Inspection on 01/08/05 for Glebe House Care Home

This inspection was carried out on 1st August 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 Care Home 08/05/07

Glebe House Care Home 08/05/06

Glebe House Care Home 05/12/05

Glebe House Care Home 28/02/05

Glebe House Care Home 02/08/04

Glebe House Care Home 06/02/04

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

CARE HOME ADULTS 18-65 Glebe House 7 Southdale Caistor Lincs LN7 6LS Lead Inspector Wilma Crawford Unannounced 01 August 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 C53-C04 S2566 GlebeHouse V240998 010805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Glebe House Address 7 Southdale Caistor Lincs LN7 6LS 01472 852282 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) Health & Care Services (UK) Limited Mrs Karen Diane Walker Care home only 24 Category(ies) of MD Mental disorder (23) registration, with number MD(E) Mental disorder - over 65 (1) of places Glebe House C53-C04 S2566 GlebeHouse V240998 010805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 28 February 2005 Brief Description of the Service: Glebe House is operated by Health & Care Services UK and located in the village of Caistor, where there are a variety of local facilities such as shops, churches and community facilities. The home offers accommodation to 24 service users with mental health difficulties. The home’s current certificate of registration is to provide care for 22 younger adults and two service users over 65 years of age. The building is set in its own grounds, with car parking to the rear of the property. The home is a two-storey building with a lift providing access to the 1st floor. All of the rooms are single bedrooms, some with ensuite facilities and there are three lounges, one used by people who smoke and a separate dining room. The home has use of a minibus and has easy access to public transport. The home provides a minibus for service users use. On the first floor there is a rehabilitation unit, which provides accomodation for six residents. This consists of a lounge/dining area, kitchen, bathroom and six single bedrooms. Glebe House C53-C04 S2566 GlebeHouse V240998 010805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 5 hours. A tour of the premises was conducted with the manager. The main method of inspection used was called case tracking which involved selecting three residents and tracking the care they receive through the checking of their records, discussion with them, the care staff and observation of care practices. A pre-inspection questionnaire was completed by the manager, and 16 comment cards from residents were received, which were overall positive. Other documents were inspected What the service does well: What has improved since the last inspection? What they could do better: The home has a unique staffing system where members of the team take turns in acting as the senior carer, on a roistered basis. The staff team are competent, but this system does not allow the manager to delegate responsibilities to other members of her team, as all staff take a turn as working as a senior carer. The home no longer has an administrative assistant, which makes further demands of the manager’s time. Glebe House C53-C04 S2566 GlebeHouse V240998 010805 Stage 4.doc Version 1.40 Page 6 The organisation needs to review the staffing levels and structure in the home to support the manager in her role, to maintain the high standard of care that has been provided. 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 C53-C04 S2566 GlebeHouse V240998 010805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Glebe House C53-C04 S2566 GlebeHouse V240998 010805 Stage 4.doc Version 1.40 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 standard(s) 2,3,4,5 There are good systems for the assessment and introduction of residents to the home, ensuring that their wishes and views are taken into account. Residents are admitted into the home only after a full needs assessment has been carried out either by the home or health care or social care agencies. EVIDENCE: The home has an admission policy and procedure, which includes an assessment being carried out prior to admission, this is undertaken to make sure that the home can meet prospective residents needs. Residents said that a new resident had visited the home, to meet the other residents before moving in permanently. Social workers and relatives had been involved in the assessment process and visited the home to see if they felt it was suitable. A newly admitted resident was able to confirm that he had been able to visit the home before moving in. A contract of terms and conditions is available in each residents file. Glebe House C53-C04 S2566 GlebeHouse V240998 010805 Stage 4.doc Version 1.40 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 standard(s) 6,8,9 Care plans contain comprehensive information, which identify the care needs and personal preferences of the residents. Risk assessments are of a good quality, providing management strategies that enable residents to be as independent as possible. EVIDENCE: Care plans are extremely comprehensive, and contain detailed information about daily living needs, ongoing support and assessments. Each resident has a detailed care plan, which reflects his or her individual needs. Three residents confirmed that they had been involved in the review of their care plan and said that these had also included parents and other professionals. They also said that residents meetings are held to discuss menu’s, domestic chores, social and leisure activities and other aspects of daily living. Comprehensive risk assessments had been completed which included any potential risks to the resident and the management strategies that would enable them to be as independent as possible. There is also a rehabilitation unit within the home which gives residents the opportunity to develop or maintain their independent living skills. One resident Glebe House C53-C04 S2566 GlebeHouse V240998 010805 Stage 4.doc Version 1.40 Page 10 had recently left the home to live independently in his own flat. Staff were knowledgeable about the needs and preferences of the residents, who confirmed that their needs were being met. Glebe House C53-C04 S2566 GlebeHouse V240998 010805 Stage 4.doc Version 1.40 Page 11 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 standard(s) 12,13,15 There are both educational and leisure opportunities for residents, which ensure that independent living skills are developed. EVIDENCE: Residents gave numerous examples of community activities that they take part in, including college placements and said that they are able to choose how to spend their time, and who with. They also gave examples of safeguards that are in place to ensure