Inspection on 27/06/06 for Glebe Lodge

This inspection was carried out on 27th June 2006.

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 01/11/05

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 Unannounced Inspection 27th June 2006 14:36 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.V297685.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. Glebe Lodge DS0000008601.V297685.R01.S.doc Version 5.2 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.V297685.R01.S.doc Version 5.2 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). 1st November 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.V297685.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection, which took place over the course of a day. A senior carer assisted the inspector in the morning and the registered manager in the afternoon. Care plans, assessment documentation, and other records were examined. The inspector spoke with a number of residents, and members of staff who were on duty and one relative who was visiting the home at the time of the inspection. There were eleven service users in the home at the time of the site visit. What the service does well: Glebe Lodge is a large spacious home that offers comfortable accommodation. There is ample communal living space with residents having a choice of two lounge areas one being a smoking area. Everyone who is admitted to Glebe Lodge undergoes a full assessment of his or her care needs before an admission is arranged and they are provided with information about the home to assist them in making a choice about whether to move into the home. Several residents told the inspector that they liked living at the home and that they felt well cared for. One resident said that living at Glebe Lodge was like living in ‘one big happy family’. One relative with whom the inspector spoke said she was very happy with the care provided for her relative and described the home as having a ‘nice atmosphere’, it was ‘always clean and smells nice’ and said that care staff had been very supportive towards both her and her relative following his admission to the home. Residents appeared to be well cared for and supported by a competent and trained workforce who had undertaken specific training in mental health awareness. There have been no complaints about the home since the last inspection. Glebe Lodge DS0000008601.V297685.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: At the time of the site visit the majority of service users had gone to bed for the afternoon and there were no organised activities scheduled. Several residents do like to go out and make their own arrangements but a portion of other residents remained in the home. Previously the registered provider has been asked to review and provide a range of activities that met the needs of all residents at the home. This requirement remains and the registered providers must consult with residents about their prefered activities and demonstrate that consultation has taken place. Staff do not receive formal supervision on a regular basis. The registered manager must ensure that all staff employed at the care home are supervised. At the previous inspection the registered manager was required to fit window restrictors to all bedroom windows on the first and second floor levels. Window restrictors have been fitted, however most of the restrictors were broken due to poor workmanship and the home was waiting for the company to repair the restrictors. A number of vanity units in residents bedrooms were worn and in poor repair and need to be replaced. The side garden area of the home is overgrown and unkempt and needs to be maintained for residents to use. Glebe Lodge DS0000008601.V297685.R01.S.doc Version 5.2 Page 7 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.V297685.R01.S.doc Version 5.2 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.V297685.R01.S.doc Version 5.2 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): 1, 3 and 4. Quality in this outcome area is good. Service users’ care needs were fully assessed before admission and they received sufficient information that informed them about the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: At the time of the site visit copies of the Service User Guide were displayed in the entrance hall area. Prospective service users were given copy of the Service User Guide and all service users at the home had received a copy of the Service User Guide. A checklist was in place on service users’ file, which indicated when they had received copies of the service user guide, the homes charter and a copy of the complaints procedure. One relative confirmed that she had been given information about the home prior to her relative moving in and that she had found the information useful and informative. Glebe Lodge DS0000008601.V297685.R01.S.doc Version 5.2 Page 10 Information held on the service users files confirmed that the service user had been assessed prior to their admission to the home. Detailed assessments were obtained from social workers and health professionals involved in the admission and the home completed its own assessment documentation. Detailed mental health assessments were in place and were regularly reviewed and up dated. The inspector met several service users at the home who said that they were happy with the way in which the home was meeting their needs and that they had no complaints. Care staff told the inspector that they regularly updated their moving and handling training and health and safety training and evidence to confirm this practice was made available. Care staff demonstrated a good understanding of service users care needs. Glebe Lodge DS0000008601.V297685.R01.S.doc Version 5.2 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. Quality