Inspection on 08/05/06 for Glebe House Care Home

This inspection was carried out on 8th May 2006.

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 found no outstanding requirements from the previous inspection report, but made 1 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 05/12/05

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 Key Unannounced Inspection 8th May 2006 09:30 Glebe House DS0000002566.V292403.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 DS0000002566.V292403.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 DS0000002566.V292403.R01.S.doc Version 5.1 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.V292403.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 05/12/05 Brief Description of the Service: Glebe House is operated by Health & Care Services UK and is 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 building is set in its own grounds, with car parking to the rear of the property. The home is a twostorey building with a lift providing access to the 1st floor. All of the rooms are single bedrooms, some with en-suite 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. The current weekly fee range is £297.00 - £552.20. No additional costs are made Glebe House DS0000002566.V292403.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit was made to the home to form part of a key inspection. It started at 09:20 and lasted 5.5 hours. Information already held on file was used to plan the visit. This consisted of notifications to the Commission and correspondence with the provider. Twenty- two resident surveys were received and these will be mentioned throughout the report. This site visit focused on key inspection standards and checking whether requirements from previous inspections had been met. A partial tour of the home was undertaken and a sample of records were inspected. The main method used for this was “case tracking” a sample of three residents with a range of needs via their records, discussion with two of them and one member of staff on duty during the visit. No relatives or representatives were seen during this visit. The acting manager and deputy manager facilitated this inspection. What the service does well: What has improved since the last inspection? Action has been taken to address all the requirements and recommendations highlighted during the previous inspection. These included the review of care plans and risk assessments and ensuring residents are involved in this process. Developing a planned programme for residents living in the rehabilitation unit enabling them to achieve their goals has also been addressed. A new mini-bus has been purchased. Glebe House DS0000002566.V292403.R01.S.doc Version 5.1 Page 6 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.V292403.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 DS0000002566.V292403.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Information about the service is available and procedures are in place to ensure residents are only admitted into this home after a full needs assessment has been carried out. EVIDENCE: The statement of purpose and service user guide, which is given to residents as part of their admission process provides them with information about the home. One resident spoken to said he had not been given this information and a copy was given to him during the visit. Two of the files inspected had written records showing that this document had been given to the resident. The majority of resident surveys identified that they had received enough information about the home prior to moving in. Residents records included contractual information and demonstrated that the home has a thorough assessment procedure, which includes writing to the resident with the outcome of their assessment. Glebe House DS0000002566.V292403.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): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents are involved in their care planning and are able to make decisions and choices as to how they lead their lives at this home. EVIDENCE: The care plans of three people were seen. These have been re-written since the previous inspection and have improved in content. Comments from residents confirmed that they are involved in this process and are able to make decisions regarding how they live their lives. Individual risk assessments have been written in relation to residents needs and these are clear and show the action staff need to take to minimise the risk. The home has a “key worker” system and residents spoken to were aware of who their key-worker is and all said how well they get on with them. Glebe House DS0000002566.V292403.R01.S.doc Version 5.1 Page 10 The rehabilitation unit aims to enable residents to plan for their future, and the manager said that two residents have recently moved, one into supported living and one to live independently. Staff spoken to had a good knowledge of the support that residents need. Residents spoken to felt that they were able to make decisions and gave examples of different activities they do. Residents living in the rehabilitation unit plan menus and shopping, prepare and cook their own meals and carry out cleaning and laundry tasks. Glebe House DS0000002566.V292403.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. This home provides a range of activities and leisure interests both within the home and community. These are based on the preferences of residents who are encouraged to make choices about their preferred lifestyles and routines. Residents rights are respected. Meals are well managed in the main home and the rehabilitation unit. EVIDENCE: The Company has recently employed a full time activities co-ordinator to work alongside residents enabling them to pursue hobbies and develop new interests. During a discussion she confirmed that regular meetings are held with residents either on a one to one basis or in a group to decide what activities are carried out. However, no records are held of these meetings, although residents verified that these are held. Individual records were available of recent activities and outings for each resident. During the visit residents were observed painting pictures which could later be transferred onto Glebe House DS0000002566.V292403.R01.S.doc Version 5.1 Page 12 windows. Other residents were listening to music or sitting outside in the sunshine. During the afternoon six residents went to one of the local pubs with two members of staff. Residents said that they felt their rights are respected by staff, one resident spoken to who has not been living in the home long, said that he is able to make his own decisions with regards to how he lives his life and is able to go home every Saturday to spend the day with family. One resident said he has a ‘one to one’ worker funded by the NHS and said how much he enjoys going out to different places with her. The manager also said that one resident goes out to work every day and two residents attend a workshop two days each week. Transport is provided through the use of a minibus, however, some residents use public transport. The majority of resident surveys confirmed that residents usually enjoy the meals although one survey commented that meals are repetitive. Menus seen follow a four week selection and evidenced choice and variety. A comment on one of the resident surveys received read ‘I wish we could have a cup of tea/coffee when we want one’ and there was evidence that this had been discussed during a resident meeting and action has been taken to ensure this is available. Resident meeting minutes were seen and these showed that meals are discussed during bi-monthly meetings, however, it is recommended that a specific meeting is held with the head cook and residents when the summer menu is to be drawn up. Glebe House DS0000002566.V292403.R01.S.doc Version 5.1 Page 13 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): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The health and care needs of people the service supports and their preferred lifestyles is being met. This is supported by the care planning system and staff’s knowledge of individual needs. EVIDENCE: The majority of resident surveys indicated that residents feel they receive the medical support that they