Inspection on 05/10/05 for Glebe Road, 69

This inspection was carried out on 5th October 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 Road, 69 20/02/07

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 69 Glebe Road Bedlington Northumberland NE22 2HB Lead Inspector Deborah Haugh Announced 5 October 2005 10:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. 69 Glebe Road B53-B03 S35343 Gebe Road V240136 051005 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 69 Glebe Road Address Bedlington Northumberland NE22 2HB Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01670 823831 01670 821108 n/a Northumberland County Council SSD Mrs Cynthia Ann Pegg CRH 15 Category(ies) of LD Learning Disability (10) registration, with number LD(E) Learning Disability - over 65 (5) of places 69 Glebe Road B53-B03 S35343 Gebe Road V240136 051005 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 26/07/05 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 the Local Authority. Glebe Road is registered for 15 places for people with a learning disability. The home cannot provide nursing care. The accommodation comprises of the Main House with 10 people, a Bungalow for 2 people, a Bed Sit accommodating 2 other people and a separate Flat for 1 person. The home has undergone completion of extensive refurbishment. 69 Glebe Road B53-B03 S35343 Gebe Road V240136 051005 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The announced inspection took place on 5/10/05 from 10.00 until 3pm. The Registered Manager, Cynthia Pegg was on duty during the visit. Time was spent looking around the home to check the cleanliness, maintenance and decoration during the visit. Prior to the inspection questionnaires were provided to service users and relatives. Seven questionnaires were completed by service users and they also shared their views during the inspection. Time was also spent observing the contact between the service users and staff. Seven questionnaires were completed by Relatives /Visitors. At the time of the inspection there were no visitors. Two Care Plans and two behaviour plans were examined. Arrangements for the administration and management of medication were checked. Health and safety arrangements were examined as well as the catering, training, protection and complaints. What the service does well: Glebe Road has a homely atmosphere. The smaller living areas help provide a personalised approach and service users bedrooms are individualised. All of the service users said they liked living at Glebe Road, felt safe, liked the food and felt that staff treated them well. Some service users have recently been on holiday to Rothbury, Berwick and York trips. Relatives and visitor comments were very positive and included; - ‘Over the past few years I have been very happy with the support and service provided by Glebe Road.’ - ‘I have never seen X so happy and contented …. that is all down to the dedicated staff who work there.’ -‘I have no complaints or criticism whatsoever.’ -‘I am very pleased.’ -‘Thanks to the caring staff at Glebe Road and relaxed atmosphere.’ The management are responsive to change and want to develop and improve the service. There is a good multi-disciplinary approach to care. The staff team is stable and have good relationships with the service users. Staffing levels were appropriate to meet the needs of the service users. 69 Glebe Road B53-B03 S35343 Gebe Road V240136 051005 Stage 4.doc Version 1.40 Page 6 The catering arrangements are very good and service users are involved in planning the menus. What has improved since the last inspection? 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. 69 Glebe Road B53-B03 S35343 Gebe Road V240136 051005 Stage 4.doc Version 1.40 Page 7 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 Standards Statutory Requirements Identified During the Inspection 69 Glebe Road B53-B03 S35343 Gebe Road V240136 051005 Stage 4.doc Version 1.40 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Assessed at last inspection July 2005. EVIDENCE: 69 Glebe Road B53-B03 S35343 Gebe Road V240136 051005 Stage 4.doc Version 1.40 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 & 9 Service users have care plans and risk assessments which enable them to fulfil their potential and have their needs met. NMS 7 was assessed at the last inspection in July 2005. EVIDENCE: Two service user care plans and two service user behaviour plans were examined and are in good detail to guide the practice of staff. Multidisciplinary team work is in place from psychologists and the Behaviour Analysis Intervention Team (BAIT) and other professionals where necessary such as Speech & Language Therapy Team (SALT). Risk assessments are in place and reviewed periodically. Reviews organised by care managers have not been held for a year for one service user and the manager is dealing with this. 69 Glebe Road B53-B03 S35343 Gebe Road V240136 051005 Stage 4.doc Version 1.40 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 17 Service users enjoy a wholesome, well- balanced and nutritious diet that they are able to plan and choose. NMS 12,13,15 & 16 were assessed at the last inspection in July 2005. EVIDENCE: Service users spoke positively about the food in the home and in particular the staff member who cooks for the majority of the time for the Main House. The smaller living areas cook for themselves with staff support. Service users are asked what foods they like each Sunday and they plan the menu together with staff. The Inspector shared lunch with the service users and staff. The meal was relaxed and consisted of steak, broccoli, carrots and potatoes. Salad, pasta or sandwiches were also available. The dessert was cheesecake and fruit. An assortment of hot and cold drinks were served. 69 Glebe Road B53-B03 S35343 Gebe Road V240136 051005 Stage 4.doc Version 1.40 Page 11 Service users help with meal preparations such as setting the tables and changing the menu board pictures. Special diets are provided and evidence of Speech and Language Team (SALT) involvement is in the kitchen and the care plans. 