CARE HOMES FOR OLDER PEOPLE
Glebe House Retirement Home Rectory Lane Hollesley Woodbridge Suffolk IP12 3JS Lead Inspector
Helen Fontaine Unannounced Inspection 8th February 2006 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 Retirement Home DS0000024398.V282983.R01.S.doc Version 5.1 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 Retirement Home DS0000024398.V282983.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Glebe House Retirement Home Address Rectory Lane Hollesley Woodbridge Suffolk IP12 3JS 01394 410298 01394 411557 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 Glebe House Retirement Home DS0000024398.V282983.R01.S.doc Version 5.1 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 27th July 2005 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. Glebe House Retirement Home DS0000024398.V282983.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection of Glebe House took place over four hours and was the second statutory inspection visit in the inspection programme for 2005/6. Over the course of the two visits, all core standards have now been assessed. Four requirements made at the time of the last inspection have not yet been met and have been restated in this report with a new timescale for compliance. It must be pointed out that one of these requirements has been repeated twice before. Further information about unmet requirements can be found in the relevant standard. Unmet requirements impact upon the welfare and safety of service users. Two further requirements and two recommendations were identified at this inspection. A tour of the home was undertaken, one resident was spoken to individually and several more were talked to in groups. The homes new cook was spoken to and a number of the homes documents were looked at. Mr & Mrs Squirrell were present during some of the inspection, the assistance of a Senior carer was very much appreciated. What the service does well: What has improved since the last inspection?
The home is the in the process of addressing the issue over radiator covers, although not yet fitted they are being made. Glebe House Retirement Home DS0000024398.V282983.R01.S.doc Version 5.1 Page 6 The home do have formal supervision sessions and in addition to this the staff have yearly appraisals. 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 DS0000024398.V282983.R01.S.doc Version 5.1 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 Retirement Home DS0000024398.V282983.R01.S.doc Version 5.1 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 were not inspected at this inspection but found to be met at the last inspection. EVIDENCE: The above standards were not inspected on this visit. Glebe House Retirement Home DS0000024398.V282983.R01.S.doc Version 5.1 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 and 9 Residents can be assured that their health care needs are met but are not protected by the homes medication practices. EVIDENCE: The care plans looked at documented the health care needs of the residents and the daily report book documented visits by health professionals. In the care plan issues around chiropodist visits, dental checks, medical history was documented and any allergies written in red. Medical conditions such as arthritis was documented and in one case when the nighttime catheter needed to be connected. On this care plan and in the daily report book, it was documented when the District Nurse came for catheter care. The care plans looked at were found to reflect the current needs of the resident however plans were not being reviewed or documented on a monthly basis. It was also noted during the inspection the involvement of Mr & Mrs Squirrell in supporting residents to attend hospital appointments. Both Mr and Mrs Squirrell were out taking residents to the hospital during the time the inspector was present at the home.
Glebe House Retirement Home DS0000024398.V282983.R01.S.doc Version 5.1 Page 10 At the last inspection the home had a requirement around the safe storage of medication. This was with regard to the residents who self medicate and do not have either a lockable draw or cupboard to keep their medication in. Residents who self medicate still do not have lockable storage. The Medication Administration Record (MAR) was looked at and all but one of the sheets was appropriately documented. One of the residents, who had been staying at the home for respite, had at the last minute decided to extend their stay at the home. Medication been given but it had not been signed for on the MAR sheet. It was noted by the inspector that the GP did come to the home and review the medication. Glebe House Retirement Home DS0000024398.V282983.R01.S.doc Version 5.1 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): 14 People who use this service can expect to be able to choose how they spend their time. EVIDENCE: The home does have a number of resident who are very independent and two married couples. The home has developed areas for the married couples to give them a bedroom and a lounge area. It was observed during the tour of the home that one of the married couple had an area where they had their electric keyboard and office desk. One of the residents still has their car and also still have their boat, the senior said that sometimes two of the residents go out in the boat together. Residents spoken to during the inspection said that they could have their breakfast in bed, or in their own room if they wished. Another resident said that they have a lot of interests and go out shopping as well as going out for a meal. The Senior carer said that some of the residents go out to a local club in the evening and others go out to a nearby day centre. The home encourages residents to personalise their rooms and the rooms seen during the inspection all had lots of personal affects. Glebe House Retirement Home DS0000024398.V282983.R01.S.doc Version 5.1 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): 18 Residents are protected from abuse but the policies are still not fully documented. EVIDENCE: The previous two inspections identified a requirement around the home’s policies on adult abuse. The homes policy does not reflect the areas around whistle blowing and what steps to be taken by staff when responding to either a suspicion or incident. Staff spoken to are clear about what they would need to do in the event of any incident around adult abuse. Three residents spoken to individually all said that they felt very confident that any complaint or concern would be