need. Records showed that residents regularly see their GP, practise nurse or consultant psychiatrist. Visits to see the dentist, optician and chiropodist are also recorded. Residents spoken to confirmed that they would speak to their key-worker or another member of staff if they felt unhappy. Procedures are in place for the safe handling of medicines and staff dispensing medication have undertaken relevant training. Three residents currently selfmedicate, risk assessments have been written and agreements have been made with them to store their medication safely. Glebe House DS0000002566.V292403.R01.S.doc Version 5.1 Page 14 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 & 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The complaints procedure is not clear. The procedure for following up complaints must ensure residents are not at risk. Procedures are in place for reporting any allegations of abuse. EVIDENCE: There are policies and procedures in place relating to complaints and adult protection. The home uses the company’s procedure and the Local Authority Adult Protection procedure dated February 2005. A discussion was held with the manager regarding obtaining a copy of the most recent procedure entitled ‘Safeguarding Adults’. Staff spoken to knew who to report to and training records showed that staff have undertaken specific adult protection training courses. A record is kept of all complaints made and these showed that no complaints have been made since the previous inspection. However, records relating to a complaint made in September 2005 did not show if any action had been taken to address a complaint made by a resident, which may have resulted in an adult protection issue. The commission has not received any complaints since the last inspection. Staff were observed throughout the visit to be listening to residents views about everyday issues and responding to any requests for assistance or Glebe House DS0000002566.V292403.R01.S.doc Version 5.1 Page 15 support. Two residents spoken to said that they would feel comfortable to raise concerns with the manager or their key-worker and felt confident that these would be dealt with. However, there was a mixture of responses received through resident surveys relating to whether residents know how to make a complaint. The majority ticked that they did with four ticking usually, two sometimes and one never. It is recommended that how to make a complaint is discussed during a resident meeting to ensure all are aware of the procedure to take. Glebe House DS0000002566.V292403.R01.S.doc Version 5.1 Page 16 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): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents live in a homely, comfortable environment, which is clean and well maintained. EVIDENCE: During a tour of the building the home was seen to be clean and well decorated. All furnishings are of a domestic nature and residents said they like the home and are happy with their bedrooms and felt that they are kept clean. No unpleasant odours were noted. Two residents bedrooms were seen, these were spacious, well personalised, individually decorated and furnished. One resident said that her room had recently been decorated and she had chosen the colours and accessories. All bedrooms have locks and residents confirmed that staff knock before entering. Cleaning schedules were available and records are kept of all maintenance checks which are carried out by the home’s handyman. Glebe House DS0000002566.V292403.R01.S.doc Version 5.1 Page 17 The home has a separate laundry room. This home was given a four star award by the Environmental Health Officer on 05/04/06 Glebe House DS0000002566.V292403.R01.S.doc Version 5.1 Page 18 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): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The staff group are an established team and staffing levels are sufficient to meet the current needs of residents. Staff are provided with training to ensure they have the skills needed to carry out their roles and are committed to the work they do. EVIDENCE: Records showed that there are normally three care staff on duty from 07.15 – 21.30hrs, one of whom is deployed in the rehabilitation unit. In addition, the manager and deputy manager work from 09.00 – 1700hrs. There is also a cleaner and a cook. The majority of resident surveys received prior to the visit identified that they feel that staff are always or usually, available when needed. Specific comments were ‘The staff are very kind and helpful’ and ‘all staff are excellent and care and always help’. Comments from staff indicated that there is an ongoing programme of training which they attend that includes updates in relation to some matters such as fire training, health and safety and first-aid. During the visit arrangements Glebe House DS0000002566.V292403.R01.S.doc Version 5.1 Page 19 were confirmed that staff are to access specific training in relation to the mental health needs of residents. Two new staff members have been employed since the last inspection and their records showed that they had been recruited using robust procedures based on equal opportunities. Satisfactory CRB/Pova checks had been received prior to their employment. However, staff have not been given copies of the General Social Care Council code of conduct and it is recommended that this is addressed. Glebe House DS0000002566.V292403.R01.S.doc Version 5.1 Page 20 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, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. This home is well managed and the health, safety and welfare of residents are promoted. EVIDENCE: The acting manager is in the process of submitting an application for registration to the Commission. He has been working in the home since December 2005 and has made significant improvements to raise standards, in particular regarding care planning and developing a new programme for residents accommodated in the rehabilitation unit. Staff said that they get good support from both the manager and deputy and both are approachable and available for advice when required. The deputy manager demonstrated a clear overview of the daily issues and provided direct support to staff when needed. There was evidence of Glebe House DS0000002566.V292403.R01.S.doc Version 5.1 Page 21 delegation of work and good levels of communication between the staff team. A discussion was held around quality audit systems as the manager was unaware of any process in place. This should include quality assurance questionnaires being sent out to all relatives and other professionals using the service to review the quality of care provided and developing a report which is to be made available to residents and the Commission. Although the Commission had not received monthly reports from the provider, these were available in the home. Regular staff meetings are held and records are kept. 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.V292403.R01.S.doc Version 5.1 Page 22 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 3 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 2 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Glebe House DS0000002566.V292403.R01.S.doc Version 5.1 Page 23 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 YA39 Regulation 24 Requirement A system must be in place for reviewing at appropriate intervals and improving the quality of care provided in the home. Timescale for action 31/07/06 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. 2. 3. 4 Refer to Standard YA17 YA22 YA22 YA34 Good Practice Recommendations It is recommended that a specific meeting is held with the head cook and residents when the summer menu is to be drawn up. Action taken to address complaints must be recorded. It is recommended that how to make a complaint is discussed during a resident meeting to ensure all are aware of procedures to take. It is recommended that staff are given individual copies of the General Social Care Council code of conduct. Glebe House DS0000002566.V292403.R01.S.doc Version 5.1 Page 24 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.V292403.R01.S.doc Version 5.1 Page 25 - 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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