that they are safe whilst out in the community, and comprehensive risk assessments are in place. Two residents seen during this inspection commented that their visitors are always made welcome in the home and refreshments are made available. The homes signing in book was seen and showed that visitors attend this home in numbers at various times of the day. Comments included “I really enjoy the days out and particularly the painting activities.” ”There is plenty for everyone to do, but I have my own interests and this is respected.” Glebe House C53-C04 S2566 GlebeHouse V240998 010805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 18,19 Staff provide a supportive service that respects residents privacy and individual preferences. The health needs of residents are met. EVIDENCE: Care plans gave details of contact numbers and involvement of services such as G.P’s, psychologists, opticians, dentists and chiropodists. Residents spoken with were aware of the content of their care plans and had signed them. Comments included: ”I like it here the staff look after us.” Residents were aware that they were able to access their care plans at any time. Observation and discussions with staff showed that they were aware of the need to respect residents’ privacy. Bedroom doors are fitted with locks and staff, ask for permission from the resident if they wish to enter. Residents confirmed this “Staff always knock.” Glebe House C53-C04 S2566 GlebeHouse V240998 010805 Stage 4.doc Version 1.40 Page 13 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 standard(s) 23 Staff, had received abuse training and were clear on the action to take in the event of this occurring. EVIDENCE: The manager and staff had a good understanding of procedures to follow regarding reporting any suspected abuse to the Commission and social services. Staff comments and training records demonstrated that staff had received appropriate training in this subject which would help them to recognise and take appropriate action should the need arise. Glebe House C53-C04 S2566 GlebeHouse V240998 010805 Stage 4.doc Version 1.40 Page 14 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 standard(s) 24,25,30 The standard of the environment within the home is good, providing residents living there with a clean, comfortable and homely environment. EVIDENCE: Further refurbishment and redecoration programme has been completed during the last year. This has included the fitting of a new kitchen, the fitting of a new carpet to the dining room and a number of bedrooms being redecorated and having new curtains and bedding purchased. People who were spoken with said that they were very happy with the refurbishment of the home. Residents said that they liked their rooms and felt that they had everything they wanted. Bedrooms seen had been were personalised to the individuals taste. One resident told the inspector that he had been able to chose the colour and design of his curtains and bedding. The home was clean and tidy with no offensive odours. Glebe House C53-C04 S2566 GlebeHouse V240998 010805 Stage 4.doc Version 1.40 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34,35 The procedures for recruitment of staff are robust and ensure that residents are protected. Residents are supported by experienced well-trained staff. EVIDENCE: The company has a comprehensive training programme, which includes induction training. Staff records showed that they had received regular supervision and appraisal sessions. Each file contains a staff development plan, which highlights their training needs. Records and staff comments confirmed that training had taken place as planned, this included; Protection of Vulnerable Adults, Crisis Prevention and Intervention and Mental Health issues. On the day of inspection there were three staff on duty, one of which was working in the rehabilitation unit. There were several appointments where residents needed to be accompanied, leaving the home two staff. This meant that organised activities in the main part of the home had to be postponed until later. Glebe House C53-C04 S2566 GlebeHouse V240998 010805 Stage 4.doc Version 1.40 Page 16 Staff and residents spoken to felt that there is adequate staffing available, to meet residents needs, but there are occasions where the home would benefit from having an extra person on duty. Glebe House C53-C04 S2566 GlebeHouse V240998 010805 Stage 4.doc Version 1.40 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38,39,43 The home is managed competently and the staff are supported and supervised to carry out their roles. The residents are involved in contributing to the running of the home. EVIDENCE: The manager holds a nursing qualification, has five years managerial experience within a residential care setting and has completed the Registered Manager’s Award. Staff said they are well supported and they are confident to approach the manager, with concerns or ideas. Comments include; “ She is very approachable , she will work with you to resolve problems.” The minutes from the recent residents meeting show that residents do contribute and raise issues, and that action is taken to address these. The manager supervises the staff both formally and during every day observation. Annual appraisals take place and are recorded. Glebe House C53-C04 S2566 GlebeHouse V240998 010805 Stage 4.doc Version 1.40 Page 18 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score N/A 2 3 3 3 Standard No 22 23 ENVIRONMENT Score N/A 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 N/A 3 3 N/A Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 N/A N/A N/A N/A 3 Standard No 11 12 13 14 15 16 17 N/A 3 3 N/A 3 N/A N/A Standard No 31 32 33 34 35 36 Score N/A 3 3 3 3 N/A CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Glebe House Score 3 3 N/A N/A Standard No 37 38 39 40 41 42 43 Score N/A 3 3 N/A N/A N/A 3 C53-C04 S2566 GlebeHouse V240998 010805 Stage 4.doc Version 1.40 Page 19 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 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. 1. Refer to Standard YA33 Good Practice Recommendations The organisation should consider reviewing the current staffing levels and structure to ensure that there is adequate support available for the manager, and there is enough staff available to support residents with appointments, without in house activities being affected. Glebe House C53-C04 S2566 GlebeHouse V240998 010805 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Unity House, The Point Weaver Road Off Whisby Road Lincoln, LN6 3QN 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 C53-C04 S2566 GlebeHouse V240998 010805 Stage 4.doc Version 1.40 Page 21 - 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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