Inspection on 01/11/05 for Glebe Lodge

This inspection was carried out on 1st November 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Glebe Lodge 25/11/08

Glebe Lodge 29/11/07

Glebe Lodge 27/06/06

Glebe Lodge 12/06/05

Glebe Lodge 10/11/04

Glebe Lodge 12/05/04

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

CARE HOMES FOR OLDER PEOPLE Glebe Lodge 2 Hall Street Offerton Stockport Cheshire SK1 4DA Lead Inspector Kathleen Mcall Announced Inspection 10:00 1st & 2 November 2005 nd 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 Lodge DS0000008601.V263005.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 Lodge DS0000008601.V263005.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Glebe Lodge Address 2 Hall Street Offerton Stockport Cheshire SK1 4DA 0161-480 2025 0161 480 2025 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) Care UK Mental Health Partnership Limited (Arc Healthcare Limited) Mrs. Ruth Marshall Care Home 17 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (14) Glebe Lodge DS0000008601.V263005.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The number of persons for whom residential accommodation is provided shall not exceed 3 people MD and 14 MD (E). 12th June 2005. Date of last inspection Brief Description of the Service: Glebe Lodge is a residential care home that is registered to provide care for up to 17 residents whose primary care needs are due to them having a diagnosed mental illness; three of whom are aged between 50 years and 65 years of age. The registered manager is Mrs Ruth Marshall. Glebe Lodge is one of 75 care homes owned by the Care UK group who focus on providing rehabilitation services for residents with mental health difficulties. Glebe Lodge is a listed building; it is a large, detached house set in its own grounds. All bedrooms are single person occupancy spread over three floors. There are no ensuite facilities at the home, however all bedrooms have a vanity unit. The home has three bathrooms, one of which is fitted with an assisted bath. A shower is also available for those service users who prefer to shower. The home has two lounges one of which is a smoking lounge and a dining room. There is a large car park to the rear of the house with gardens to the side and front. The home is not suitable for wheelchair users; there is a fourperson passenger lift to assist residents around the home. There are a number of steep steps to the front of the property and ramp access is available to the rear of the home. Glebe Lodge is situated close to the town centre with good access to cinemas, local shops, library and park. Stockport town centre, motorway network and public transport are easily accessible. Glebe Lodge DS0000008601.V263005.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which took place over the course of a day and a half. A regulation manager accompanied the inspector on the first day of the inspection. The registered manager accompanied the inspector throughout the inspection process. Care plans, assessment documentation, medicines and their storage were examined. The inspector spoke with a number of residents, several members of staff and a relative who was visiting the home at the time of the inspection. Four service user comment cards were returned; three cards indicated that residents like living at the home and one responded that sometimes they liked living at the home. Two service users indicated that they liked the food and two said that they sometimes liked the food provided. All four cards indicated that the service users felt safe living at the home and all knew who to talk to if they had a problem. All indicated that they felt well cared for living at Glebe Lodge and that the staff treated them well. Two cards expressed a degree of dissatisfaction with the activities on offer and two cards said that the home sometimes provided suitable activities. Further dissatisfaction was expressed during discussions with individual service users who said that they would like more activities and would like staff to spend more time talking with residents. Three relatives comment cards were returned to the inspector; three cards indicated that relatives always felt welcome at the home, they were kept informed of important matters affecting their relative and that they could visit their relative in private. One card said that there was not always sufficient staff on duty and that they would like staff to spend time talking with residents. One card said that they would like the providers to provide transport for residents’ trips out and that this should not be the responsibility of carers. One other comment card said when her relative first went to Glebe Lodge they were poorly and depressed. Their relative is now happy and has put weight on and wrote, ‘I can’t believe the change in him and I can’t thank the staff enough. They are all angels, the care my dad gets is wonderful.’ One GP comment card was also returned which said it was ‘quite nice there’. A relative visiting the home at the time of the inspection made a complaint concerning visitors and staff smoking in non-smoking areas of the home. This was discussed with the registered manager who gave reassurances that smoking would be restricted to smoking areas of the home and the staff room. Glebe Lodge DS0000008601.V263005.R01.S.doc Version 5.0 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Glebe Lodge DS0000008601.V263005.R01.S.doc Version 5.0 Page 7 Care plans and risk assessments still require some further improvements, to ensure that all information from assessments is transferred to a residents care plan, to enable staff to fully meet a residents care needs. The registered manager needs to review the current range of activities on offer at the home. Feedback from residents and relatives felt that there were not enough one-to-one activities taking place with residents. The registered manager did not follow appropriate recruitment procedures when employing new members of staff; this has been addressed in a separate letter to the registered providers. 