Inspection on 14/06/06 for Glebe House (Charnwood) Limited

This inspection was carried out on 14th June 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 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 (Charnwood) Limited 30/11/07

Glebe House (Charnwood) Limited 14/08/05

Glebe House (Charnwood) Limited 03/07/05

Glebe House (Charnwood) Limited 04/11/04

Glebe House (Charnwood) Limited 07/08/04

Glebe House (Charnwood) Limited 13/02/04

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

CARE HOME ADULTS 18-65 Glebe House (Charnwood) Limited 190 Forest Road Loughborough Leicestershire LE11 3HU Lead Inspector Martin Hefferman Announced Inspection 14th June 2006 01:30 DS0000001818.V298224.R01.S.doc Version 5.2 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 DS0000001818.V298224.R01.S.doc Version 5.2 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. DS0000001818.V298224.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glebe House (Charnwood) Limited Address 190 Forest Road Loughborough Leicestershire LE11 3HU 01509 218096 01509 210881 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) Glebe House (Charnwood) Limited Mrs Beverley Jakubas Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000001818.V298224.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No one under the age of 16 years may be accommodated in the home. Date of last inspection 14th August 2005 Brief Description of the Service: Glebe House provides a wide range of day and evening services for adults and children who have a learning disability, many of whom also have a physical disability. The residential element of Glebe House, which is the focus of this inspection, provides respite care in the form of weekend breaks (Friday p.m. until Monday a.m.) for sixteen service users, who prefer to be referred to as guests. In the past, this provision has only been open twelve weekends a year. However, as a result of recent charity fundraising efforts, Glebe House hopes to provide a number of additional weekends this year. The flat in which respite takes place is registered to accommodate three guests for each stay, having one shared and one single bedroom. There is a well-equipped large kitchen / dining room and a generous sized comfortable lounge in addition to toilet and bathroom provision. Glebe House stands in attractive and secluded gardens, close to the town centre of Loughborough. The provision is registered to accommodate adults from the age of sixteen, however to date no one under the age of eighteen has received the weekend break service. At the time of the inspection, the local authority funded twelve weekend breaks at Glebe House. Additional weekends are to be funded through fundraising efforts. As a result, guests do not pay any fees. Information about the service has been produced for guests & their families. DS0000001818.V298224.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Visits to the home took place on 14th & 16th June 2006, lasting approximately four hours in total. The main method of inspection used during those visits was ‘case tracking’ which involved selecting three guests and tracking the care they receive through review of their records, discussion with them, the care staff and observation of care practices. Three guests and two members of care staff were spoken to on 16th June. The care manager facilitated the earlier visit, which focused on examining records. The inspection also took account of all information received since the date of the last visit, including the provider’s self-assessment. 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. DS0000001818.V298224.R01.S.doc Version 5.2 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 DS0000001818.V298224.R01.S.doc Version 5.2 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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessment practices are thorough, ensuring that guests’ needs are identified prior to their stay. EVIDENCE: The guests who were chosen for the purposes of case tracking have used various services at Glebe House for a number of years and are, therefore, well known to staff members. The files that were inspected contained copies of assessments and reviews completed by social workers. Guests and their families are asked to notify staff at Glebe House of any changes to their needs prior to the start of their stay. DS0000001818.V298224.R01.S.doc Version 5.2 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): 6, 7 & 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Guests are actively involved in planning their stay and are supported to take acceptable risks. EVIDENCE: Individual plans were available for the three guests who were chosen for the purposes of case tracking. The plans that were inspected were clear and comprehensive. Records indicated that they had been reviewed during the course of the week preceding the inspection. A risk assessment had been completed for each guest. This also identified the strategies needed to manage each risk. Prior to the start of their stay guests are asked to indicate the activities they would like to undertake whilst at Glebe House. This information is used to draw up a timetable for the weekend, reflecting each guest’s preferred activity. The guests are also asked to indicate the food they would like to eat over the weekend. During the course of the visit, guests were asked whether they wanted to attend a social group, which also meets at Glebe House, and were able to DS0000001818.V298224.R01.S.doc Version 5.2 Page 9 choose whether care staff accompanied them. Staff members are able to use a range of communication methods, including signing & pictures, to assist guests to make decisions. DS0000001818.V298224.R01.S.doc Version 5.2 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): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Guests enjoy an active and stimulating weekend break. EVIDENCE: Guests are asked to indicate the activities they would like to undertake whilst at Glebe House. The timetable for the weekend of the inspection included attending a social group, visits to a monastery, a local pub & a bowling alley, and a video / DVD