CARE HOMES FOR OLDER PEOPLE
Glebe House Retirement Home Rectory Lane Hollesley Woodbridge Suffolk IP12 3JS Lead Inspector
Cecilia McKillop Key Unannounced Inspection 27th February 2007 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 DS0000024398.V331319.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 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. DS0000024398.V331319.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Glebe House Retirement Home Address Rectory Lane Hollesley Woodbridge Suffolk IP12 3JS 01394 410298 01394 411557 sallysquirrel@yahoo.co.uk 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) Mrs Sally Ann Squirrell Mr Nigel David Squirrell Mrs Sally Ann Squirrell Care Home 17 Category(ies) of Dementia (1), Learning disability (1), Old age, registration, with number not falling within any other category (17) of places DS0000024398.V331319.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 1 The home may accommodate one service user aged 60 years whose name was made known to the Commission for Social Care Inspection in November 2004. 2 The home may accommodate one service user under the age of 65 years who requires care by reason of dementia and whose name was made known to the Commission for Social Care Inspection in May 2005 9th February 2006 2. Date of last inspection Brief Description of the Service: Glebe House is located on the edge of the village of Hollesley, in a former rectory within seven acres of mature grounds. The accommodation is of a high standard and all bedrooms have en-suite bathrooms. The communal areas consist of a lounge, dining room and conservatory and the areas are all well furnished with pleasant views over the garden. Bedrooms are located on the ground, first and second floors and there is a lift and a chair lift. The home is owned by Mr and Mrs Squirrel who are both actively involved in the management of the home. The home has traditionally cared for residents who are relatively independent and at the time of the inspection provided one member of waking night staff. Mr and Mrs Squirrel reside in an adjacent property and provide on call services at night should the need arise. DS0000024398.V331319.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This report follows an unannounced inspection, which was conducted over a five hour period. A tour of the home was undertaken and six residents were spoken with about life in the home. Two staff and the cook were interviewed, and a sample of records were examined. Mrs Squirrel the proprietor / manager was available throughout the day and assisted with the inspection. What the service does well: What has improved since the last inspection?
The requirements made at the last inspection have been addressed. Residents who self medicate have been provided with lockable cupboards. Care plans are detailed and informative and are regularly being reviewed. A whistle blowing policy was on display. Residents reported that a residents meeting had recently been held and they had been encouraged to express their views. A quality assurance system is in place and the views of service users and their relatives are ascertained on a
DS0000024398.V331319.R01.S.doc Version 5.2 Page 6 yearly basis. Radiators guards had been fitted in a sample of the bedrooms visited. Since the last inspection a new activity programme has been drawn up and was on display. 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. DS0000024398.V331319.R01.S.doc Version 5.2 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 DS0000024398.V331319.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 Quality in this outcome area is good. Prospective residents are enabled to make a choice about whether the home can meet their needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The registration certificate was on display. The certificate has conditions in place relating to DE and age. These conditions were agreed by the CSCI to allow the home to accommodate two residents with specific needs however they are no longer resident. Mrs Squirrel confirmed that the home does not intend to provide care to residents with dementia in the future. The records on a newly admitted resident were examined as part of the inspection. A pre admission assessment had been undertaken.
DS0000024398.V331319.R01.S.doc Version 5.2 Page 9 In addition there was an admission checklist for staff to complete as part of an admission and the GP was contacted directly by the home. The documentation in place was of a good standard and evidenced that residents were offered choices about how they wanted to be cared for and included areas such as how they wished to be addressed and whether they wanted to self medicate or not. The home does not offer intermediate care. DS0000024398.V331319.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10.Quality in this outcome area is good. The care that the resident receives at Glebe House is based on their needs and on good principles of care. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans looked at documented the health and care needs of the residents. The plans were detailed and informative and set out the actions to be taken by staff to meet resident’s needs. Resident’s preferences for their care were recorded and the plans were reviewed regularly. Residents interviewed confirmed that they had good access to medical support and the home transports residents to the local surgery to see their GP. A small number of residents continue to take responsibility for the storage and administration of their own medication. Lockable storage has been provided to these residents.
DS0000024398.V331319.R01.S.doc Version 5.2 Page 11 The home operates a monitored dosage system and there are clear systems in place for the receipt and ordering of medication. Medication was being stored appropriately in locked metal cabinets. Administration records were examined and were generally satisfactory and corresponded with the medication on site. Two incidents were noted however where staff had not signed to indicate that they had administered medication. It was agreed with the manager Mrs Squirrel that the procedures would be amended to ensure that gaps in recording would be immediately clarified by the next member of staff administering the medication. The staff were observed speaking to residents in a respectful manner and the residents who were spoken with confirmed that staff spoke to them appropriately and their privacy was upheld DS0000024398.V331319.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is excellent. People who use this service can expect to be able to choose how they spend their time. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home does have a number of residents who are very independent, and one resident has a workshop in the garden as well as his own boat. Residents spoken with confirmed that they were able to come and go as they wished, walk in the garden, meet friends and go out for lunch. The Library brings books regularly, newspapers are delivered and a number of the residents were observed reading quietly in the conservatory. A member of staff has taken on responsibility for organising in house activities and a programme was on display on the notice board. Recent activities had included cooking, crafts and board games. The inspector was informed that the home has the use of a minibus and trips out to places of interest are organised in the spring and summer.
