

Glebe House 18/05/04

Glebe House 04/02/04

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

CARE HOME ADULTS 18-65 Glebe House Glebe Road Rainham Essex RM13 9LH Lead Inspector Ms Edi O`Farrell Unannounced Inspection 26th January 2006 11:15 Glebe House DS0000015591.V277441.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Glebe House DS0000015591.V277441.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Glebe House DS0000015591.V277441.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Glebe House Address Glebe Road Rainham Essex RM13 9LH 01708 554 711 01708 526 469 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) The Avenues Trust Limited Brian James Smith Care Home 12 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (12), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (12) Glebe House DS0000015591.V277441.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. No service users under 40 years of age. Date of last inspection 10th October 2005 Brief Description of the Service: Glebe House is a care home with nursing care. The home provides accommodation for up to 12 people of either gender with enduring mental health problems. All residents are over the age of 40. The Registered Provider is The Avenues Trust. The home is purpose built and consists of two storeys with lift access to the first floor. All the rooms are single with en-suite. There is a large wellmaintained garden. The home is situated in a residential area of Rainham and is close to local community facilities. The home is easily accessible by public transport and by car via the A13 and M25. The home also has its own transport. All beds in the home are contracted to Havering Primary Care Trust, and there are clear admission criteria defined by the Trust. Glebe House DS0000015591.V277441.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This, unannounced, inspection took place on a weekday, and was the second statutory inspection visit in the inspection programme for 2005/6. Over the course of the two visits all core Standards have now been assessed. All but four standards were assessed at the previous inspection on 10 October 2005, when no Requirements were set. This visit concentrated on checking on the Requirements set at a specialist pharmacist inspection on 25 October 2005, and on Health & Safety. The building was toured, records were examined, and medication administration charts were checked. The findings of the inspection were discussed with the manager. Where Standards were assessed as met at the last inspection, they were not reassessed during this visit, as there have been no changes since October 2005. Some information from that visit has been used in this report. What the service does well: What has improved since the last inspection? What they could do better: Most of the Standards were checked at the previous inspection, when the home was described as ‘operating to a good standard’, and no Requirements needed to be set. Since then a separate visit, made by one of our pharmacists, identified that some changes need to be made to the policies and procedures for administering medication. These changes need to be made so that staff always know what to do, for example, when they need medical advice, but cannot get hold of the GP. The changes have to be made by the Glebe House DS0000015591.V277441.R01.S.doc Version 5.1 Page 6 company who run the home, as they also affect the other homes that they run. The changes have not yet been made, so the company has been given more time to do this. The health and safety of service users and staff is very important, and there are certain checks that have to be carried out on a regular basis. One of these is the checking of electrical appliances, such as kettles and toasters. This is to make sure that they are not faulty, as if they were this could cause an electric shock, or start a fire. These tests have not been carried out when they should have been, so the company has been given a deadline for when they must be. They have also been reminded that these, and other similar tests, must always be done within the correct timescale. 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 DS0000015591.V277441.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glebe House DS0000015591.V277441.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None at this inspection These Standards were not tested on this visit. However evidence from the last inspection was that the home’s Statement of Purpose and Service User Guide are good. They provide service users, prospective service users, and their representatives with all the information they need to make a decision about moving into the home. Service users’ needs are fully assessed prior to admission. Service users have access to specialist services if they need them. EVIDENCE: The above Standards were not specifically tested on this visit, as there were no outstanding Requirements. At the time of the last inspection all of the outcomes were assessed as met. These Standards will be re-tested at a future inspection. Glebe House DS0000015591.V277441.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None at this inspection These Standards were not tested on this visit. However evidence from the last inspection was that there is a clear and consistent care planning system in place, which provides the information staff need to meet the needs of the residents. Residents are supported to make active choices and decisions throughout their daily lives. Areas of risk are assessed, and information about service users is kept confidential. EVIDENCE: The above Standards were not specifically tested on this visit, as there were no outstanding Requirements. At the time of the last inspection all of the outcomes were assessed as met. These Standards will be re-tested at a future inspection. Glebe House DS0000015591.V277441.