Inspection on 30/11/07 for Glebe House (Charnwood) Limited

This inspection was carried out on 30th November 2007.

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 14/06/06

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 Ruth Wood Unannounced Inspection 30 November 2007 01:30 th Glebe House (Charnwood) Limited DS0000001818.V341459.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 Glebe House (Charnwood) Limited DS0000001818.V341459.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. Glebe House (Charnwood) Limited DS0000001818.V341459.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 annfolkes.glebe190@virgin.net 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 Glebe House (Charnwood) Limited DS0000001818.V341459.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 June 2006 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 is able to provide a number of additional weekends during this and the coming 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 wellequipped 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. At the time of the inspection, the local authority funded twelve weekend breaks at Glebe House. Additional weekends are funded through fundraising efforts. As a result, guests do not pay any fees. Information about the service, the ‘Weekend Break Guide’ has been produced for guests & their families. Glebe House (Charnwood) Limited DS0000001818.V341459.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An Annual Quality Assurance Assessment (AQAA) was completed by the service and returned to the Commission prior to the inspection visit. The Commission also issued surveys to guests and their relatives and received responses from five guests and four relatives. Information from these sources together with that gathered during the inspection visit were used to produce this report. The inspection visit took place on a Friday afternoon/early evening between 1.30pm and 5:30pm. The first part of the visit (before guests arrived) focussed on examining the assessments and support plans for the three people staying that weekend together with staff training and recruitment files and records relating to health and safety. Discussion was held with the Project Coordinator about the service’s policies and procedures and all areas of the respite flat were seen. Later, the inspector spoke to two guests and the staff on duty(which included the Weekend Break Coordinator) about the plans for the weekend and how guests’ needs were met. Interaction between staff and the guests was observed and the arrangements for the administration of medication were examined. What the service does well: The service offers excellent opportunities for guests to make choices about their stay such as the activities they wish to be involved in, the food they wish to eat and to a certain extent who they wish to stay with. Staff are well trained and have a very person-centred approach, which takes account of each individual’s needs and interests. The two guests spoken with at the inspection appeared happy and relaxed and very much looking forward to their weekend break. The assessment process prior to guests’ stay is very thorough which means that support plans clearly detail how individual’s needs should be met. Information about how to meet health, personal care and medication is particularly well documented and all staff have received training in meeting personal care needs and in administering medication. Both guests and their relatives express a high level of satisfaction with the service, one said “I think it does everything very well” When asked by the Commission how the service could improve one relative said “I’m not really sure if it can although I’m sure they will if they can” Good systems are in place to monitor the ongoing quality of the service provided and all guests and their relatives are asked to give feedback after Glebe House (Charnwood) Limited DS0000001818.V341459.R01.S.doc Version 5.2 Page 6 every stay. This is used to inform changes and improvements to the service offered. 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. The summary of this inspection report can be made available in other formats on request. Glebe House (Charnwood) Limited DS0000001818.V341459.R01.S.doc Version 5.2 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 (Charnwood) Limited DS0000001818.V341459.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 Quality in this outcome area is good Assessment practices are thorough, ensuring that guests’ needs are identified prior to their stay and met during their stay. Good quality information about the service is made available to guests and their relatives. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The information in the current service user guide is comprehensive, written in a clear and accessible style and includes feedback from previous guests. Most guests and their relatives who responded to the Commission’s surveys said they receive sufficient information about the home before their stay. Assessment procedures are very thorough. Before their visit each guest and their family complete a self-assessment questionnaire, which details their support needs in all areas. Many of the guests who use the weekend break service have used various services at Glebe House for a number of years and are therefore well known to staff members. Discussions with the project coordinator and organiser demonstrated that staff have a very good knowledge of guests before they come to stay. There is flexibility as to how long people can stay ranging from a day, to overnight, to the full weekend. This flexibility in the length of stay available was introduced in response to feedback from guests. Glebe House (Charnwood) Limited DS0000001818.V341459.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is excellent Service users are actively involved in planning their stay and are supported to take acceptable risks. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The individual support plans for the three guests staying the weekend had been drawn up with guests and their families prior to their stay. These give detailed information as to how each person’s needs may be met. Plans are always reviewed and updated before each weekend stay. Comprehensive risk assessments are in place for all guests covering all aspects of care and support; these outline the strategies needed to manage each risk identified. The emphasis of guests’ stay is very much about choice and before the weekend they are asked to indicate the activities they would like to take part in and this information is used to draw up a timetable. Guests are also asked to indicate the food they would like to eat over the weekend and the bedroom they would like to sleep in. All the service users who responded to the Commission’s survey said that they could always or usually do what they wanted during the day and in the evening. Staff were observed to Glebe House (Charnwood) Limited DS0000001818.V341459.R01.S.doc Version 5.2 Page 10 communicate very effectively with guests during the inspection visit, giving them multiple opportunities, and the time, to make their own decisions. Glebe House (Charnwood) Limited DS0000001818.V341459.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome area is excellent Guests enjoy an active and stimulating weekend break. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The service provides a break for both guests and their carers and supports people to increase their level of independence. The two guests that the inspector met were very positive about staying at the flat and looking forward to the activities they had chosen. There was much discussion with staff about what would be possible given the weather forecast but a visit to the pub for a meal, some shopping and possibly bowling were anticipated. The flat is near to the centre of Loughborough, therefore many facilities are within walking distance or can be accessed by public transport. Glebe House also has its own transport to access facilities further away. Efforts are made to ensure that the people who stay together know each other and are compatible. The two guests that the inspector met knew each other from other settings and appeared to get on well. One respondent to the Commission’s survey said that they did not like some of the people that they had to stay with. Glebe House (Charnwood) Limited DS0000001818.V341459.R01.S.doc Version 5.2 Page 12 While at the flat guests have the opportunity to get involved in meal preparation and other domestic activities. Guests also have access to the wider facilities of Glebe house during their stay such as computers with broadband access. People are asked about what they like to eat before they come to stay and food served appears to be nutritionally well balanced and meets individual and cultural preferences. The two guests who spoke to the inspector said that the food was good and that they enjoyed it. Glebe House (Charnwood) Limited DS0000001818.V341459.