Inspection on 29/11/05 for Glebe House

This inspection was carried out on 29th November 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 07/09/06

Glebe House 13/07/05

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

CARE HOMES FOR OLDER PEOPLE Glebe House Stein Road Southborne West Sussex PO10 8LB Lead Inspector Mrs G Davis Unannounced Inspection 29th November 2005 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 DS0000052212.V270846.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 DS0000052212.V270846.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Glebe House Address Stein Road Southborne West Sussex PO10 8LB 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) 01243 375198 01243 375198 Shaw healthcare Ltd Ms Ida Kristina Bostrom Care Home 34 Category(ies) of Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (27) of places Glebe House DS0000052212.V270846.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The total number of service users should not exceed 34 at any one time. 13th July 2005 Date of last inspection Brief Description of the Service: Glebe House is registered for thirty-four older people (over the age of 65), eight of who have dementia. Owned by Shaw Health Care, Mr Jeremy Nixey is the Responsible Individual. The registered manager, Ms Ida Bostrom is currently on leave of absence and Mrs Marion Tupper has been appointed as Acting Manager and is responsible for the day to day running of the establishment. The property is on a single level and accommodation is provided in thirty-four single rooms. There is a large lounge area with three smaller lounges and two dining areas. The property is surrounded by garden. Glebe House is located within a residential area and is close to local amenities. A new purpose built home is being built on some of the land adjacent to the existing building and it is anticipated that the residents will move into the new build in the late spring of next year Glebe House DS0000052212.V270846.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection of the two inspections (minimum) that an inspector must make in a year. On this occasion this inspection was unannounced and took place over one day in November 2005. The aim of this inspection was to find out how the home cared for the residents and to inspect those standards not inspected previously. Observation of the interaction between the staff members and residents and of the body language of those residents who were unable to give the inspector verbal opinions confirmed that they were content and comfortable with their surroundings and the people who were supporting them. Conversation with a number of residents indicated that they were very happy at the home; one person told the inspector “ I like it here------the staff have the right attitude”. When asked if they felt that they would be able to complain they replied “ I could definitely complain and they would put it right”. Another said” It’s quite nice and comfy here, very friendly and always someone to give a hand – if they can’t come straight away they will let you know”. There was evidence that the home utilises local facilities and services such as the Age Concern Club, Country View Club and Companions Club, as well as providing a number of weekly/bi weekly in house activities including, movement to music, bingo, carpet bowls and visiting entertainers. The home’s layout lends itself to providing a number of areas for residents to sit and includes some areas where individuals can sit quietly and enjoy their own chosen pursuits. Each wing has its own dining room. A tour of the home took place. Staff and care records were inspected as well as the Home’s Statement of Purpose, Service Users Guide and some of the Policies and Procedures. All of the staff on duty, and most of the residents were spoken to during the course of the inspection. What the service does well: There have been no real changes in the period between inspections. The home continues to undergo a period of change that has been managed successfully by the staff members of Glebe House. The welfare of the residents is at the forefront of everything that staff members do at Glebe House and any upset that the change of manager, transfer of ownership and the imminent move to the new building may have created has not impacted on the residents. Conversations with some of the residents showed that the staff members were very helpful, one person said, “ I was ill the other night –they were kind” When asked if they knew how to complain, all who were able to talk to the inspector said that they did, although all of those spoken to did not consider they had anything to complain about. One person said, “ everything is O.K. no Glebe House DS0000052212.V270846.R01.S.doc Version 5.0 Page 6 complaints”. Another, “I have nothing to complain about”. This appeared to be the opinion of the majority of the residents spoken to. Observed interaction between the care staff and those who were unable to converse with the inspector confirmed that the care staff treated the residents with respect and dignity in a discreet and unobtrusive manner. Shaw Health Care has introduced policies, procedures and records and these provide excellent guidance for the care staff and protection for the residents. The care plans are very detailed and contain information regarding the health and personal care needs as well as the interests, and identified preferences of the residents. It was seen that they were given choice in all that they did and that there were no petty rules to observe. 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 DS0000052212.V270846.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 DS0000052212.V270846.