in this outcome area is good. Care plans accurately reflected how service users’ care needs were met and service users were treated with respect and dignity at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The standard of care plans had improved significantly since the last inspection. Care plan files were well organised. Information recorded on assessments was transferred to care plans. Risk assessments were in place for all identified risks with strategies in place to minimise risks. Key workers were responsible for recording on care plans, reviewing and updating care plans. Care plans were reviewed both weekly and monthly and changes implemented. Information recorded on daily records was clear and concise and gave a clear picture of how a service users care needs was being met. Service users had access to GP support, district nursing services, social work support, chiropody and community psychiatric nursing services when required. Glebe Lodge DS0000008601.V297685.R01.S.doc Version 5.2 Page 12 Psychology services were accessed via the GP if required. One relative told the inspector that staff were very good at keeping her informed of any changes in her relatives health. She visited the home 3-4 times per week at different times and had found the same standard of service at each visit. On a previous inspection it was observed that an additional member of staff had not validated handwritten medication details. At the time of the site visit the recording and administration of medication was satisfactory. Staff with responsibility for medication administration had updated their training. 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.V297685.R01.S.doc Version 5.2 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. Quality in this outcome area is adequate. The day-to-day routine of the home including mealtimes was relaxed and informal, however service users social and recreational interests were not met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The day-to-day routine of the home was relaxed and flexible. A relative described the home as having a ‘relaxed atmosphere, flexible not rigid’. Service users could spend time in their rooms or in communal areas of the home. Some service users liked to go out to local venues and for walks. One service user had just returned from a holiday in another care home outside of the area and one service user had organised a weekend away in Scotland for herself. One service user said she would like more activities to take place in the home and said that she would like the home to arrange day trips out. One relative expressed concern that her relative went to bed every afternoon and that she thought some stimulating activities might help. At the time of the site visit the majority of service users had gone to bed for the afternoon. The inspector had a discussion with the registered manager about this, and asked if this was the service user’s choice or was it habit due to Glebe Lodge DS0000008601.V297685.R01.S.doc Version 5.2 Page 14 lack of stimulation and no structured activities taking place. Care staff told the inspector that they did try to motivate service users to undertake activities but they had not been successful. Service users lifestyles and interests were recorded at the time of their admission and residents meetings were held every six months. At a previous inspection the registered provider was required to review and provide a range of activities that met the needs of all service users at the home. This requirement remains and the registered providers must consult with service users about a preffered activities programme and demonstrate that consultation has taken place. 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. 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 told the inspector that they had enjoyed their lunch. One service user said that the ‘food had improved’. Glebe Lodge DS0000008601.V297685.R01.S.doc Version 5.2 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. Quality in this outcome area is good. Service users felt confident that their complaints would be taken seriously and acted upon. Staff had undertaken training in adult protection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There had been no complaints since the last inspection. Service users told the inspector that they knew who to complain to and felt that their complaint would be dealt with in a suitable manner. The home had a procedure for responding to allegations of abuse. A number of care staff had undertaken appropriate training in adult protection as part of their National Vocational Qualification training and as part of their induction. A training matrix detailing those staff that had undertaken this training was made available at the fieldwork visit. Glebe Lodge DS0000008601.V297685.R01.S.doc Version 5.2 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, 24 and 26. Quality in this outcome area is good. The home was well maintained and provided comfortable living accommodation for service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home provided comfortable accommodation throughout. It was clean, tidy, bright and airy and was free from any unpleasant odours. The lounges areas in the home had been swapped round. The non-smoking lounge was much larger than the smoking lounge and the home accommodated a number of residents who smoked. The new smoking lounge comfortably accommodated the numbers of smokers and the non-smoking lounge had been recarpeted and refurnished which gave it a very homely and comfortable feeling. Glebe Lodge DS0000008601.V297685.R01.S.doc Version 5.2 Page 17 A selection of service users rooms were seen, these were also furnished and equipped to a comfortable standard, many had been personalised by the occupants. A