CARE HOMES FOR OLDER PEOPLE
Glebe House Retirement Home Rectory Lane Hollesley Woodbridge Suffolk, IP12 3JS Lead Inspector
Cecilia McKillop Unannounced 27th 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 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 Retirement Home I54-I04 S24398 Glebe House V241469 050727 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Glebe House Retirement Home Address Rectory Lane, Hollesley, Woodbridge, Suffolk, IP12 3JS 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) 01394 410298 01394 41157 None Mr and Mrs Squirrell Mrs S Squirrell CRH 17 Category(ies) of OP - 17, LD - 1, DE - 1 registration, with number of places Glebe House Retirement Home I54-I04 S24398 Glebe House V241469 050727 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: There are two conditions on the homes registration which relate to the placement of two individuals under the age of 65 years , one of whom has been identified as having Dementia Date of last inspection 9th November 2004 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 ensuite 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 adjacant property and provide on call services at night should the need arise. Glebe House Retirement Home I54-I04 S24398 Glebe House V241469 050727 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was a routine unannounced inspection carried out over 3.5 hours on a weekday afternoon and early evening. During the inspection the inspector spoke with a number of the staff on duty, which included the manager, the deputy manager and two care staff. A number of records were examined and the inspector spoke with 4 residents as well as the live in carer for one resident. What the service does well: What has improved since the last inspection?
A sample of contracts were examined and these now document the level of fee payable. Risk assessments have been undertaken on a range of areas including the windows and it was agreed that these should be kept under review to take account of the changing needs of the residents. References are now obtained on staff before they take up their position and the manager confirmed that where a criminal record bureau check is overdue they have begun to liaise with the applicant and the CRB to address the problem. The complaints procedure is now attached to the statement of purpose. Glebe House Retirement Home I54-I04 S24398 Glebe House V241469 050727 Stage 4.doc Version 1.40 Page 6 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 Retirement Home I54-I04 S24398 Glebe House V241469 050727 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Glebe House Retirement Home I54-I04 S24398 Glebe House V241469 050727 Stage 4.doc Version 1.40 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 standard(s) 2,3,4,5, Residents have an opportunity to visit the home to assess the suitability of the home before their admission and an assessment is undertaken of their needs by the staff at the home. EVIDENCE: A number of new residents had been admitted to the home since the last inspection and these residents had the opportunity to visit the home prior to their admission. The manager and the deputy had also visited the residents in hospital or in their own home as part of a pre admission assessment. One resident who was on a month’s trial stay was positive about how her admission had been managed. There is an admission checklist for staff to complete as part of an admission and the GP is 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 resident contract now documents the fee payable.
Glebe House Retirement Home I54-I04 S24398 Glebe House V241469 050727 Stage 4.doc Version 1.40 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 standard(s) 7,9,10 Resident have an individual plan of care, which sets out his or her needs. Residents are enabled to look after their own medication however more secure storage should be provided. Residents are treated in a respectful manner. EVIDENCE: A sample of care plans were examined as part of the inspection and these were informative and detailed and included information about the residents interests and care needs. Staff had begun to develop care plans for the newly admitted residents but had sufficient information to enable them to care adequately for the residents in the interim period. Advice is obtained from the district nurse and the local dietician. Staff undertake regular recording of residents changing care needs and the care provided. The recording was generally satisfactory but the manager’s attention was drawn to one inappropriate comment and it was agreed that this would be discussed with the member of staff. Glebe House Retirement Home I54-I04 S24398 Glebe House V241469 050727 Stage 4.doc Version 1.40 Page 10 The home supports residents to maintain their independence and a number of residents continue to take and look after their own medication. Secure storage is not provided for all residents who self medicate. 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. The manager confirmed that residents are offered a key to their bedroom and it was noted that a small number of residents have chosen to have one. Glebe House Retirement Home I54-I04 S24398 Glebe House V241469 050727 Stage 4.doc Version 1.40 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 standard(s) 12,13,15 Residents are supported to maintain contacts with friends and families and access activities both within the home and in the local community. Residents have a choice of meals and the food is well presented. EVIDENCE: On the afternoon of the inspection a game of crib had been organised for residents. There are lots of large print books available and some painting equipment was laid out in the conservatory. Residents reported that they were satisfied with the organised activities and in the weeks preceding the inspection there had been a number of outings arranged to places of interest. The inspector was given examples by staff and of how the home assists residents to maintain contact with family and friends. The home is located on the edge of the village of Hollesley and residents reported that they were able to visit the local shop. One newly admitted resident had begun to attend a club in the local village and it was hoped that this could be expanded to involve other residents and clubs. The homes proprietor is also willing to transport residents into Woodbridge the nearest town. Glebe House Retirement Home I54-I04 S24398 Glebe House V241469 050727 Stage 4.doc Version 1.40 Page 12 Meals are served in the