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None at this inspection These Standards were not tested on this visit. However evidence from the last inspection was that residents are provided with support to maintain their independence. Personal development is encouraged according to their needs and wishes. Service users are engaged in community life, and enjoy a range of leisure activities, and a varied and nutritional diet. EVIDENCE: The above Standards were not specifically tested on this visit, as there were no outstanding Requirements. At the time of the last inspection all of the outcomes were assessed as met. These Standards will be re-tested at a future inspection. Glebe House DS0000015591.V277441.R01.S.doc Version 5.1 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The recording of medication stock has been improved, but the policy and procedure document still needs to be updated. The remaining Standards were not tested on this visit. However evidence from the last inspection was that personal, physical, and emotional healthcare is provided to meet service users’ needs and wishes. Service users’ wishes in the event of death are established and are handled with respect. EVIDENCE: A specialist pharmacist inspection was carried out on 25 October 2005, and several Requirements were set. These fell into two categories; practice issues, that the manager could action, and policy changes, that need action by senior managers of the company. The former have been met, but the latter remain outstanding. This is Requirement 1, which has been brought forward from the pharmacy inspection report, with a new timescale, which must be met. The remaining Standards were not specifically tested on this visit, as there were no outstanding Requirements. At the time of the last inspection all of the outcomes were assessed as met. These Standards will be re-tested at a future inspection. Glebe House DS0000015591.V277441.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None at this inspection These Standards were not tested on this visit. However evidence from the last inspection was that the home provides a satisfactory complaints system, and service users feel that their views are listened to and acted on. Policies, procedures, and staff training are provided that protect service users from abuse. EVIDENCE: The above Standards were not specifically tested on this visit, as there were no outstanding Requirements. At the time of the last inspection all of the outcomes were assessed as met. These Standards will be re-tested at a future inspection. Glebe House DS0000015591.V277441.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None at this inspection These Standards were not tested on this visit. However evidence from the last inspection was that service users benefit from living in a safe, well-maintained, and clean environment. Décor, furnishings and fittings are of a good standard, and provide a homely, and pleasant, environment. EVIDENCE: The above Standards were not specifically tested on this visit, as there were no outstanding Requirements. At the time of the last inspection all of the outcomes were assessed as met. These Standards will be re-tested at a future inspection. Glebe House DS0000015591.V277441.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None at this inspection These Standards were not tested on this visit. However evidence from the last inspection was that staff are aware of their, and other’s, job roles and responsibilities. There is a good match of qualified staff offering consistency within the home. Staff Morale is high resulting in an enthusiastic workforce, which works positively with service users to improve their quality of life. Recruitment processes are robust and ensure the protection of people living at the home. The staff group receive adequate training to meet the needs of residents. Staff receive supervision on a regular basis. EVIDENCE: The above Standards were not specifically tested on this visit, as there were no outstanding Requirements. At the time of the last inspection all of the outcomes were assessed as met. These Standards will be re-tested at a future inspection. Glebe House DS0000015591.V277441.R01.S.doc Version 5.1 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 The health, safety, and welfare, of service users and staff is given a high priority by the home. Electrical appliance checks are out of date, potentially placing service users and staff at risk. The remaining Standards were not tested on this visit. However evidence from the last inspection was that service users benefit from an experienced manager, who recognises their needs, and manages the home well. The manager has a clear vision for the home, which he effectively communicates to service users, relatives, and staff. Service users are safeguarded by the home’s record keeping policies. The systems for service user consultation are good, with evidence that their views are sought, and acted on. Glebe House DS0000015591.V277441.R01.S.doc Version 5.1 Page 16 EVIDENCE: Heath and Safety records were checked, and the building toured. There is a comprehensive in-house, monthly audit, and the companies Health and Safety officer inspects yearly. Environmental Health carries out regular inspections, with one being due in about two months time. The fire alarm is tested on a weekly basis, and is regularly serviced. Fire drills are carried out every four to six months, and the records detail how long evacuation took. All required checks are up to date, except the portable electrical appliance tests. The manager had received a memo from head office stating that these would be delayed till after 1 April 06, due to the contractor being ill. This is unacceptable, as it could result in faulty equipment being used by staff and service users. The company should have made alternative arrangements, and must do so if a similar situation occurs in the future. This is Requirement 2. The tests must be carried out within the timescale set for this Requirement. The remaining Standards were not specifically tested on this visit, as there were no outstanding Requirements. At the time of the last inspection all of the outcomes were assessed as met. These Standards will be re-tested at a future inspection. Glebe House DS0000015591.V277441.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X X X X 2 X Glebe House DS0000015591.V277441.R01.S.doc Version 5.1 Page 18 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard 20 Regulation 13 (2) Requirement Timescale for action 31/03/06 2 42 The Responsible Individual must ensure that the corporate policy/procedure used by the home for medication administration is amended, so as to comply with all Requirements set out in the Commission’s letter of 8 November 2005. Previous timescale of 25/01/06 not met. 12,13(4)&23(2)c The Responsible Individual must ensure that all Health & Safety checks are always carried out in the correct timescale. Where contractual arrangements do not allow for this, then alternative arrangements must be made. Portable electrical appliance tests must be carried out. 14/04/06 Glebe House DS0000015591.V277441.R01.S.doc Version 5.1 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Glebe House DS0000015591.V277441.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU 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 DS0000015591.V277441.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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