evening. Sufficient time had been left on one of the days in case guests wanted to go shopping or undertake another activity. Guests stated that they would like a lie-in on Sunday morning. They are encouraged to develop independent living skills whilst at Glebe House. The guests know each other from attending other services at Glebe House and from previous weekend stays. They appeared to enjoy a positive relationship both with each other and with staff members. Guests are asked to indicate the food they would like to eat over the course of the weekend. Their preferences are taken into account by staff when they DS0000001818.V298224.R01.S.doc Version 5.2 Page 11 devise the menu. Guests stated that they enjoy the food provided during their stay. The care manager stated that staff members are able to cater for a number of different dietary requirements. DS0000001818.V298224.R01.S.doc Version 5.2 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 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 this service. Arrangements for meeting guests’ personal & healthcare needs are well managed. EVIDENCE: The individual plans that were inspected detailed the support each person requires with their personal care, including any preferences they might have. The plans also set out details of any healthcare needs that have been identified and of any action that is felt to be necessary as a result. At the time of the inspection, staff members were in the process of completing a ‘Health Information for Hospital’ booklet and ‘grab sheets’ for use in an emergency. None of the residents who were chosen for the purposes of case tracking were able to manage their medication. Staff members had recorded the medication they had received for each guest. No medication had been administered at the time of the visit. Administration records relating to previous weekend stays met relevant requirements. Staff members have received training on relevant healthcare & medication issues. DS0000001818.V298224.R01.S.doc Version 5.2 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 the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements for dealing with complaints and for responding to allegations of abuse help to protect the people who use the service. EVIDENCE: A guest stated that she would speak to staff if she had any concerns. A complaints procedure is included within the information given to guests and their families. No complaints have been received since the date of the last inspection. Glebe House has policies and procedures on the protection of children & vulnerable adults. Staff members have received training on the action to be taken in the event of an allegation or suspicion of abuse. DS0000001818.V298224.R01.S.doc Version 5.2 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 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 this service. Guests stay in a comfortable and safe environment. EVIDENCE: The flat in which respite takes place is decorated and furnished to a good standard. There is one single and one shared bedroom. Guests have access to a large well-equipped kitchen / dining room and a generous sized comfortable lounge in addition to toilet and bathroom provision. They also have access to the rest of Glebe House and its grounds. There is a ramp at the front of Glebe House. The service was in the process of purchasing a new stair lift at the time of the inspection. DS0000001818.V298224.R01.S.doc Version 5.2 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 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 excellent. This judgement has been made using available evidence including a visit to this service. Arrangements for the recruitment and training of staff are well managed. EVIDENCE: One of the guests stated that she got on really well with staff members. All of the guests appeared to enjoy a positive relationship with the staff on duty at the time of the visit. The records relating to two members of staff were inspected. Both indicated that appropriate pre-employment checks had been carried out. New members of staff complete an in-house induction training programme which incorporates the Learning Disability Award Framework and the standards set by Skills for Care (the Training Organisation for Personal Social Services). Records indicate that 75 of the staff team have completed National Vocational Qualification level 2 or above. Staff members have received training on a wide range of issues related to their work. The care manager stated that they were in the process of completing person-centred & health action plan training at the time of the inspection. DS0000001818.V298224.R01.S.doc Version 5.2 Page 16 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 this service. The respite service is well managed. EVIDENCE: The care manager is a Registered General Nurse. She is in the process of completing the Registered Managers Award. Regular monitoring visits are undertaken by the Registered Provider and reports forwarded to the Commission for Social Care Inspection. Guests are consulted during the course of their stays. The care manager stated that a yearly questionnaire is sent to guests and their families. She agreed to look into whether it would be possible to publish the results of those surveys. Staff members have received training on a number of safe working practices. Records indicate that fire tests & drills take place at the required frequency. Risk assessments have been completed on a range of issues. DS0000001818.V298224.R01.S.doc Version 5.2 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 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 3 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 4 33 X 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 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 3 X X 3 X DS0000001818.V298224.R01.S.doc Version 5.2 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. 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 DS0000001818.V298224.R01.S.doc Version 5.2 Page 19 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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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