dining room, which is comfortable and accessible. The inspector observed the serving of the evening meal and noted that residents had a choice between sandwiches, corned beef salad and fish fingers. The food was nicely presented and appeared to be enjoyed by residents. One resident requested something else and this was organised quickly. Glebe House Retirement Home I54-I04 S24398 Glebe House V241469 050727 Stage 4.doc Version 1.40 Page 13 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 standard(s) 16,18 The home has a complaints procedure and staff are clear about how they should respond to complaints and other concerns. EVIDENCE: No formal complaints have been received by the Commission over the last year. At the last inspection the home had been required to amend its statement of purpose to include details of how to make a complaint and the home have confirmed that it now attaches a copy of the complaints procedure to the statement of purpose. The home has information on vulnerable adults and how to respond to any concerns and it was agreed that the homes management might find it helpful to consider updating training. Staff were clear about how to respond to concerns however the manager was unable to locate the abuse policy on the day of the inspection. A requirement had been made at the last inspection regarding this policy and this has been repeated. Glebe House Retirement Home I54-I04 S24398 Glebe House V241469 050727 Stage 4.doc Version 1.40 Page 14 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 standard(s) 19,26 The home is clean and well maintained EVIDENCE: The home was clean tidy and odour free the day of the inspection. No hazards were noted. There was evidence of ongoing maintenance and upgrading. Handles and a step had been fitted at the entrance to the conservatory to assist one service user. Residents reported that where there were breakdowns of equipment these were addressed speedily. A small number of radiators were found not to have either covers or low surface temperatures. The manager agreed to conduct risk assessments on these. Glebe House Retirement Home I54-I04 S24398 Glebe House V241469 050727 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29, The staffing levels on the day of the inspection were adequate however the staffing rota must reflect the staff on duty. The systems in place for the recruitment of staff offers better protection for residents and training is provided for new staff. EVIDENCE: The home was found to be adequately staffed on the day of the inspection with 3 care staff on duty with 16 service users. Staff were observed taking time to assist resident’s. At night the home was being staffed by one waking member of waking night staff, with the proprietor sleeping in an adjoining property. It has been agreed with the proprietors that they must continue to monitor the levels of dependency of the residents and increase the levels of staffing at night should residents require the assistance of two staff. The staffing rota was examined and it was noted that the hours worked by the manager was not documented on the rota. The inspector had a query about staffing levels at the weekends but this could not be clarified from the rota. The manager confirmed that she was in the process of changing how the rota is documented and it was agreed that the hours worked by the manager would be recorded on the rota. At the last inspection the inspector raised issues about the length of hours worked by some staff. One of these staff was interviewed as part of the inspection and she confirmed that she had regular breaks during the long shift.
Glebe House Retirement Home I54-I04 S24398 Glebe House V241469 050727 Stage 4.doc Version 1.40 Page 16 It was agreed that the home’s management would continue to monitor this arrangement to ensure that it best meets the needs of residents. The recruitment records on a recently appointed, member of staff was examined as part of the inspection. Two references had been obtained and there was evidence to confirm that the applicant had been interviewed and her ID had been checked. While there was evidence to show that a CRB check had been commenced there was no evidence on the file to show that a POVA first check had been undertaken prior to her starting work. The inspector was however informed on the day following the inspection that the POVA first check had not been correctly filed and that it had been undertaken. This will be followed up at a future inspection. There was evidence on staff files of staff receiving formal induction about the caring role and the inspector was informed that staff had recently attended training on nutritional screening. Glebe House Retirement Home I54-I04 S24398 Glebe House V241469 050727 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,36 Glebe house is run by an experienced management team, who have good relationships with staff and residents. EVIDENCE: The proprietors have managed the home for over 10 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 although formal supervision has lapsed. 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. Since the last inspection a number of risk assessments have been undertaken. Glebe House Retirement Home I54-I04 S24398 Glebe House V241469 050727 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3
COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 x x x 2 x x Glebe House Retirement Home I54-I04 S24398 Glebe House V241469 050727 Stage 4.doc Version 1.40 Page 19 yes 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. 3. Standard 9 27 25 Regulation 13 17 23 Requirement Secure storage must be provided for all medication. The manager must maintain an up to date duty roster of all staff working at the home. Risk assessments must be undertaken on all radiators and where a risk is identified a guard fitted. The policy on abuse should be expanded to provide more details on areas such as whistle blowing and the steps to be taken by staff when responding to either a suspicion or an incident. Timescale for action 01/10/05 01/10/05 01/10/05 4. 18 13 01/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 36 Good Practice Recommendations It is recommended that the home set up formal supervision sessions for care staff Glebe House Retirement Home I54-I04 S24398 Glebe House V241469 050727 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection 5th Floor, St Vincent House 1 Cutler Street Ipswich Suffolk, IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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