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 Lodge DS0000008601.V263005.R01.S.doc Version 5.0 Page 8 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 Lodge DS0000008601.V263005.R01.S.doc Version 5.0 Page 9 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): 2, 3 and 4. Service users had been issued with a written contract and their care needs were fully assessed before admission. EVIDENCE: Service users recently admitted to the home had a written contract which detailed the terms and conditions of their stay. There had been several new admissions to the home since the last inspection. Service users were assessed prior to their admission to the home; no service users were admitted to the home without their care needs having been assessed. Assessments were obtained from social workers and health professionals if they had been involved in the admission. Those files of service users recently admitted to the care home were examined and were found to contain a considerable amount of detailed and up to date information in respect of each person. Glebe Lodge DS0000008601.V263005.R01.S.doc Version 5.0 Page 10 Service users told the inspector that they were satisfied with the way in which the home met their care needs. Care staffs interaction with service users was observed to be positive and caring. Glebe Lodge DS0000008601.V263005.R01.S.doc Version 5.0 Page 11 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 and 10. Care plans do not accurately reflect how a service users cares needs were met. Service users were treated with respect and dignity at all times. EVIDENCE: All service users had a care plan. Care plan files were well organised, easy to read and easy to relate one section to another. Whilst there had been some improvement in the standard of care plans it was however observed that information held on service user assessments was not always transferred into the care plan. Risk assessments were similar in that identified risks were not always transferred to the care plan with actions and strategies in place to minimise the identified risk. There had been some improvement in the standard of recording on daily information sheets. Service users had access to GP support, district nursing services, chiropody and CPN services when required. Psychology services were accessed via the GP if required. Glebe Lodge DS0000008601.V263005.R01.S.doc Version 5.0 Page 12 The administration of medication to service users and the storage of medication at the home were satisfactory. On examination of medication records it was found several incidences where medication details had been handwritten. All handwritten medication details and their instructions must be validated by an additional member of staff. Staff with responsibility for medication administration had updated their training and had undertaken training on how different medicines interact with each other and how these may affect a service users health. Service users told the inspector that staff treated them well and they were very satisfied with the care they received. Care staffs approach towards service users was observed to be respectful, sensitive and caring at all times. Glebe Lodge DS0000008601.V263005.R01.S.doc Version 5.0 Page 13 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, 13, 14 and 15. Not all service users social and recreational interests and needs were met. Service users were able to exercise choice and control. Mealtime arrangements were well managed and satisfied the majority of service users expectations. EVIDENCE: The day-to-day routine of the home was relaxed and flexible with service users having the choice of spending their time in their rooms or using the communal areas of the home and some service users preffered to go out to local venues, shops and for walks. The home offered a range of activities, which included board games, music afternoons and trips out to a local market. At the time of the inspection a large proportion of service users were sitting in the smoking lounge watching TV, other service users preferred to use the non-smoking television lounge and the home had acquired two kittens for the residents, which had proved popular. Some service users felt that there was not enough activity provided and one service user told the inspector that she would like to do crafts and that she would like staff to sit and talk with her more often as she found this helpful. One relative told the inspector that he felt the activities on offer were not suitable for his father due to his health problems, he could not join in board games and did not enjoy television and that he would like staff to be able to spend more one to one time with his father as he enjoyed this. Glebe Lodge DS0000008601.V263005.R01.S.doc Version 5.0 Page 14 Visitors were made welcome at the home and service users kept in touch with family and friends. Service users confirmed that they could have visitors at all times. Since the last inspection the registered manager had provided all service users with information regarding local advocacy services. The kitchen at Glebe Lodge was designed and fitted with equipment for the storage and preparation of chilled ready-made meals and other food items. Service users comments were mixed with some liking and other disliking the food provided, however the vast majority of service users were satisfied with the meals provided. Service users told the inspector that they had enjoyed their lunch and that the meals provided were very good and, that a wide choice was available. Glebe Lodge DS0000008601.V263005.R01.S.doc Version 5.0 Page 15 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 and 18. Service users felt confident that their complaints would be taken seriously and acted upon. Staff had undertaken appropriate training in adult protection. EVIDENCE: The home had a detailed complaints policy and procedure; information provided for inspection purposes indicated that there had been no complaints since the last inspection. However the inspector met with a relative who told her that he had complained about visitors and staff smoking in designated non-smoking areas of the home on two separate occasions despite having been given reassurances that this would not happen again. The registered manager agreed to address this problem. Service users with whom the inspector spoke said that they knew who to complain to if they had a problem and all felt confident that the problem would be resolved in a satisfactory manner. The home had a procedure for responding to allegations of abuse. All staff had completed training in adult protection. Glebe Lodge DS0000008601.V263005.R01.S.doc Version 5.0 Page 16 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. The home was well maintained and provided comfortable living accommodation for service users. EVIDENCE: The home provided comfortable accommodation throughout. However the carpet in the smoking lounge area was starting to show signs of wear and tear. Service users bedrooms on the first floor and second floor areas still required window restrictors to be fitted. The registered manager provided evidence that confirmed that window restrictors were due to be fitted on the 4th November 2005. (See standard 38) The grounds of the home were well kept and suitable garden furniture had been provided since the last inspection. A number of service users rooms were seen, these were also