Inspection on 27/07/05 for Glebe House

This inspection was carried out on 27th July 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 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 10/01/06

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 Announced 27-28 July 2005 09:30 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 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 D56 D05 S20277 Glebe House V229642 27280705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Glebe House Address 5 Sundays Hill Lower Almondsbury South Glos BS32 4DS 01454 616116 01454 616118 www.bristolcarehomes.co.uk Avonedge Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ms Jacqueline Brown Care Home with Nursing for Older People 53 Category(ies) of OP Old age for 53 registration, with number PD Physical disability for 5 of places Glebe House D56 D05 S20277 Glebe House V229642 27280705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 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 15 February 2005 Unannounced 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 pleasantly 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. The home prides itself in providing care to a high standard for residents and support to their families and friends. Glebe House D56 D05 S20277 Glebe House V229642 27280705 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Eighteen residents were consulted to find out their views of the Home and the service provided. The inspector also spoke to the registered manager, one registered nurse three care assistants, and one of the chefs about their roles and responsibilities, training needs, and how they assist and support residents. There were a number of pre-inspection feedback forms sent to the Commission for Social Care Inspection area office, from residents and from one of the GPs. who takes responsibility for residents medical care at the Home. 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 range of resident’s care records and care plans were also reviewed. The majority of the environment was seen; the only areas not viewed were a small number of resident’s bedrooms. The inspection took place over two consecutive days. What the service does well: What has improved since the last inspection? What they could do better: The safety of residents, staff and visitors would be further enhanced if the Home were to ensure monthly checks of fire fighting equipment were carried out, and a record of these checks maintained. There would be an additional safeguard to the protection of residents, if all staff were able to attend up to date training to increase their overall understanding of issues around the protection of vulnerable adults from abuse. Glebe House D56 D05 S20277 Glebe House V229642 27280705 Stage 4.doc Version 1.30 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 D56 D05 S20277 Glebe House V229642 27280705 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Glebe House D56 D05 S20277 Glebe House V229642 27280705 Stage 4.doc Version 1.30 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 standard(s) 1,3,4. Prospective residents and their representatives are provided with the necessary information to assist them to make an informed choice about the Home, and residents assessed needs are met. EVIDENCE: Five residents care records were reviewed to ascertain how residents care needs are assessed. The assessment records were informative, and showed the Home had consulted with residents and their representatives to ascertain the range of physical, mental and social needs the person had. 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. A copy of the statement of purpose and service users guide were looked at. These documents should inform residents of the fees, and the services the Home provides. Both documents contained a range of detailed and helpful information about life in the Home, the staffing structures and levels, and the service that is provided. Glebe House D56 D05 S20277 Glebe House V229642 27280705 Stage 4.doc Version 1.30 Page 9 There were many comments of satisfaction expressed by residents about the care they receive. Examples of comments made included, ‘they seem to cater for your needs’, ‘the staff are wonderful you couldn’t find a better group’, and, ‘the staff are caring and loving’. These comments were reflective of the majority of comments made by residents. Several residents commented on how busy staff often seem to be, however they also said staff were kind and caring. Glebe House D56 D05 S20277 Glebe House V229642 27280705 Stage 4.doc Version 1.30 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 standard(s) 7,8,9,10 Residents’ nursing care needs are met, and there is a safe system for dealing with residents’ medication. 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. Medication procedures and practices were also inspected, and demonstrated the Home operates a safe system of administration, and disposal of resident’s medication. There are three rooms used to store residents’ medication, one of the rooms has a thermometer in it and the temperature is monitored to ensure it does not exceed the safe guideline maximum level. The two smaller `cupboard’ style rooms do not yet have thermometers in them. The registered manager said she would be purchasing the required thermometers as a priority. Glebe House D56 D05 S20277 Glebe House V229642 27280705 Stage 4.doc Version 1.30 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 standard(s) 12,13,15 Resident’s, social and recreational interests are met, and a well balanced diet is provided. EVIDENCE: The Home employs a full time activities organiser, and an activities assistant. There is also a hairdresser and manicurist who works part time in the Home. A small group of female residents were being given manicures during the inspection, which they were clearly enjoying. Several residents said they enjoyed the range of arts and crafts, games and quizzes that take place. There are also regular exercise groups, as well as trips out into the community, in the Home’s own minibus. While meeting residents, the inspector was also able to meet a number of relatives who said that they are able to visit at any time they so wish. Glebe House D56 D05 S20277 Glebe House V229642 27280705 Stage 4.doc Version 1.30 Page 12 The resident’s menu was inspected and, the choices seen 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. Tables were laid with linen tablecloths and flower arrangements, and there are two and four seated tables provided, this helped to make the lunchtime meal a relaxed and social experience