Inspection on 09/12/05 for Glebe House Nursing Home

This inspection was carried out on 9th December 2005.

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 Nursing Home 28/03/07

Glebe House Nursing Home 02/06/05

Glebe House Nursing Home 10/08/04

Glebe House Nursing Home 14/04/04

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

CARE HOMES FOR OLDER PEOPLE Glebe House (Chaldon) Church Lane Chaldon Surrey CR3 5AL Lead Inspector Mary Williamson Unannounced Inspection 9th December 2005 10:00 X10015.doc Version 1.40 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 (Chaldon) DS0000013324.V272370.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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 (Chaldon) DS0000013324.V272370.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Glebe House (Chaldon) Address Church Lane Chaldon Surrey CR3 5AL 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) 01883 344434 01883 341504 Glebe Care Limited Mrs Sarah Elizabeth Vincent Care Home 43 Category(ies) of Physical disability (6), Physical disability over 65 registration, with number years of age (43) of places Glebe House (Chaldon) DS0000013324.V272370.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 4 (four) beds may be used for Palliative Care. Date of last inspection 2nd June 2005 Brief Description of the Service: Glebe House is a well- established care home providing nursing care for fortythree older people. The home has recently been extended to provide an extra four beds for people who are terminally ill. Accommodation is provided in single and shared rooms spread over three floors. There is a shaft lift and chair lift to provide access to all areas of the home. There is ample communal space to include a large lounge, dining room, and a conservatory, which provides ramp access to a mature well-maintained garden. Glebe House (Chaldon) DS0000013324.V272370.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and the second in The Commission for Social Care Inspection programme year 2005/2006. Mary Williamson, who is the lead inspector for the service undertook the inspection. The Registered Manager who is also The Provider was off duty. Staff Nurse Kay Stolle was present throughout the inspection. For the purpose of this report the service users living at Glebe House wish to be referred to as residents. There was the opportunity to meet with all the service users, and talk with some in more detail than others. There were no relatives visiting the home during the inspection. A tour of the premises was undertaken and records relating to the care of the service users and the care of the staff were examined. The home was functioning well and all the residents were well cares for in a relaxed atmosphere by staff in a caring and respectful manner. Most of the staff were spoken to. They all had a good understanding of the needs of the residents and the care they provide. They were also able to give a detailed account of the training they had received and the forthcoming training planned. The inspector would like to thank the residents and staff for their time and input to this inspection. What the service does well: The home provided good quality nursing care to residents as outlined in individual care plans. The environmental standard of the home is good and both communal and individual areas of the home meet the needs of the residents. The home is well managed and the staffing levels are sufficient to meet the assessed needs of the residents. Glebe House (Chaldon) DS0000013324.V272370.R01.S.doc Version 5.0 Page 6 The social and recreational arrangements provide a varied programme of events. 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 (Chaldon) DS0000013324.V272370.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glebe House (Chaldon) DS0000013324.V272370.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards remain unchanged. Please refer to the previous inspection report dated 2nd June 2005. EVIDENCE: Glebe House (Chaldon) DS0000013324.V272370.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, and 11. Resident’s health and personal care needs are met as outlined in individual care plans. Policies relating to privacy, medication administration and bereavement safeguard the residents in the home. EVIDENCE: Individual care plans are in place which are written with input from the residents whenever possible. Information from relatives, and the multidisciplinary team is also included. Several care plans were sampled, which are well maintained and reviewed on a regular basis. There was however no care plan in place for the most recent resident admitted to the home. A requirement has been made accordingly. All residents are registered with a local GP and are well supported by her. The GP visits the home every Thursday or more frequently if required. Arrangements are in place for residents to see the dentist, chiropodist and optician regularly. The chiropodist was visiting the home during the inspection and gave very positive feedback regarding the care provided and the professionalism of the staff team. Glebe House (Chaldon) DS0000013324.V272370.R01.S.doc Version 5.0 Page 10 Physiotherapy is provided and is inclusive of fees. The Physiotherapist visits the home weekly and also undertakes the initial moving and handling assessment. Several residents were being nursed in bed and the care provided was good. All the beds are supplied with pressure relieving mattresses, and there is a wide range of pressure relieving equipment in place to promote good nursing practice. There is a policy in place for the administration of medication. There is also a copy of The NMC Professional Code of Conduct in place. Chemitex Ltd. supply all the medication and undertake occasional audits. All qualified staff undertakes regular medication update training. The controlled medication is stored correctly and was randomly checked. The medication recording charts were seen and are well maintained. There was however several photographs for the purpose of identification missing from these charts and need to be replaced. Resident’s privacy and dignity is respected at all times. Staff are polite, and address residents by their preferred choice. All staff knock on bedroom doors prior to entering. Screens are provided in shared rooms. All staff have training in caring for the dying and the death of a resident. The inspector was assured that in such circumstances sensitive support is offered to the resident and their family and that spiritual preferences are respected. Glebe House (Chaldon) DS0000013324.V272370.