Inspection on 03/07/05 for Glebe House (Charnwood) Limited

This inspection was carried out on 3rd July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 14/06/06

Glebe House (Charnwood) Limited 14/08/05

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 Trisha Gibbs Unannounced Inspection Sunday, 03 July 2005 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 (Charnwood) Limited C51 S1818 Glebe House (Charnwood) Limited V225759 030705.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Glebe House (Charnwood) Limited Address 190 Forest Road Loughborough Leicestershire LE11 3HU 01509 218096 01509 210881 annfolkes.glebe190@virgin.net Glebe House (Charnwood) Limited 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) Mrs Beverley Fern Care Home (with Annex Accommodating 16-17 Year Olds) 3 Category(ies) of Learning Disability (LD) - 3 registration, with number of places Glebe House (Charnwood) Limited C51 S1818 Glebe House (Charnwood) Limited V225759 030705.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: No-one under the age of 16 may be accommodated in the home. Date of last inspection 14th December 2004 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 unannounced Inspection, provides respite care in the form of weekend breaks (Friday p.m. until Monday a.m.) for fourteen service users, who prefer to be referred to as guests. This provision is only open twelve weekends a year and there is a waiting list. The flat in which respite takes place is registered to accommodate three guests for each stay, having one double 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 young person under the age of eighteen has received the weekend break service. Glebe House (Charnwood) Limited C51 S1818 Glebe House (Charnwood) Limited V225759 030705.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection took approximately three hours and was the first statutory unannounced Inspection this year. One resident’s case was fully tracked and others looked at during the Inspection. The Inspector looked at files, observed and talked to three guests, looked at communal rooms and bedrooms, and held discussions with two care staff, the Weekend Break Organiser and Care Manager. Nine comment cards were received from relatives, all indicating satisfaction with the service provided. One carer said ‘we are very pleased with the service.’ Another ‘my son really looks forward to his respite stays, we only wish he could have more’ and ‘the carer’s are very helpful’. Nine service user comment cards were returned, some completed by carers. All were positive. One noted that the breaks at Glebe House were like ‘home from home’ and another ‘the food is good, the care is good and there are lots of things to do’. What the service does well: Provides a unique respite break facility and a very good standard of weekend care, based on normal living principles, for people who have a learning disability and, in some instances, related physical disabilities. Provides very good person centred, care planning documents, and risk assessments for each guest. Ensures that guests are consulted and facilitated to make choices about everything they do while on their break. Provides an attractive, nicely decorated and well-equipped flat in addition to other recreational facilities, to enable guests enjoy an informal weekend away. Provides a full and relevant training programme for the staff team. Glebe House (Charnwood) Limited C51 S1818 Glebe House (Charnwood) Limited V225759 030705.doc Version 1.40 Page 6 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 (Charnwood) Limited C51 S1818 Glebe House (Charnwood) Limited V225759 030705.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 (Charnwood) Limited C51 S1818 Glebe House (Charnwood) Limited V225759 030705.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 Guest’s individual needs are assessed and reviewed on a regular basis. EVIDENCE: Guest’s files contained good evidence of an ongoing assessment of need, in addition to regular reviews. Very good communication systems are in place between families and the staff team, who are informed of any change of need prior to weekend breaks. Glebe House (Charnwood) Limited C51 S1818 Glebe House (Charnwood) Limited V225759 030705.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) 6,7,9 Guests are positively supported to make choices, and to take acceptable risks. EVIDENCE: • There are very good care planning documents, drawn up for each guest who attends for the respite service over the year, and these are maintained securely in an office within the main house. At the time of each weekend break, the detailed plans for the three guests staying are moved to the flat for immediate reference. Staff members on duty were noted to have an excellent understanding about the individual needs of each guest. Prior to their weekend breaks, guests are forwarded a questionnaire asking them about which activities they would like to take part in, over the weekend. There was evidence in files, that the risk assessment process is used in respect of the full range of activities that guests participate in. • • Glebe House (Charnwood) Limited C51 S1818 Glebe House (Charnwood) Limited V225759 030705.doc Version 1.40 Page 10 • The staff team were observed use signing systems to communicate with one guest in order to ascertain his choice of breakfast. Photographs, signs and symbols designed to assist with communication, were seen around the flat, and the main body of the house. Glebe House (Charnwood) Limited C51 S1818 Glebe House (Charnwood) Limited V225759 030705.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) 13,15,16,17 Guests are enabled to enjoy an active and stimulating weekend break. EVIDENCE: • On the day of the Inspection the group were going for a shopping trip and had bought money with them to purchase items that they had already planned to purchase. The Inspector was impressed with the manner in which the two staff members quietly encouraged the three guests through their individualised morning ‘routines’ in a relaxed and unhurried manner, before they all finally set out for a morning’s shopping. Guests are supported to develop independence skills during their weekend break. On the previous night the group attended a show and were discussing this with staff and Inspector at breakfast. One guest showed the Inspector photographs of previous outings and activities. There are also large photographs for guests who have impaired vision. C51 S1818 Glebe House (Charnwood) Limited V225759 030705.doc Version 1.40 Page 12 • • Glebe House (Charnwood) Limited • Each guest has the opportunity, prior to their break, to let the staff team know which meals they would especially like to have over the weekend and this is facilitated as far as possible. Families keep in very close contact with staff. There are