Inspection on 05/12/05 for Glebe House Care Home

This inspection was carried out on 5th December 2005.

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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glebe House Care Home 08/05/07

Glebe House Care Home 08/05/06

Glebe House Care Home 01/08/05

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 Elisabeth Pinder Unannounced Inspection 5th December 2005 10:00 Glebe House DS0000002566.V271668.R01.S.doc Version 5.0 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 DS0000002566.V271668.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 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 DS0000002566.V271668.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Glebe House Address 7 Southdale Caistor Lincs LN7 6LS 01472 852282 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) Blair.house@craegmoor.co.uk Health & Care Services (UK) Limited Care Home 24 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (23), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (1) Glebe House DS0000002566.V271668.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st August 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 homes 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 mini-bus for service users use and there is also easy access to public transport. On the first floor there is a rehabilitation unit, which provides accommodation for six residents. This consists of a lounge/dining area, kitchen, bathroom and six single bedrooms. Glebe House DS0000002566.V271668.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 4.5 hours and was carried out by one inspector as the 2nd of two statutory inspections for 2005/6. The main method of inspection used was “case tracking”. This involved selecting three residents and tracking the care they receive through the checking of their records, discussion with two of them, the care staff and observation of care practices. One bedroom was viewed and a selection of care records inspected. What the service does well: 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 DS0000002566.V271668.R01.S.doc Version 5.0 Page 6 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 DS0000002566.V271668.R01.S.doc Version 5.0 Page 7 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): The above standards were not inspected on this occasion. EVIDENCE: Glebe House DS0000002566.V271668.R01.S.doc Version 5.0 Page 8 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): 7 Care plans including risk assessments contain sufficient information to ensure the care needs of residents are met, but must evidence that residents or their representatives are involved in this process. EVIDENCE: The care plans of three people were seen and these contained detailed information about their daily living needs, ongoing support and assessments. However, they did not show that they had been reviewed or that residents had been involved in the care planning process. One resident spoken to said that he had not looked at his care plan for some time and felt staff shortages were to blame. However, both residents said they have regular meetings where they discuss menu’s, domestic chores, social and leisure activities and other aspects of daily living. Residents also said that they felt they are able to make decisions as to how they live their lives in the home and gave examples of different activities they do which increases their independence. For example, one resident said how he enjoys country and western nights, sometimes staying overnight with a friend. Residents living in the rehabilitation unit have a kitchen with a domestic style cooker where they are able to prepare their own meals and drinks. Glebe House DS0000002566.V271668.R01.S.doc Version 5.0 Page 9 Glebe House DS0000002566.V271668.R01.S.doc Version 5.0 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): 16 & 17 Residents rights are respected, meals in the main home are well managed, providing daily variation but need more planning and organisation in the rehabilitation unit. EVIDENCE: Residents said that their rights are respected and they feel that staff give them the privacy they need. They confirmed that their mail is received unopened and staff only enter their bedrooms with permission. They also said that they can choose when to be alone or in company. Individual records detail the dietary likes and dislikes of residents and those spoken to said that the food is good and that they welcomed the daily choices offered. Menus were examined and were found to be balanced and interesting. Meal-time arrangements are flexible enough to accommodate individual preferences, however, one resident spoken to who lives in the rehabilitation unit described how he and other residents are not always able to do a weekly shop due to staff shortages. This was brought to the attention of the acting manager who said that he is aware of current staffing issues and is taking action to address them. Glebe House DS0000002566.V271668.R01.S.doc Version 5.0 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): 19 & 20 There are good links with health care services, ensuring that health needs of residents are met. Medication storage and administration systems are satisfactory, although recording of medication must be improved. EVIDENCE: Care records showed that arrangements are in place for residents to be registered with a GP from a local surgery. Staff spoken to were aware of the particular health needs of the people asked about and said where needed guidance and support is given regarding personal hygiene. Assessment information also includes arrangements to visit the dentists, opticians and hairdresser. The arrangements for residents to take control over their own medication was discussed with the member of staff in charge and these were found to be satisfactory. One resident showed the inspector where he kept his medication and this was kept securely. Medication records examined showed a number of gaps on one of the ‘Mar’ sheets and this was brought to the attention of the senior carer. An