DS0000024398.V331319.R01.S.doc Version 5.2 Page 13 On the morning of the inspection a number of the residents were taken to a local social group in the village where they had lunch. Residents are assisted to exercise control over their lives, and the inspector was informed that the deputy matron speaks with each resident individually each morning to discuss the day’s planned events. Residents confirmed that they were able to bring their own belongings with them and the bedrooms viewed had all been personalised. Residents spoken with confirmed that they good access to hot and cold drinks and individual preferences could be catered for. Breakfast is served in either the dining room or in the resident’s bedroom. The inspector observed the lunchtime routines as part of the inspection. The meal was served in the dining room, which was nicely laid with tablecloths and napkins. The atmosphere was very pleasant and relaxed. On the day of the inspection the choice was between salmon and broccoli pie and beef in Guinness with vegetables and potatoes. One resident had requested the salmon pie without the pastry topping and this was accommodated. The pudding served was stewed apple and custard. Residents informed the inspector that fresh fruit was also available. The meal served was tasty and nicely presented. DS0000024398.V331319.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. Residents can be assured that their views and concerns will be taken seriously. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager Mrs Squirrel informed the inspector that the home had not received any formal complaints over the last year .The Commission has also not received any complaints. There is a complaints procedure in place and residents interviewed said they thought that any complaints would be examined if raised with the proprietors. Overall residents reported that they felt listened to and taken seriously. The home has a copy of the vulnerable adults procedure within Suffolk. The whistle blowing procedure was on display in the office for staff to read. Formal training in this area is not however currently provided for staff and a recommendation has been made regarding this. DS0000024398.V331319.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,26 Quality in this outcome area is excellent. Residents who live in this home can be assured that they will be provided with a very comfortable, clean and well maintained environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is located in a beautiful old rectory, which is set in very pleasant gardens with lots of mature plants and wild flowers. Residents said that they enjoyed watching the wildlife, which comes into the garden. The home is maintained to a very high standard and was spotlessly clean. All the bedrooms are single bedrooms with ensuite facilities and some of the bathrooms have been fitted with equipment to allow residents to bath in their own ensuite. The bedrooms visited had all been highly personalised. The laundry facilities are
DS0000024398.V331319.R01.S.doc Version 5.2 Page 16 located in the basement and residents reported that the arrangements worked well. DS0000024398.V331319.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. Residents who live in this home are cared for by sufficient numbers of trained and competent staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection there were 3 care staff, two housekeeping and the cook on duty. Mrs Squirrel the manager was also available. The inspector was informed that the home mainly operates with 4 staff in the morning but the deputy manager was on holiday. The levels of staff observed on the day of the inspection were good. The home cares for a number of the residents who are relatively independent. The home has a hoist but none of the residents required this to transfer. Staff were observed responding appropriately to service users requests for assistance. Residents said that they did not feel rushed and staff were able to spend time with them. Staffing levels are lower at night and the home operates with only one member of waking night staff. This is an area that the homes management are aware
DS0000024398.V331319.R01.S.doc Version 5.2 Page 18 must be kept under review and increased should the needs of the residents change. The staff interviewed reported that they had access to a range of training and updates were due to undertaken shortly. The manager informed the inspector that approximately 50 of care staff had undertaken NVQ2 and all new staff were undertaking TOPPs induction training. Records were maintained in the staff files to evidence that staff had undertaken an induction to their role. The recruitment records of two members of staff were examined as part of the inspection and these were generally satisfactory. The last two members of staff who had been appointed were in 2005 and 2006. There was evidence of references being taken up and it was positive to note that these were also followed up by telephone. One of the members of staff had worked for a few weeks at another care home but the home had not taken up a reference with this home, as required. It was agreed that despite the short duration a reference request should have been made. Criminal Record Bureau checks and POVA first checks were being undertaken, however in 1995 a member of staff was noted to have started work before the result to the POVA check had been made known the home. The staff member who had been appointed in 2006 did not start work until the results of the check were known. DS0000024398.V331319.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. Glebe house is run by an experienced management team, who have good relationships with staff and residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The proprietors have owned and managed the home for many years. The deputy manager is experienced and there are clear lines of responsibility between her and the proprietors. The staff reported that they are well supported by management and that they receive supervision on a regular basis.
DS0000024398.V331319.R01.S.doc Version 5.2 Page 20 Residents spoke highly of the homes management and of staff and said that staff and management were approachable and the care that they received was of a good quality. Residents said that there were residents meetings held and the inspector was shown copies of questionnaires which had been sent to residents and their families to complete. The manager agreed to look at how the results when collated could be fed back to residents and their families. The home safeguards small amounts of money for a small number of residents. A sample of the records were examined as part of the inspection and were found to be maintained in good order. The homes practices around health, safety and welfare of the residents and staff were looked at during this inspection. It was noted that the documentation by the cook and the kitchen staff, were done to a very high standard. All the homes records around Fire related issues were all up to date and this included the emergency lighting and testing. The water testing temperatures were documented and there was evidence of regular servicing of the lifts. DS0000024398.V331319.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 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 X 3 X X x HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 DS0000024398.V331319.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13 Requirement The registered person must ensure that there is a clear policy, which is adhered to addressing the steps that staff should take when there are gaps in the medication administration records. The registered person must take up references with prospective staffs last employer, and POVA first checks prior to them taking up post. Timescale for action 01/04/07 2 OP29 19 01/04/07 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 Good Practice Recommendations
DS0000024398.V331319.R01.S.doc Version 5.2 Page 23 1. 2. Standard OP33 OP18 It is recommended that feedback from the quality questionnaires is made available to prospective residents, residents and their families It is recommended that training to staff is provided on the procedures for vulnerable adults and the Department of Health guidance, no secrets DS0000024398.V331319.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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
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