very good written and informal communication systems. Most of the guests also attend for other community day services at Glebe House. • Glebe House (Charnwood) Limited C51 S1818 Glebe House (Charnwood) Limited V225759 030705.doc Version 1.40 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 standard(s) 18,19,20 Very good attention is given to the personal and health care needs of guests. EVIDENCE: • Care plans contained clear details about the different healthcare needs of each guest. Contact numbers are clearly indicated in the event of staff needing emergency medical advice or assistance over the weekend. The staff team are routinely provided with training to equip them to meet the individual health care and personal needs of the guests who stay at the flat over the year. The Care Manager for Glebe House is a Registered General Nurse who, along with other health professionals, delivers health care and medication training to staff. She informed the Inspector that the medication documentation is currently being reviewed and updated. Systems for the receipt of medication as guests arrive for the weekend, and the signing off on departure, were explained to the Inspector. These are rigorous. Medication charts were carefully and appropriately completed. • • Glebe House (Charnwood) Limited C51 S1818 Glebe House (Charnwood) Limited V225759 030705.doc Version 1.40 Page 14 Glebe House (Charnwood) Limited C51 S1818 Glebe House (Charnwood) Limited V225759 030705.doc Version 1.40 Page 15 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) 22,23 The views of guests are sought and they are kept safe. EVIDENCE: • Although there is a Complaints Procedure available, guests are routinely given the opportunity to have their say about the respite service during their weekend stay. Very good attention is given to staff awareness about Adult Protection and there are clear Procedures to respond to allegations, in addition to Child Protection Procedures for potential guests who are under the age of eighteen. Training sessions are provided routinely to ensure all staff members are aware of their respective responsibilities in relation to recognising and reporting potential Adult Protection situations. • • Glebe House (Charnwood) Limited C51 S1818 Glebe House (Charnwood) Limited V225759 030705.doc Version 1.40 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 standard(s) 24,30 Guests enjoy their respite breaks in a comfortable, colourful, and homely flat. EVIDENCE: • The flat is decorated and furnished to a good standard, and was clean throughout on the day of Inspection. The guests enjoy a very large, recently decorated and refurbished kitchen/dining room. The bright substantial lounge provides plenty of opportunities for guests to read, watch television and listen to music. The guests also have access to other facilities at Glebe House, including the substantial garden and grounds. There is one large double bedroom and one single bedroom available for respite stay; these are always completely booked for the year. Guests have choices about which room they prefer to stay in (in advance) and the coordinator confirmed that some guests prefer and enjoy sharing the double room with friends, and that the arrangement had not caused any C51 S1818 Glebe House (Charnwood) Limited V225759 030705.doc Version 1.40 Page 17 • • Glebe House (Charnwood) Limited difficulties. Most of the guests know each other well. Bedrooms are nicely decorated and furnished and have washing facilities. • • The good-sized bathroom is fully equipped with appropriate aids to cater for all guests, and is being decorated later this year. An impressive new ramp has been built at the front of the house and one guest who uses a wheel chair was clearly delighted with the improvement to the old ramp. He gave the Inspector a demonstration of how well the ramp worked. Glebe House (Charnwood) Limited C51 S1818 Glebe House (Charnwood) Limited V225759 030705.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 A well-trained and committed staff team provides person centred care for the guests. EVIDENCE: • The Inspector spoke to and observed two members of staff on duty at the flat during the Inspection. They engaged positively with guests, while carrying out their care needs. A commendable comprehensive training programme was provided to the Inspector, covering all aspects of staff roles and responsibilities. Most of the staff team have achieved or are working towards NVQ level 2 or 3. New staff members receive a solid induction, developed by the Care Manager and this links the Learning Disability Award Framework programme with TOPPS standards. • Glebe House (Charnwood) Limited C51 S1818 Glebe House (Charnwood) Limited V225759 030705.doc Version 1.40 Page 19 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) 39,42 The Health and Safety of guests is given priority and actively promoted. EVIDENCE: • • The Care Manager is undertaking the Registered Manager Award. Regular monitoring visits are undertaken by the Registered Provider and reports forwarded to the Commission for Social Care Inspection. Guests are consulted at this time. There is extensive documentation on Health and Safety for the full Glebe House service, and evidence of the regular testing of fire equipment, and visits from Environmental Health Officers. The staff team receive good training on Health and Safety, including Moving and Handling, First Aid and Food Handling. C51 S1818 Glebe House (Charnwood) Limited V225759 030705.doc Version 1.40 Page 20 • • Glebe House (Charnwood) Limited • An excellent, very detailed risk assessment was seen for the use of the outside trampoline. The Manager indicated that she intended to simplify this to make it easy for the staff team to refer to. Glebe House (Charnwood) Limited C51 S1818 Glebe House (Charnwood) Limited V225759 030705.doc Version 1.40 Page 21 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 3 x x x Standard No 22 23 ENVIRONMENT Score 3 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 4 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x x 4 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x x 4 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Glebe House (Charnwood) Limited Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 4 x x 3 x C51 S1818 Glebe House (Charnwood) Limited V225759 030705.doc Version 1.40 Page 22 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 NONE 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 NONE Good Practice Recommendations Glebe House (Charnwood) Limited C51 S1818 Glebe House (Charnwood) Limited V225759 030705.doc Version 1.40 Page 23 Commission for Social Care Inspection The Pavilions, 5 Smith Way, Grove Park Enderby Leicester LE19 1SX 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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