Inspection on 20/02/07 for Glebe Road, 69

This inspection was carried out on 20th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glebe Road, 69 05/10/05

Glebe Road, 69 26/07/05

Glebe Road, 69 02/12/04

Glebe Road, 69 11/05/04

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

CARE HOME ADULTS 18-65 Glebe Road, 69 69 Glebe Road Bedlington Northumberland NE22 2HB Lead Inspector Glynis Gaffney Key Unannounced Inspection 20, 26 and 27 February 2007 14:30 Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 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 Road, 69 DS0000035343.V304696.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 Adults 18-65. 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 Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glebe Road, 69 Address 69 Glebe Road Bedlington Northumberland NE22 2HB 01670 823831 01670 821108 cpegg@northumberland.gov.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Northumberland County Council SSD Mrs Cynthia Ann Pegg Care Home 15 Category(ies) of Learning disability (10), Learning disability over registration, with number 65 years of age (5) of places Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th October 2005 Brief Description of the Service: 69 Glebe Road is located in Bedlington. The home is within walking distance of local shops and amenities. The home is owned and managed by Northumberland County Council. Glebe Road is registered to provide 15 places for people with learning disabilities. Nursing care is not provided. The accommodation consisted of - the main house catering for ten people, a bungalow for two people, a bed-sit for two others and a separate flat for one other person. There was a car park and close-by street parking. The current scale of charges ranges from £?. Additional charges are made for hairdressing, chiropody, newspaper, outings and toiletries. Copies of the Commission’s Inspection reports were available to visitors, staff and residents. Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over ten hours and involved one inspector. A range of evidence has been used to support the judgements reached in this report, including interviews conducted with the home’s manager, members of her staff team and residents. The premises were inspected, as were a sample of care records, policies and procedures. Comments from surveys completed by residents have been included throughout this report. During the inspection, it was identified that a satellite service managed by Glebe Road was providing care and support to two service users with complex care needs. Following negotiations with a senior manager from the learning disability service, the Commission reached the view that Glebe Road’s current Conditions of Registration did not cover this service. This matter is being addressed with the Northumberland Care Trust. Plans are in place to develop an Autism service at the home. This initiative is still at the very early planning stage. What the service does well: The manager and her staff team adopted a positive approach to the inspection process and were willing to engage in a constructive debate about inspection outcomes. Staff moral was high and there was a strong commitment to providing residents with the best possible support. Monthly staff meetings had been held providing the Glebe Road staff team with opportunities to be involved with the running of the home. The premises were well maintained and pleasantly furnished throughout. Residents had been provided with their own bed-sits, which they had personalised according to their own personal preferences. The premises were safe and free from hazards. The kitchen was clean and hygienic. There were no unpleasant odours present in the building. A robust system was in place for reporting building defects. As part of the inspection, staff went to the trouble of providing the inspector with a pen-picture that described the needs of each of the residents whose care records were examined. This helped the inspector to better understand each resident’s needs and the background to their admission into Glebe Road. Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 6 Staff had been provided with two days training to help them understand the needs of a recently admitted resident who had behaviours that were difficult to manage. The complaints procedure and service user guide were available in a format that could be more easily understood by residents. Where residents displayed behaviours that were challenging to work with, arrangements had been made for staff to receive guidance and support from other professionals such as the Behaviour and Intervention Team. For one resident, regular meetings had been held between Glebe Road staff and other professionals to address concerns as they arose. The home had recently agreed to offer a placement to a person with a hearing impairment. As part of the admission, staff had devised a Communication Dictionary that included photos, the names of staff and pictures of the signs this person used to communicate. Monthly reviews are completed by key workers in consultation with residents. Three monthly reviews of residents’ care plans are also undertaken. Northumberland Care Trust provided staff with access to an extensive training programme. Glebe Road is committed to providing its residents with ‘end of life’ care where this is required and, as long as each individual’s medical needs can be met by community health care services. Residents said that they were very satisfied with the care and support they received at Glebe Road and felt that staff listened to their opinions and views. Residents said that they enjoyed the meals served at Glebe Road. The manager had delegated key tasks to members of her senior team and this had resulted in Glebe Road being able to provide a more efficient and effective service. What has improved since the last inspection? Following requirements set in the last inspection report, the following improvements had been made: • Eye ointments – staff now date both the tube and the box. When medication is administered, two staff signatures are obtained. Tubs of Sudacreme are labelled for individual use. A new fridge had been purchased to store medicines requiring cold storage. The Boots Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 7 • • monitored storage system had been introduced into the home. Boots had visited the home and provided staff training; The bath in the bungalow had been replaced; Alcohol gel bottles are now carried by staff to minimise the spread of infection within the home. Alcohol gel wash had been made available in the laundry, kitchen and toilet areas. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2,3 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had obtained the information staff needed to provide residents with a good standard of care. This meant that staff were able to fully meet the care needs of residents admitted into the home. Residents, and their families, had been encouraged to visit the home before moving in. This enabled them to form a view of the quality of care and services provided by Glebe Road staff. EVIDENCE: The manager was able to clearly describe why it was important for prospective residents to have access to sufficient information when choosing whether to live at Glebe Road. The home had developed clear information about the care and services it provided. It contained helpful information about the accommodation provided, the qualifications and experience of staff and how to make a complaint. The statement of purpose was available in an ordinary printed format. The manager said that it could be provided in other formats upon request. The home’s service user guide was written in simple language and included photographs of the building and its facilities. It was confirmed that the guide could be made available in Braille, audio or video formats. Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 10 Admissions into the home had not taken place until after a full assessment had been done. Where a care manager had done the assessment, Glebe Road had obtained a summary of the assessment and a copy of the care plan. People only moved into the home if the manager was confident that staff had the skills and training to meet their assessed needs. The manager said that, with the support of her senior team and line manager, she carefully considered any information received about a prospective resident before agreeing to the admission. A resident who had recently been admitted into the home was provided with opportunities to visit Glebe Road on a number of occasions. This included staying for four evening meals and two overnight stays. The resident was also given the opportunity to meet staff, including the manager. As part of her introduction to the home, she was consulted about who her key worker would be and was told about Glebe Road’s day-to-day routines. Another prospective resident with a hearing impairment had been given the opportunity to have five overnight stays before being asked to make a decision about whether they wanted to live at Glebe Road. Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were clear care planning and review processes in place. This meant that staff were clear about how they should meet residents’ needs and how they should involve them in this process. Staff respected residents’ needs and wishes regarding privacy, dignity and independence. This meant that residents felt valued and able to retain control over the way they wanted to live their lives. The health, safety and welfare of residents was promoted and protected. This meant that residents were able to lead fulfilling lives within a safe environment where the potential threat of risks had been minimised. EVIDENCE: Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 12 Residents had a care plan that had either been agreed with them or their family. Although the care plans examined had been written in plain simple language, they were not available in alternative formats. The care records examined covered a range of areas such as: • • • • • Life history information; An assessment of residents’ levels of dependency; A monthly overview of the events that had occurred in each resident’s life; An assessment of each resident’s needs in areas such as mobility, eating and using the toilet; Care plans setting out how the home intended to meet their assessed needs. A key worker system enabled staff to establish special relationships with residents and work more closely with them on a one to one basis. Where residents had developed behaviours that were difficult to manage, complex behavioural support plans had been put in place. The manager and her staff said that they believed it was essential to involve residents in planning for their care especially where it affected their lifestyle and quality of life. A member of staff said that, wherever possible, assessment and personal profile information was completed with the help of each resident. She also said that residents were invited to attend their own reviews and comment on the care they received at Glebe Road. There was also written evidence that care plans had been updated to reflect changes in residents’ needs. A range of risk assessments had been completed for each resident covering such areas as checking the temperature of hot water to using gym equipment safely. But, it was identified that for one resident, risks referred to in their behavioural support plan had not been assessed in terms of their implications for Glebe Road staff implementing the guidance. There was evidence that the manager and her staff team understood the importance of residents being supported and encouraged to take control of their own lives and make their own decisions and choices. For example, residents said that they chose: • • • • • Who came into their bed-sits; Who they made friends with; What they ate at meal times; When they had a bath; What they wore each day. Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 13 Residents also said that staff consulted them about the things that went on in their lives such as work placements and medical appointments. They also said that they were invited to their reviews. Formal residents’ meetings were not used as a way of involving them in the running of the home. The manager said that one to one consultation with residents worked much better for the current people living at Glebe Road. Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Glebe Road staff actively encouraged and provided varied opportunities for residents to develop and maintain social, emotional, communication and independent living skills. Residents were able to enjoy a full and stimulating lifestyle. Residents were supported to make positive and informed choices about the meals they ate. Mealtimes were relaxed and staff were patient, helpful and, allowed residents the time they needed to finish their meal comfortably. Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 15 EVIDENCE: Residents had been provided with opportunities to develop and maintain important personal and family relationships. There was evidence in the monthly key worker reports prepared by staff that a new resident had been supported to maintain contact with her family after admission. For example, over the Christmas period, the resident had been visited by her sister and brother-in-law on Christmas day and during December 2006, her father visited her on two occasions. Her care records contained important information about her family and friends. There was also evidence that staff had supported her to make new friends once she moved into the home. Another resident continued to attend a social club that she had visited before coming to live at Glebe Road. She also had regular contact with her family on all special occasions. In each resident’s care records, staff had drawn a ‘map’ that identified the important people in their lives. There was evidence that staff had supported residents to join in meaningful daytime activities of their own choice. For example, staff had prepared a ‘map’ of the activities that one resident enjoyed participating in. Staff had established that the resident liked to eat out, attend an activity centre, visit the hairdressers and attend a local gym. The assessment completed for another resident showed that staff had assessed her ability to make choices and had identified that she needed assistance to make appropriate decisions about how she wanted to live her life. Staff had identified was she was good at and where she needed help. One resident said that they were supported to ‘go out just like everybody else’. She also told the inspector that she had just got back from work and could now spend the evening relaxing and talking with staff and her friends. Another resident said that they had been to visit the swimming baths during the week and had then gone out for a meal at a local pub. One resident interviewed said that he just preferred to spend time at home now that he had retired and said that this was okay with staff. Education and occupation opportunities were encouraged, supported and promoted. For example, one resident attended a local employment centre five days a week. Another resident enjoyed attending a local Gateway Club and eating out. There was evidence in another resident’s care records that they attended a local sheltered employment centre. Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 16 None of the residents whose care records were examined required assistance with feeding. A recently admitted resident had been supported by staff to attend a dietician’s appointment at a local hospital. There was evidence that staff had provided guidance and support to enable this person to persevere with a weight reducing diet. This person’s care records contained useful information about the support she required with eating and drinking. In another resident’s care records, information about their food likes and dislikes had been recorded. Staff confirmed that residents were consulted on a weekly basis about the meals that they wanted to see on the menu each week. The menus were varied with a number of choices including a healthy option. Records were available confirming that residents had been given a daily choice about what they wanted to eat. The meals were nutritionally balanced and catered for residents’ dietary needs. Staff had prepared photographs of the various types of meals that could be cooked to help residents make more informed choices about what they wanted to eat. All three residents said that they were very happy with the food served at the home. Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health care needs of residents had been satisfactorily met allowing them to lead healthy, comfortable and pain free lives. Staff demonstrated a good understanding of how to meet residents’ personal support needs. This meant that residents could feel confident that care staff would meet their need for personal support in a sensitive and responsive manner. The systems in place to support the safe administration, storage and disposal of medication were satisfactory and promoted residents’ good health. But, the home’s medication policy had not been updated to include reference to the latest good practice guidance. EVIDENCE: Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 18 The home’s statement of purpose included information about how residents’ health care needs would be met. Staff interviewed spoke knowledgeably about how residents were supported to maintain their good health. Information about residents’ health needs had been recorded in their care records. In one resident’s records there was comprehensive information about her health care needs at the point of admission into Glebe Road. For example, shortly after moving into the home, she had been provided with opportunities to visit her dentist, optician, chiropodist and GP. In November 2006, the same resident also attended a Well Woman Clinic and had a hearing test. There was evidence in another resident’s monthly review reports that arrangements had been made for her to have monthly blood checks and regular asthma reviews. All three residents whose care records were examined had seen their dentist and optician during the previous 12 months. The inspector was not able to directly observe staff providing personal care. But, a member of staff was observed consulting a resident about whether she wanted to have a bath. The member of staff ensured that proper attention was given to the resident’s privacy and dignity whilst she took her bath. A resident interviewed said that the staff that helped her to get ready in the morning and to go to bed at night were nice and did not rush her. There was evidence that staff had received training in meeting residents’ health care needs. For example, some staff had completed training in the following areas – visual impairments, personal relationships and sexuality, epilepsy, HIV and Aids. Although a medication policy was available within the home, it had not been updated since 1996. A copy of the latest guidance issued by the Royal Pharmaceutical Society of Great Britain was available for staff to refer to. The cupboards used to store medication were clean and hygienic. All medication had been properly secured. Photos to identify each resident had been placed on their medication records. Records were in place covering the receipt, administration and disposal of medicines. Relevant staff were in the process of completing accredited medication training. The manager intends to offer this training opportunity to all staff in the future. Staff had also completed medication training as part of their qualifying training. There were no residents administering their own medication at the time of the inspection. It t was also noted that: • • Hand wash facilities were not available in all of the areas in which medicines were stored; Checks of the air temperature of the areas in which medications were stored had not been completed. Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The arrangements in place for handling complaints were satisfactory and residents were confident that their complaints would be listened to, taken seriously and acted upon. Satisfactory arrangements were in place to protect residents from harm or abuse. This meant that residents could feel safe and protected in their own home. EVIDENCE: The provider had a detailed complaints procedure that was up to date, clearly written and easy to understand. A staff guide to reporting and responding to complaints was available. A process was in place to handle unresolved complaints. The complaints procedure was available on request in a variety of formats. The manager confirmed that the County had reached an agreement with Gateshead Library to produce the procedure in Braille and in audio and video formats on request. Residents had been provided with their own personal copy of the procedure. It was confirmed that a user-friendly version was under preparation. Residents interviewed were clear about what they would do if they needed to make a complaint. Neither the home nor the Commission had received any complaints since the last inspection. Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 20 A comprehensive vulnerable adults policy was in place and had recently been re-drafted. Staff spoken with were clear about what action they would take to protect residents from potential harm. Of the three staff files that were examined, two had received training in the protection of vulnerable adults. Arrangements had been made for the other member of staff to complete this training. Neither the home nor the Commission had been notified of any adult protection concerns. Residents said that they were very satisfied with the care provided and felt safe and well supported by staff. The manager was very clear that concerns about the well-being of a resident would be addressed immediately. Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment was good providing residents with an attractive and homely place to live. The overall quality of the furnishings and fittings was good. This meant that residents were able to live in a safe, wellmaintained and comfortable environment, which encouraged independence. Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 22 EVIDENCE: The home had been adapted to meet the needs of the residents living there. The environment was well-maintained and provided specialist aids and equipment to meet the needs of the residents. The home was nicely decorated and its furnishings and fittings were of a good standard. The home was safe and free from unnecessary hazards. There were no unpleasant odours. Residents had access to larger than average bedrooms providing them with both a bedroom and a lounge area. The lay out and design of the home allowed for smaller groups of residents to live together resulting in a noninstitutional environment. Staff confirmed that residents were encouraged to personalise their private space. The bed-sits visited were all different and individual. Residents were proud of their bed-sits. There was a choice of communal space ranging from a large lounge in the main building to the smaller lounge areas in the flat, bungalow and two-person bed-sit. The home had a good infection control policy. Generally, staff had received training in the control of infection. Two of the three staff whose files were checked had received training in how to control MRSA. Staff were observed carrying alcohol gel bottles to ensure good hand hygiene. Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There were sufficient staff rostered on duty to meet the assessed needs of residents. This meant that residents could be sure that they would get the help and assistance they required to live more independently. The arrangements for ensuring that staff regularly updated their training in key areas were unsatisfactory. This could mean that staff might not have the skills and knowledge required to meet residents’ identified needs in a safe manner. There was a satisfactory programme of regular and structured staff supervision. This meant that staff were properly supervised and their performance regularly appraised. Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager had developed an approach to devising the home’s rotas that worked well for staff and service users at Glebe Road. For example, when planning for the admission of a new resident, careful consideration is given to whether Glebe Road has the required staffing levels and staff who have the right balance of skills and knowledge. The manager said that a new admission would not go ahead unless this was the case. Rotas showed that consideration had been given to the need to ensure that extra staff were available during busy times of the day. This approach also helped to ensure that there were enough staff rostered on duty to support residents to be independent both within the home and out in the local community. There was little use of agency or temporary staff. A comprehensive training programme was available to Glebe Road staff. The programme covered mandatory training courses and training aimed at developing staffs’ knowledge in specialist areas such as person-centred planning and working with challenging behaviours. Also, where the home had agreed to provide placements to residents with complex support needs, specialised training input had been arranged. Residents interviewed felt that staff looked after them very well. A sample of staff records was examined and it was noted that a training action plan and training needs analysis had been completed for each person. Some of the training needs analysis forms had not been fully completed. Certificates confirming that staff had completed training in key areas were not always in place. Over 50 of the staff team had obtained a relevant qualification in care. Staff that had completed a care qualification had covered equality and diversity issues as part of this training. Some staff had also received equal opportunities training provided by the County. A sample of staff records were examined and it was noted that: • • • • All staff had completed training in basic food hygiene; None of the staff had received certificated fire training since 2001; None of the staff had completed health and safety training during the last three years; Two staff had completed first aid training and one member of staff had been registered to complete training in this area. Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 25 A robust recruitment procedure was in place and clearly defined the processes to be followed. The policy had recently been reviewed and updated. Not all of the information required to confirm that newly appointed staff had been subject to rigorous pre-employment checks was available within the home. For example, original Criminal Records Bureau Disclosure Certificates for staff appointed since the last inspection. Also, copies of application forms and references were not held on site. The manager confirmed that residents were involved in the home’s recruitment process. She said that they were invited to prepare and ask questions and, with the support of staff, to provide the interview panel with feedback. Residents had not received training in the provider’s recruitment and selection procedures. Staff meetings had taken place on a monthly basis and detailed minutes had been kept. Meetings covered issues such as the well-being of residents and rota management issues. Staff had signed the minutes to confirm that they had read them. There was evidence that staff had received regular structured supervision. For example, each of the staff whose records were examined had received six supervision sessions in 2006. Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager provided a clear sense of leadership, involved staff and residents in the management of the home, and demonstrated a commitment to providing residents with good quality care. This meant that residents lived in a home which was run and managed by a person who was fit to be in charge, was of good character and able to discharge her responsibilities fully. Steps had been taken to promote the health and well being of residents and to protect them from potential hazards. This meant that residents lived in a home where health and safety concerns were taken seriously and where concerns were promptly addressed to prevent them suffering unnecessary harm. Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 27 EVIDENCE: The manager was a qualified social worker and had obtained a relevant qualification in management. Mrs Pegg had extensive experience of working with adults with a learning disability and displayed the professional competent required to manage such a home. She was ably supported by an experienced senior management team. There was evidence that she and her team worked very hard to improve residents’ quality of life. Staff felt that the manager ran the home in an open and transparent manner. The home offered care that was service user focused and staff worked well in partnership with families and other professionals. The manager was aware of current developments in her own field and was interested to know more about the Commission’s ‘Inspecting for Better Live’ Programme. A range of health and safety records were examined and generally found to be up to date. A tour of the premises identified no health and safety concerns. Weekly health and safety monitoring and daily cleaning sheets had been completed to ensure that the kitchen areas were maintained in a safe and hygienic condition. Records were available showing that fridge and freezer temperature checks had been undertaken. Although staff had access to sound policies and procedures, some of these had not been reviewed since 1996. Systems were in place to monitor staff adherence to policies and procedures during their day-to-day practice. Supervision sessions were used to provide staff with feedback on their performance. An audit of the home’s fire records were undertaken and it was confirmed that the required fire prevention checks had been completed. For example, the home’s emergency lighting and fire extinguishers had received monthly visual checks. Staff had participated in a minimum of two fire drills during the last 12 months. The home’s accident record had been well completed. Residents’ finance records were well maintained. Staff signatures had been obtained for all monies spent on behalf of residents and receipts had been obtained and attached to their financial balance sheets. Unannounced monthly visits to monitor the standard of care provided at Glebe Road had been carried out. Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 28 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score Standard No 22 23 Score 3 3 2 X 3 3 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 x 30 3 STAFFING Standard No Score 31 x 32 2 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 DS0000035343.V304696.R01.S.doc LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 Score PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 Glebe Road, 69 Score 3 X 2 3 X X X X 3 Version 5.2 Page 29 21 x 43 X Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 30 No 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. Standard YA20 Regulation 13(2) Timescale for action The manager must ensure that 01/04/07 regular checks of the air temperature in the areas in which medications are stored are completed. The provider and manager must 01/09/07 ensure that: Staff receive refresher training in moving and handling and health and safety at least once a year; • Staff records contain documentary evidence of training undertaken by staff. The provider must ensure that 01/08/07 the following information is available with the home: • Original Criminal Records Bureau Disclosure Certificates for staff appointed since the last inspection; Copies of application forms; Copies of references; Proof of identity; Version 5.2 Page 31 Requirement 2. YA32 18 • 3. YA34 7, 9 and 19 Schedule 2 • • • Glebe Road, 69 DS0000035343.V304696.R01.S.doc 4. YA40 12 & 18 Evidence that verification has been sort regarding the reason why prospective applicants had left their last post where it involved working with vulnerable adults or children. The provider must update the 01/10/07 home’s policy and procedural manual. • 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 YA9 Good Practice Recommendations The manager should ensure that the potential risks faced by Glebe Road staff when implementing behavioural support plans are considered and written risk assessments put in place where appropriate. The provider should ensure that hand wash facilities are available in all areas in which medicines are stored and administered. The manager should ensure that staff receive certificated fire training at least once every three years to supplement in-house training. The provider should ensure that residents are provided with training that helps them to understand how staff are recruited to work in their home. 2. 3. YA20 YA32 4. YA34 Glebe Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Road, 69 DS0000035343.V304696.R01.S.doc Version 5.2 Page 33 - 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. 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