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, and13. The leisure and recreational activities in the home meet the needs of the residents. Family links are maintained. EVIDENCE: Arrangements are in place to provide residents with a wide range of activities. These are planned monthly and include musical entertainment, gentle exercise, board and card games, art and craft, and one to one activities. Several residents stated that they were looking forward the Christmas Party and the arranged visits from local schools to sing carols. During the inspection some residents were sitting in the large lounge, some were downstairs in the dining room smoking, and more were reading books or newspapers in the privacy of their own room. Family links are maintained and all relatives had been invited to attend the Christmas Party. Visitors are welcome in the home at any reasonable time. Relatives are also involved in the care planning process. Glebe House (Chaldon) DS0000013324.V272370.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18. The complaints procedure is satisfactory and accessible to all. Residents are protected from abuse. EVIDENCE: The complaints procedure forms part of the service users guide and is available to all residents and their relatives on admission to the home. There have been no complaints since the last inspection. There is a copy of Surrey’s Multi-Agency Protection of Vulnerable Adults policies and procedures in the home, and the home also has an abuse awareness policy in place. All staff have training in these procedures during induction training. During a conversation with staff they felt confident that any incident of abuse reported would be taken seriously and acted upon. One referral was made under these procedures since the last inspection. Glebe House (Chaldon) DS0000013324.V272370.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 24, and 26. Residents live in a safe and well -maintained environment. Both communal and individual accommodation meets the needs of the residents. EVIDENCE: The home is well maintained and decorated to a good standard. Accommodation is offered in single and shared rooms and arranged over three floors. Resident’s bedrooms have been personalised to reflect individual interests and personalities. Personal items of furniture can be brought into the home by request. The communal areas of the home include a large lounge, a Victorian conservatory, which overlooks a mature well-maintained garden. The dining room is situated on the lower ground floor near the kitchen area. There are sufficient bathrooms and toilets situated throughout the home some of which have been adapted to meet the mobility needs of the residents. Glebe House (Chaldon) DS0000013324.V272370.R01.S.doc Version 5.0 Page 14 The home employs a physiotherapist and also has access to an occupational therapist. The home has been adapted to meet the mobility needs of the residents. Grab rails have been fitted throughout the home, toilet seats are raised and have safety arms. The bathrooms have also been adapted and include a shower room on the ground floor, and an Atjo high- low bath on the first floor. Hoists are supplied for moving and handling and there is ramp access to the gardens. There is also a call bell system in place. The home was clean and tidy and free from mal odour. Arrangements are in place for the collection of clinical waste. Glebe House (Chaldon) DS0000013324.V272370.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, and 30. The number and skill mix of staff on duty was sufficient to meet the assessed needs of the residents. EVIDENCE: The staff duty rota was seen during the inspection. There were three qualified nurses, nine carers, three cleaners, one cook, one kitchen assistant, one housekeeper, and one administrator on duty. The staff team were confident and professional in their manner. On discussion with the staff they confirmed they have access to training on and off site. Most of the staff team are undertaking either NVQ level 2 or level 3. One new member of staff confirmed that she had undertaken induction training and was now completing foundation training. The qualified staff are supported to develop their careers and training for PREP development is supported. There are two adaptation nurses working in the home on placement. Glebe House (Chaldon) DS0000013324.V272370.R01.S.doc Version 5.0 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, and 38. The residents live in a home, which is well managed in their best interests, and promotes their health and welfare. EVIDENCE: The home is owned and managed by Sally Vincent who is a qualified nurse with considerable experience in the provision of care to older people. She was off duty during the inspection. The home was functioning well in the capable care of Staff Nurse Kay Stolle and the staff team on duty. It was positive to note from discussion with staff that that they are included in care reviews, and take part in regular staff meetings. The health, safety and welfare of residents and staff are promoted and protected. There is a wide range of policies and procedures relating to health and safety available in the home. Risk assessments are in place for safe working practice. Staff have been trained in manual handling, first aid, food Glebe House (Chaldon) DS0000013324.V272370.R01.S.doc Version 5.0 Page 17 hygiene, and fire safety. COSHH procedures are observed and staff have a good awareness of these procedures. The fire safety records were seen and are well maintained. Fire alarms are checked weekly and there is a contract in place for the maintenance of fire fighting equipment. Glebe House (Chaldon) DS0000013324.V272370.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 X 3 X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X X X X 3 Glebe House (Chaldon) DS0000013324.V272370.R01.S.doc Version 5.0 Page 19 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 2 Standard 7 9 Regulation 15(1) 13(2) Requirement The registered person shall ensure that individual care plans are in place. The registered person shall ensure that a photograph is attached to each individual medication-recording chart. Timescale for action 16/12/05 31/12/05 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 (Chaldon) DS0000013324.V272370.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 (Chaldon) DS0000013324.V272370.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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