number of vanity units in service users bedrooms were worn and in poor repair. The registered manager advised that there were plans to replace nine vanity units in service users rooms. The side garden area of the home was overgrown and unkempt. Service users had access to a front garden area where garden furniture was provided. The registered manager advised that the home had future plans to decorate the smoking lounge and provide new flooring. There were also plans to install walk in showers in the upstairs toilets and to decorate several bedrooms. The planned work will be phased in over the next three years. Glebe Lodge DS0000008601.V297685.R01.S.doc Version 5.2 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 and 30. Quality in this outcome area is good. The home was sufficiently staffed, with a staff group that was trained to meet needs of service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was sufficiently staffed; a staff rota showing, which staff were on duty and in what capacity, was kept at the home. A relative described the staff group at the homes as ‘friendly’ and said that staff were always very approachable. 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, including indiction training. No new staff had been employed at the home since the last inspection. At a previous inspection the registered manager was given a requirement as she had not followed appropriate recruitment procedures with regard to newly appointed staff. Employees had been employed without a CRB certificate or a POVA first check and without references. Since the last inspection the registered manager had acquired all documentation required with the exception of a recent photograph of one of the employees. Glebe Lodge DS0000008601.V297685.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38. Quality in this outcome area is adequate. Care staff were not appropriately supervised. The health and safety of staff and service users was not fully safeguarded. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Ruth Marshall has been the manager at Glebe Lodge since August 2001. She has worked at Glebe Lodge for 17 years. She holds a NVQ level 4 in care and management and the Registered Managers Award. Staff had updated their training in safe moving and handling procedures, food hygiene and health and safety. Glebe Lodge DS0000008601.V297685.R01.S.doc Version 5.2 Page 20 Certificates confirming the maintenance of the passenger lift, hoisting and lifting equipment, electrical and gas supplies to the home were seen on inspection. The home maintained records in respect of fire safety at the home. A record of all accidents concerning service users was kept at the home. Care staff did not receive regular supervision to support them in their work. At the previous inspection the registered manager was required to fit window restrictors to all bedroom windows on the first and second floor levels. Since the last inspection window restrictors had been fitted, however most of the restrictors had broken due to poor workmanship and the home was in the process of waiting for the company to repair the restrictors. The home did not manage service users monies, however small amounts of cash were kept for individual service users for day-to-day expenses ie. hairdressing costs. Records of all transactions were kept along with receipts. Service users were given the opportunity express their views about the quality of care provided at the home, through residents meetings. Residents meetings were held on a six monthly basis, though the registered manager had plans to hold these meetings on a quarterly basis. Other means of feedback on service user satisfaction included the key worker system, which operated at the home and formal staff supervision arrangements. Anonymous service user questionnaires had not been used. Glebe Lodge DS0000008601.V297685.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 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 17 X 18 3 2 X X X X 2 X 3 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 3 3 2 X 3 2 X 2 Glebe Lodge DS0000008601.V297685.R01.S.doc Version 5.2 Page 22 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 OP12 Regulation 16(2)(n) Requirement The registered provider must consult with service users about their social interests and provide evidence of the consultation process. (Timescale of 01/02/06 not met). The registered provider must ensure that garden areas are safe for use by service users and suitably maintained. The registered provider must ensure that worn vanity units in service users bedrooms are replaced. The registered provider must ensure that all records held in respect of persons working at the home as listed in Schedule 2 of the Care Homes Regulations 2001 are in place before a member of staff is employed at the home. (Timescale of 01/11/05 not met.) The registered provider must establish and maintain a system for reviewing and improving the quality of care provided at the home and actively seek feedback from service users on its DS0000008601.V297685.R01.S.doc Timescale for action 27/09/06 2. OP19 23 27/07/06 3. OP24 23 27/09/06 6. OP29 Schedule 2. 27/06/06 7. OP33 24 27/10/06 Glebe Lodge Version 5.2 Page 23 8. OP36 18 9. OP38 performance. The registered provider must ensure that all staff working at the home are appropriately supervised. 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.) 27/07/06 04/11/06 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.V297685.R01.S.doc Version 5.2 Page 24 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. Extracts may not be used or reproduced without the express permission of CSCI Glebe Lodge DS0000008601.V297685.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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