furnished and equipped to a comfortable standard, many had been personalised by the occupants. Glebe Lodge DS0000008601.V263005.R01.S.doc Version 5.0 Page 17 The home complied with the requirements of the fire authority. Service users had a choice of three bathrooms, one of which was fitted with a shower. Since the last inspection the home has had an assisted bath fitted. Several service users expressed appreciation that the home an assisted bath for their use. The home was clean, tidy, bright and airy throughout and was free from any unpleasant odours, with the exception of bedroom 22 which had an odour problem. Staff told the inspector that they were considering alternative flooring in an attempt to eradicate the odour. Glebe Lodge DS0000008601.V263005.R01.S.doc Version 5.0 Page 18 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, 28, 29 and 30. The home was sufficiently staffed with a staff group that was trained to undertake their duties. The procedures for the recruitment of staff at the home did not provide protection to service users. EVIDENCE: At the time of the inspection the home was sufficiently staffed, a staff rota showing which staff are on duty and in what capacity was kept at the home. Since the last inspection the registered manager had provided separate facilities for staff, staff now had a staff room were they could take a break, which was also a designated smoking area for staff. Lockers had been provided for them to store their personal belongings. Care staff on duty at the time of the inspection confirmed that they had undertaken further training to assist them in their role as carers. Over 46 of car staff held an NVQ level 2 qualification in care. Four new members of staff had commenced employment at the home since the last inspection; the registered manager had not followed appropriate recruitment procedures with regard to newly appointed staff. Employees had been employed without a CRB or POVA check and without references. Two members of staff concerned had been employed as night care assistants. Care staff on duty at the time of the inspection confirmed that they had undertaken further training to assist them in their role as carers. At the time Glebe Lodge DS0000008601.V263005.R01.S.doc Version 5.0 Page 19 of the inspection a number of staff were undertaking a course “introduction to mental health”. Glebe Lodge DS0000008601.V263005.R01.S.doc Version 5.0 Page 20 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, 36, and 38. Staff were supervised in their work. The health and safety of staff and service users were fully safeguarded. EVIDENCE: Glebe Lodge had an annual development plan in place, which reflected aims and outcomes for service users. Anonymous service user questionnaires had been given out to service users, which asked questions about their experiences of living at the home. Although a small number were returned that registered providers were able to collate this information in a report that was made available at the time of the inspection. The registered providers had plans to look at improving and developing areas highlighted in the report. Glebe Lodge DS0000008601.V263005.R01.S.doc Version 5.0 Page 21 Since the last inspection two residents meetings had been held, initially these were poorly attended however several service users told the inspector that they thought they were a good idea and gave them an opportunity to air their views. Staff received regular supervision to support them with their work, evidence of supervision records and discussions with staff confirmed that this was the practice. The home complied with the requirements of the fire authority. The home maintained records in respect of fire safety at the home. Staff had updated their training in safe handling and moving procedures, fire safety, food hygiene and health and safety. Certificates confirming the maintenance of the passenger lift, electrical and gas supplies to the home were seen on inspection. Since the last inspection adequate storage had been provided for all equipment used in the home. The home did not appear to have a clear understanding of when and accident form should be completed, consequently not all accidents were recorded. At the previous inspection the registered manager was required to fit window restrictors to all bedroom windows on the first and second floor levels before the 12th July 2005. At the time of this inspection window restrictors had not been fitted, the registered manager advised the inspector that window restrictors were due to be fitted on the 4th November 2005 and produced evidence to confirm this. Glebe Lodge DS0000008601.V263005.R01.S.doc Version 5.0 Page 22 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 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 3 3 3 X 3 X 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X 3 X 2 Glebe Lodge DS0000008601.V263005.R01.S.doc Version 5.0 Page 23 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. Standard OP7 Regulation 15 Requirement The registered provider must ensure that all information concerning a service users care needs and any identified risks are transferred to a care plan. The registered provider must ensure that an additional member of staff validates handwritten medication details on the medication administration records. The registered provider must review and provide a range of activities that meets the needs of all service users at the home. The registered provider must keep a record of all complaints made by service uses and relatives about the operation of the care home and the action taken by the registered person in respect of any such complaint. The registered providers must ensure that bedroom 22 is kept free from odours. The registered provider must ensure that all records held in respect of persons working at the home as listed in Schedule 2 DS0000008601.V263005.R01.S.doc Timescale for action 01/01/06 2. OP9 13(2) 01/11/05 3. OP12 16(2)(n) 01/02/06 4. OP16 Schedule 4(11) 01/01/06 5. 6. OP26 OP29 16(2)(k) Schedule 2. 01/12/05 01/11/05 Glebe Lodge Version 5.0 Page 24 7. OP38 8 OP38 of the Care Homes Regulations 2001 are in place before a member of staff is employed at the home. 13(4a,b,c) The registered providers must fit window restrictors to all rooms to which service users have access to on the 1st and 2nd floors of the home. (Timescale of 12/07/05 not met.) 17(1)(a) The registered providers must keep a record of any accident affecting a service user in the care home. 04/11/05 01/11/05 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 Lodge DS0000008601.V263005.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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. 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