listened to and dealt with. All the residents spoken to said that they felt safe in the home and felt safe with the staff at all times. One resident who’s partner needed a lot of help, said that they chose this home after a visiting a number of other homes and they are delighted with the care and support they receive. Glebe House Retirement Home DS0000024398.V282983.R01.S.doc Version 5.1 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, 25 and 26 This home provides a clean and well-maintained environment for service users. The communal facilities are of a high standard. EVIDENCE: The home was a really beautiful old rectory, which has been maintained to a very high standard. The home was spotlessly clean in every area and in particular was the kitchen, which was organised very precisely. The garden area was extremely pleasant and one of the rooms, which looked out over the garden, gave the residents a good view of the wildlife and birds. Despite this inspection taking place during the winter months, the home was bright and well light. At the last inspection there were a number of radiators found to need covers. The senior carer said that they had been made and were just waiting to be fitted. After discussion with the manager, it has been agreed that the radiators will be fitted in two months time. Glebe House Retirement Home DS0000024398.V282983.R01.S.doc Version 5.1 Page 14 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 People who use this service can expect that the number of staff and the training they receive will allow their needs to be met. EVIDENCE: The requirement from the previous inspection about the staff roster, still needs to be addressed. The roster did show the staff on duty and from the documentation about the care needs of the residents, the staffing levels were adequate to meet their needs. However the managers hours are still not documented, although it was noted that the manager was very busy supporting residents attend hospital appointments. Staff files were looked at during the inspection and the issues around staff training were noted. The files documented training in, moving and handling, certificate in food hygiene. Although each of the staff’s file had their training documented, there was no staff-training programme as directed by the National Training Organisation. Such a programme will assist staff and management to be clear who needs training and when re-fresher courses are due. Glebe House Retirement Home DS0000024398.V282983.R01.S.doc Version 5.1 Page 15 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): 33, 35 and 38 Resident’s may have their views taken into account and the resident’s finances are kept safely but not documented. The residents can be assured that their health, safety and welfare are promoted and protected. EVIDENCE: The homes quality assurance programme and the documentation was looked at. The last process to actually take place was in 2004 and the home must make sure that this exercise is carried out each year. The Senior carer said that the home are looking at updating the current questionnaires and this is the reason that it has not taken place in 2005. The home did used to have residents meetings, however only one or two residents turned up and others asked said they did not want to attend. The Senior carer said that the staff do as a matter of course go round regularly and talk to everyone and establish if there are any problems. Glebe House Retirement Home DS0000024398.V282983.R01.S.doc Version 5.1 Page 16 Residents finances are kept securely in the homes safe, residents, family or representatives can deposit money for safe keeping and withdraw it anytime they want to. Each of the resident’s money is kept in separate bags and in the bags there is a notebook where it is documented how much money was taken out. However it was noted that an amount of money had been placed in one residents bag and the only documentation was an unsigned note. 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 the inspection report for electrical installations and the stairlift. The home were able to produce for the inspector a large file where all the necessary documentation around health and safety were kept. This method of keeping records did greatly assist the inspector with evidencing that this standard was met. Glebe House Retirement Home DS0000024398.V282983.R01.S.doc Version 5.1 Page 17 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 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 X X X X X 2 3 STAFFING Standard No Score 27 2 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X 2 X X 3 Glebe House Retirement Home DS0000024398.V282983.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? YES 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 OP7 OP9 Regulation 15(b) 13 Timescale for action The registered person must 22/03/06 review the care plan once a month. The registered person must 08/03/06 make sure that secure storage must be provided for all medication. This requirement has been repeated from the last inspection. The registered person must 08/05/06 ensure that all administered medication is recorded on the MAR sheets. The registered person must 22/03/06 ensure 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. A copy of the amended policy on adult abuse must be sent to the Commission. This requirement has been repeated from the previous two inspections. The registered person must 08/05/06 ensure that there is a sound
DS0000024398.V282983.R01.S.doc Version 5.1 Page 19 Requirement 3. OP9 13(2) 4. OP18 13 5. OP33 24(1)(3) Glebe House Retirement Home 6. OP27 17(2) Sch 4 7. OP19 23 quality assurance system in place that includes resident’s comments and wishes. The registered person must 22/03/06 maintain an up to date duty roster for all staff working at the home including the manager. This is a repeat requirement from the previous inspection. The registered person must have 08/04/06 all radiators identified as a risk fitted with a guard. This is a repeat requirement from the previous inspection. 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. 2. Refer to Standard OP35 OP30 Good Practice Recommendations Arrangements are made to keep more accurate records of resident’s money. The home put in place a staff-training programme. Glebe House Retirement Home DS0000024398.V282983.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Suffolk Area Office St Vincent House 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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