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): 3.4.6. All prospective residents, or their representatives, have a number of opportunities to make an informed choice about whether they want to live at Glebe House. An assessment of need is undertaken prior to admission. Intermediate care is not provided EVIDENCE: The home provides a comprehensive Statement of Purpose and Service User Guide to all prospective residents, their families and their Care Managers. Prior to admission a thorough assessment of need is carried out and information from that assessment is used to inform the care plan. Everybody concerned with the prospective resident is encouraged to visit as often as they like and a four-week trial period is used to allow the new resident to settle in and make sure that they are happy with the situation. Glebe House DS0000052212.V270846.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): 9.11. Appropriate policies and procedures are in place regarding the storage, administration and disposal of medication. Residents are assured that the staff will treat them with sensitivity, respect and care at the time of their death. EVIDENCE: Residents are involved with the drawing up of a plan of their individual needs and preferences. Where a resident is not able to be involved with the drawing up of their care plans, then the residents relative or advocate is involved as far as possible. Where possible the person’s wishes regarding the arrangements to be carried out at the time of their death will be recorded on the plan. The resident, subject to a risk assessment, can choose to self medicate if appropriate. There is no one currently self-medicating. There are appropriate policies and procedures for the safe handling of medications and all aspects of the medication system were found to be satisfactory. Staff members are given training in the administration of medication. Glebe House DS0000052212.V270846.R01.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): Not assessed on this occasion EVIDENCE: The care plans had been reviewed and were up to date. Please refer to previous inspection report Glebe House DS0000052212.V270846.R01.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): Resident’s legal rights were protected EVIDENCE: All residents had been entered onto the electoral role and would be supported to vote if they wished. Advocates are obtained for those persons who require one. Glebe House DS0000052212.V270846.R01.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): 21.22.23.25. The home is a safe and well-maintained building, which is generally decorated and furnished to a reasonable standard and equipped to enable the residents to maximise their independence. Each resident has a room that has been furnished to meet their wishes and needs. There are suitable washing facilities and lavatories. EVIDENCE: During the course of the inspection the majority of rooms were visited to make sure that the environment was safe and comfortable for people who live there. It was seen that many residents had brought personal possessions into the home, including small items of furniture, ornaments and photographs. There are a suitable number of toilets and bathrooms, most are shabby and in need of refurbishment, however the new build is very advanced and it is anticipated that a move will be made in the late spring 2006. All facilities were clean and in good repair providing a safe environment. A variety of aids to assist care staff to support the residents and help them to be as independent as possible. These include walking aids, wall bars, raised Glebe House DS0000052212.V270846.R01.S.doc Version 5.0 Page 13 toilet seats and a variety of chair heights; mobile lifting hoists and bath hoists. People appear to be content with their rooms. Although shabby, the home is comfortable and well maintained. Glebe House DS0000052212.V270846.R01.S.doc Version 5.0 Page 14 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): Glebe House has an adequate number of staff members with appropriate training and skills to provide competent care to the residents at all times. This standard was not scrutinised in depth on this occasion. EVIDENCE: Some long-term absences of permanent staff members have meant that the home has had to use agency staff members to fully cover the hours. This does not appear to have impinged on the quality of care and all residents spoken to were very satisfied with the service they receive from the home. All required security checks are undertaken with new members of staff. There is an ongoing staff-training programme. Glebe House DS0000052212.V270846.R01.S.doc Version 5.0 Page 15 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): 32.34.37. The home is run in a manner that offers protection to all aspects of the residents’ interests. EVIDENCE: The registered manager is on leave of absence and an acting manager is working in her place. She holds the Registered Manager’s award and has all the skills and competence to discharge her responsibilities fully. A competent senior team and line management supports her. Corporate policies include generous budgets managed by the head of home. Robust recording procedures are used and a business plan was available but not looked at on this occasion. There are excellent policies and procedures for the guidance of the staff members and the protection of the residents. Glebe House DS0000052212.V270846.R01.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 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 X 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 x X X 3 3 3 X 3 x 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 X 3 X 3 X X 3 X Glebe House DS0000052212.V270846.R01.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. Standard Regulation Requirement Timescale for action 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 DS0000052212.V270846.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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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