69 Glebe Road B53-B03 S35343 Gebe Road V240136 051005 Stage 4.doc Version 1.40 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 20 The medication at this home is being managed but some areas continue to need improvement so that service users are protected. NMS 18 & 19 were assessed at the last inspection in July 2005. EVIDENCE: A full audit of the medication arrangements was completed. Five areas require improvement. Three are still not addressed since the last inspection. (See Requirements) 69 Glebe Road B53-B03 S35343 Gebe Road V240136 051005 Stage 4.doc Version 1.40 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 Service users can share concerns and make complaints that they know will be listened to and investigated fully. Service users are protected from potential abuse, neglect and harm. EVIDENCE: Two complaints have been made since the last inspection by two service users regarding night- time disturbance. The management have responded appropriately to these complaints. Service users know who they can talk to if they are unhappy. Staff have received training in the Protection of Vulnerable Adults and have demonstrated their knowledge of Whistle Blowing where they would report poor practice or concerns. 69 Glebe Road B53-B03 S35343 Gebe Road V240136 051005 Stage 4.doc Version 1.40 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 30 Service users live in a well maintained, clean and decorated home however some areas require attention. EVIDENCE: The location and layout of the home is suitable for the service users living at the home. Small living areas provide a personal homely feel. The new sofas and chairs add to the homely feel. Bedrooms are personalised and service users like their accommodation. Infection control measures have improved and paper towels are now available in communal toilets, bathrooms and the laundry. Staff have barrier gel as part of their hygiene management. One bathroom requires liquid soap. The bath in the Flat must be repaired or replaced where it is rusty. Two ceilings in the Main Building bathroom and bedroom room 2 in 69A must be redecorated. The kitchen was clean and well organised. 69 Glebe Road B53-B03 S35343 Gebe Road V240136 051005 Stage 4.doc Version 1.40 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 35 Staffing numbers are appropriate to the assessed needs of the residents, size, layout and purpose of the home, at all times. Service users are cared for by experienced and appropriately trained staff. 69 Glebe Road B53-B03 S35343 Gebe Road V240136 051005 Stage 4.doc Version 1.40 Page 16 EVIDENCE: The staffing arrangements in the home meet the assessed needs of the 11 service users at Glebe Road. Staffing is increased where needed to respond to the changing needs of service users. The Residential Forum calculations have been applied for the needs of the service users per unit. Night Staff Three waking night staff are required at Glebe Road. The Flat has 1 dedicated waking night staff. Bungalow At this time there are no service users living in the Bungalow and 2 people are planned to be accommodated. Main House At the time of the inspection 4 staff were on duty in the Main House, which includes extra-allocated staff members for service users in the home. Flat The flat is staffed 1:1 with a further 1 person for Flat Support. Bed Sit 1 member of staff is allocated to work in the Bed Sit. The home continues to have a training programme which is developed around the needs of the service users. Staff complete NVQ Level 2 & 3, Learning Disability Award Framework (LDAF), Protection of Vulnerable Adults, Health and Safety and Medication. Good support and training is available from the Behaviour Analysis Intervention Team (BAIT) and other professionals where necessary such as psychology and Speech & Language Therapy Team (SALT). Other mandatory training is provided. Personal Futures Planning Training is starting for staff so that service users wishes and potential can develop further. 69 Glebe Road B53-B03 S35343 Gebe Road V240136 051005 Stage 4.doc Version 1.40 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 & 42 Formal Quality Assurance systems are not in place by the Local Authority so the service is not formally audited externally. Systems are in place to protect service users from health and safety hazards. 69 Glebe Road B53-B03 S35343 Gebe Road V240136 051005 Stage 4.doc Version 1.40 Page 18 EVIDENCE: The home has its informal quality assurance system in place where service users are asked for their views on the home via meetings and informal chats on a daily basis. The home does not have a formal quality assurance system in place from the Local Authority. Monthly visits and reports on the conduct of the home are completed by the Local Authority. Maintenance checks and records are in place and risks are managed. Checks include the fire log, training and maintenance of equipment. Gas and electrical testing, hot water and Legionella prevention is in place. Moving and handling equipment is serviced at the required time. 69 Glebe Road B53-B03 S35343 Gebe Road V240136 051005 Stage 4.doc Version 1.40 Page 19 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 CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No 11 12 13 14 15 16 17 x x x x x x 4 Standard No 31 32 33 34 35 36 Score x x 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 69 Glebe Road Score x x 1 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x B53-B03 S35343 Gebe Road V240136 051005 Stage 4.doc Version 1.40 Page 20 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 20 Regulation 13(2) Requirement Timescale for action 14/10/05 2. 3. 6 24 & 30 15 23(2) Medication issues must be addressed; 1. Creams must be dated when opened OUTSTANDING July 05. 2. Two signatures must be recorded for handwritten MAR sheets. OUTSTANDING July 05. 3. MAR sheets must be written in full ie strength OUTSTANDING July 05. 4. Creams must be for individual use and not communal. 5. The Flat Medication storage must be clean and creams stored hygenically. Reviews must be held. 30/10/05 1.The Flat bath must be repaired or replaced where it is rusty.2 provide soap in 69A. 3. The ceilings in Main Building bathroom and bedroom room 2 in 69A must be redecorated. 30/1105 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 B53-B03 S35343 Gebe Road V240136 051005 Stage 4.doc Version 1.40 Page 21 69 Glebe Road 1. 20 Provide adequate storage for medication that requires cool temperatures 69 Glebe Road B53-B03 S35343 Gebe Road V240136 051005 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection Northumbria House Manor Walks Cramlington, Northumberland NE23 6UR 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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