appropriate coding system must be used to record why medication is omitted. Glebe House DS0000002566.V271668.R01.S.doc Version 5.0 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): 22 This home has detailed procedures in place for handling complaints and residents living here feel their views are listened to. EVIDENCE: The Organisation has clear policies and procedures for reporting and investigating complaints. Staff had a good understanding of these procedures and comments from residents indicated that they felt able to talk to staff and feel their views are listened to and acted upon. Specific comments were “if I have any worries I would talk to staff” and “I feel staff listen to me”. The staff member in charge during the visit said that residents currently living in the home have relatives or representatives who would act as an advocate should the need arise. Residents meetings are held where discussions centre around the daily activities including household chores. Glebe House DS0000002566.V271668.R01.S.doc Version 5.0 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): The above standards were not inspected on this occasion. EVIDENCE: Glebe House DS0000002566.V271668.R01.S.doc Version 5.0 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): 33 In order that resident’s rehabilitation activities are not restricted in any way the staffing levels and deployment in the home must be reviewed. EVIDENCE: Current staff shortages include a cook and a number of care staff. The acting manager said that he has recently carried out interviews and is waiting for the necessary legalistic checks to be undertaken and if satisfactory staff will commence. Staff spoken to said that they are very busy, some are working days and nights, others undertaking catering as well as care. The member of staff in charge of the shift said she had not had chance to read the last inspection report. During the visit the housekeeper was the ‘cook’ for the day and as previously mentioned residents spoken to commented on the staff shortages. The ‘acting’ manager is at times working as a carer. Staffing issues were raised during the previous inspection where it was highlighted that the home has a unique staffing system where members of the team take turns in acting as the senior carer. However, as this system does not allow the manager to delegate responsibilities to other members of the team and the home no longer has an administrative assistant, it was recommended that the organisation review the staffing levels and structure in the home to support the manager to maintain a high standard of care. Staff said that as yet this has not been carried out. Glebe House DS0000002566.V271668.R01.S.doc Version 5.0 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): 37 & 42 The organisation has failed to notify the Commission of the changes in management arrangements in the home which has the potential to affect the well being of residents. EVIDENCE: Since the last inspection the registered manager of the home has left, the organisation did not inform the Commission of this event. Although an acting manager has been appointed it is crucial that an application for registration is submitted as soon as possible. Residents spoken to were aware of these changes but said they liked the new manager. Risk assessments are documented in relation to health and safety issues that may arise from the environment of the home. Maintenance records are kept and there are a range of policies and procedures available relating to fire safety and fire risk assessments. There was evidence that regular fire alarm, fire drills and emergency lighting checks are carried out by the home’s ‘handyman’. Glebe House DS0000002566.V271668.R01.S.doc Version 5.0 Page 16 Certificates were available showing that the stair lift, hoist and wheelchairs had been serviced. The emergency call system had been checked and the Gas safety certificate obtained. Glebe House DS0000002566.V271668.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 2 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X 2 X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Glebe House Score X 3 2 x Standard No 37 38 39 40 41 42 43 Score 2 X X X X 2 X DS0000002566.V271668.R01.S.doc Version 5.0 Page 18 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. 1 Standard YA7 Regulation 15[2] Requirement Individual care plans including risk assessments must be regularly reviewed and evidence involvement from residents and/or their relatives/representatives. Medication must be recorded in accordance with The Administration and Control of Medicines in Care Homes and Childrens Services. Staff must be deployed in such numbers as are appropriate for the health and welfare of residents. Management hours must be supernumerary. A designated member of staff who is appropriately qualified and experienced must be appointed to supervise a new worker for the duration of their induction training. An application for the registration of the manager must be received by the Commission. The Commission must be notified as soon as it is practicable of any events taking place or is proposed to take place i.e. a person other than the registered DS0000002566.V271668.R01.S.doc Timescale for action 31/01/06 2 YA20 13[2] 31/01/06 3 YA33 18[1][a] 31/01/06 4 YA35 18[2] 31/01/06 5 6 YA37 YA41 8[1][b] 39[a] 31/01/06 31/01/06 Glebe House Version 5.0 Page 19 person manages the care home. 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 for the manager and there are enough staff available to support residents with appointments, without in house activities being affected. There should be a planned programme of development for residents living in the rehabilitation unit to enable them to achieve their goals. 2. YA16 Glebe House DS0000002566.V271668.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Lincoln Area Office 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 DS0000002566.V271668.R01.S.doc Version 5.0 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. 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