for residents .The inspector ate lunch with a group of residents on the first day of the inspection. The meal was roast chicken, freshly made stuffing, roast potatoes and two fresh vegetables, followed by a desert of ‘spotted dick’ with custard, or fresh fruits, or ice cream. There was an alternative meal option of chicken salad. The meal was tasty and well presented, however residents preferences could have been better catered for if there had been a wider range of choice of lunchtime meal other than roast chicken or chicken salad. Glebe House D56 D05 S20277 Glebe House V229642 27280705 Stage 4.doc Version 1.30 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 standard(s) 16,18 Complaints about the Home are responded to promptly and there are systems in place to protect residents from abuse. EVIDENCE: A copy of the Homes complaints procedure was on display in a well-frequented part of the Home, which means people should know how to obtain the required information if wishing to complain. There had been no complaints recorded in the complaints logbook record since before the last the inspection. There are procedures and a range of guidance information for the protection of vulnerable adults from abuse, which should help protect vulnerable adults who live at the Home. A number of staff are undertaking the National Vocational Qualification in care award, and a component of the award addresses issues around the protection of vulnerable adults from abuse. Residents’ safety would be further maintained if all staff were provided with the opportunity to attend training on the topic of protection of vulnerable adults from abuse. Glebe House D56 D05 S20277 Glebe House V229642 27280705 Stage 4.doc Version 1.30 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 standard(s) 19-26 The Home is safe, well maintained, and suitable for the needs of residents. EVIDENCE: Glebe House D56 D05 S20277 Glebe House V229642 27280705 Stage 4.doc Version 1.30 Page 15 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. 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. Glebe House D56 D05 S20277 Glebe House V229642 27280705 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30 Staff are skilled and competent, and able to meet residents needs. The Homes recruitment procedure helps to protect and safeguard residents. EVIDENCE: A selection of five staff recruitment records were viewed, each of these records contained a completed Criminal Records Bureau check, as well as two detailed references and a completed application form. This information should help to protect, residents who due to their dependency needs are a vulnerable client group. Training records also demonstrated staff attended training and updating in subjects that are relevant to the Home and to the needs of residents. On the first day of the inspection one of the registered nurses was carrying out a health and safety teaching session with staff. The inspector spent some time sitting in the communal areas observing staff carrying out their duties, assisting residents. Staff assisted residents in a calm and very courteous way. Staff communicated among each other, and worked well as a team. One of the GPs. who is responsible for residents medical care needs commented in a Commission for Social Care Inspection questionnaire very positively about the overall standard of care that is provided by staff at the Home. Glebe House D56 D05 S20277 Glebe House V229642 27280705 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,35,37,38 Resident’s needs and best interests are at the centre of the management approach in the Home, and the health and safety of residents, staff and visitors is protected. EVIDENCE: Four residents finance records, were inspected to review if the procedures in place protect residents. There were detailed and easily auditable records and invoices for all services that residents pay for. The Home employees a full time administration manager who is responsible for overseeing fees and services, who is evidently knowledgeable and very competent in her work. Glebe House D56 D05 S20277 Glebe House V229642 27280705 Stage 4.doc Version 1.30 Page 18 The environment looked satisfactorily maintained throughout. The kitchen was tidy and organised when viewed during the inspection, and staff demonstrated an understanding of safe food handling practices. There are health and safety policies and procedures in place for staff to follow to ensure the safety of themselves and residents’ is maintained. The fire logbook was checked and showed weekly tests of fire alarms being carried out, helping to demonstrate the safety of people who are in the building is maintained. However the record of fire fighting equipment was not up to date, as the last recorded check of fire fighting equipment by staff was over ten months ago, checking fire fighting equipment regularly is necessary to ensure equipment is in good working order if ever needed in an emergency. There was a record that showed staff had attended fire safety update training in the last twelve months, to ensure they were aware of fire safety procedures in the Home. Residents care records are stored securely in the Home when not in use, thereby helping to protect residents’ confidentiality. Glebe House D56 D05 S20277 Glebe House V229642 27280705 Stage 4.doc Version 1.30 Page 19 Glebe House D56 D05 S20277 Glebe House V229642 27280705 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 4 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 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 4 4 3 3 3 4 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 3 x 3 x x 3 2 Glebe House D56 D05 S20277 Glebe House V229642 27280705 Stage 4.doc Version 1.30 Page 21 no 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 38 Regulation 23.4c(v) Requirement The fire fighting equipment must be checked on a monthly basis, and a record of these checks must be maintiend. Timescale for action From 29/07/05 onwards 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 18 Good Practice Recommendations All staff should be provided with training on the subject of the protection of vulnerable adults from abuse. Glebe House D56 D05 S20277 Glebe House V229642 27280705 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection 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. Extracts may not be used or reproduced without the express permission of CSCI Glebe House D56 D05 S20277 Glebe House V229642 27280705 Stage 4.doc Version 1.30 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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