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is excellent Excellent arrangements are in place for meeting guests’ personal, medication & healthcare needs This judgement has been made using available evidence including a visit to this service. EVIDENCE: Guests’ personal care needs are clearly documented in their support plans and any changes necessary to the plan are identified prior to their stay. All staff receive training in delivering personal care and this is regularly updated. Good systems are in place to ensure that guests’ health care needs are effectively met during their stay. Each guest has a ‘hospital grab sheet’, which includes all necessary information should they need to access emergency treatment. Again prior to each stay guests and their families are asked for any updates in their healthcare needs. Epilepsy care plans are in place for those with this condition and all staff have been trained in administering rectal diazepam. Training documents show that all staff have received training in administering medication. There are clear policies and procedures in place as to how guests’ medication is received into the service and medication not in its original container is not accepted. Again guests and their carers are asked for a complete record of all medication and how it is to be administered prior to their Glebe House (Charnwood) Limited DS0000001818.V341459.R01.S.doc Version 5.2 Page 14 stay. All guests are assessed as to whether they can administer their own medication. One guest staying during the weekend of the inspection was able to do this and could choose whether to keep medication in a lockable facility in their room or in the main medication cabinet. They helped staff to enter their medication on to a Medication Administration Record; staff were observed to give the guest sufficient time to enable them to remain in control of this process. Glebe House (Charnwood) Limited DS0000001818.V341459.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good Guests’ views are listened to and acted upon and good systems are in place to protect them. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All guests who responded to the Commission’s survey said they knew who to speak to if they weren’t happy and three of the four relatives who responded said that they knew how to make a complaint. All four relatives said that the service had responded appropriately to any concerns raised. The rules for anyone using the service (guests and staff) are clearly displayed in picture format on the kitchen wall and guests are clear about what behaviour is unacceptable. There is a formal complaints procedure and staff have received training in different communication methods to ensure that guests can express their concerns using their preferred means of communication. Communication between staff and guests was observed to be open and friendly. Child Protection and Safeguarding Adults training has been combined so that staff are aware of similarities and differences and are aware of the relevant legislation in both areas. Information about the Mental Capacity Act has also been incorporated into this training. Glebe House (Charnwood) Limited DS0000001818.V341459.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is good Guests stay in a comfortable and safe environment which is suitable for their needs This judgement has been made using available evidence including a visit to this service. EVIDENCE: All staff have received training in infection control and the Department of Health’s ‘essential steps’ guidance has been used to ensure good practice in this area. Four of the five guests who responded to the Commission’s survey felt that the home was always fresh and clean; one said that it usually was. 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. Although a stair lift has been installed from the ground floor to the flat, this cannot be used by people with a physical disability but does assist those with some degree of impaired mobility. Glebe House (Charnwood) Limited DS0000001818.V341459.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome area is excellent Guests are effectively supported and protected by well-trained staff and good recruitment practices This judgement has been made using available evidence including a visit to this service. EVIDENCE: The recruitment records of three staff on duty during the weekend of the inspection were examined. All contained a completed application form, two written references and evidence that a criminal records bureau check had been obtained prior to the staff starting work. 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). All staff have either completed National Vocational Qualifications at level 2 or 3 in Care, Health and Social Care, Caring for Children and Young People or Promoting Independence or they are in the final stages of doing so. All staff are trained as Person Centred Planning facilitators and some are Health Action Planning Facilitators. Staff have recently been involved in a music therapy workshop, some undertook Makaton training on the day of the inspection and training in the Mental Capacity Act is being planned. Glebe House (Charnwood) Limited DS0000001818.V341459.R01.S.doc Version 5.2 Page 18 Four of the five guests who responded to the Commission’s survey said that staff always treat them well and listen and act on what they say – one service user said that they sometimes did. Interaction between guests and staff appeared relaxed and friendly. Glebe House (Charnwood) Limited DS0000001818.V341459.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good Good management ensures that the service is run in the best interests of the guests who use it This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager is a Registered General Nurse and has completed the Registered Managers Award. The Annual Quality Assurance Assessment (AQAA) completed by the service demonstrates that the effectiveness of the support given to guests and their families is constantly monitored. It contains evidence of changes made to policy and practice based on feedback obtained from users of the service. For example a flexible length of stay is now offered to guests of between one and three days. Questionnaires are given to guests and their families after each stay and the results are monitored, evaluated and published. A summary of guests and relatives’ comments is included in the service users guide. Glebe House (Charnwood) Limited DS0000001818.V341459.R01.S.doc Version 5.2 Page 20 Fire, heating and electrical systems are regularly serviced and staff receive training in all aspects of health and safety Glebe House (Charnwood) Limited DS0000001818.V341459.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 X 4 3 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 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 4 X 3 X 3 X X 3 X Glebe House (Charnwood) Limited DS0000001818.V341459.R01.S.doc Version 5.2 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. 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 Glebe House (Charnwood) Limited DS0000001818.V341459.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 (Charnwood) Limited DS0000001818.V341459.R01.S.doc Version 5.2 Page 24 - 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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