Inspection on 19/04/05 for Glebe, The Care Home

This inspection was carried out on 19th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Glebe, The Care Home 17/04/07

Glebe, The Care Home 06/06/06

Glebe, The Care Home 14/11/05

Glebe, The Care Home 19/10/04

Glebe, The Care Home 21/04/04

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

CARE HOMES FOR OLDER PEOPLE THE GLEBE CHURCH STREET ALFRETON DERBYSHIRE DE55 7AH Lead Inspector ROSE VEALE TUESDAY 19 TH UANNOUNCED APRIL 2005 9.30 AM 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 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. THE GLEBE C52 CO2 S35739 The Glebe V221228 190405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service THE GLEBE Address CHURCH STREET ALFRETON DERBYSHIRE DE55 7AH 01773 728347 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) DERBYSHIRE COUNTY COUNCIL MRS PEARL MOVITA LOWE CARE HOME 32 Category(ies) of OLD AGE registration, with number of places THE GLEBE C52 CO2 S35739 The Glebe V221228 190405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: NONE Date of last inspection 19/10/2004 Brief Description of the Service: The Glebe is situated in the centre of the busy market town of Alfreton, close to local shops, facilities and public transport. The Glebe is owned by Derbyshire County Council and provides 24 hour personal care and accommodation for 32 older people. All accommodation for residents is in ground floor, single rooms. There are no en-suite facilities. There is a large, well maintained garden accessible to residents. THE GLEBE C52 CO2 S35739 The Glebe V221228 190405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over one day. The manager and deputy manager were available and helpful throughout the inspection. Eight residents were spoken with during the inspection. A group of seven staff were spoken with. A tour of the building was undertaken. The case notes of five residents were seen and three of these were examined in detail. Other records relating to the staffing and management of the home were examined. What the service does well: Residents at The Glebe said they were well cared for. Residents spoke highly of the quality and choice of the meals provided. Routines in the home were flexible and residents said that staff respected their privacy and choices. Residents said they enjoyed the range of social activities offered to them. The Glebe provided pleasant, homely, comfortable accommodation. The home was well decorated, clean and tidy. Residents were able to personalise their own bedrooms with furniture, photographs and other personal possessions. The staff at The Glebe were proud of the home’s good reputation and enthusiastic about their work. Staff training was a high priority at the home. Residents and staff said they found the manager and senior staff open and approachable. Residents said they had confidence in the manager’s ability to deal with any problems or complaints. Staff said they liked the ‘hands on’ approach of the manager and senior staff. THE GLEBE C52 CO2 S35739 The Glebe V221228 190405 Stage 4.doc Version 1.20 Page 6 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. THE GLEBE C52 CO2 S35739 The Glebe V221228 190405 Stage 4.doc Version 1.20 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection THE GLEBE C52 CO2 S35739 The Glebe V221228 190405 Stage 4.doc Version 1.20 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,4 and 5 New residents were admitted on the basis of a full and detailed assessment to ensure that the home was able to fully meet the needs of residents. New residents were given the opportunity to move in on a trial basis so that they could be sure the home is suitable for their needs. EVIDENCE: All the case files seen contained the community care assessments and care plans compiled prior to the admission of the resident. All except one file had a care plan completed after admission by the home. The assessments and care plans seen were detailed and easy to follow. One care plan seen did not refer to the care required for a resident who had several recent falls. Two residents spoken with confirmed that they had been offered admission on a trial basis before deciding to stay permanently at the home. One resident spoken with was staying at the home on a short term basis and was in the process of deciding whether to make the Glebe a permanent home. THE GLEBE C52 CO2 S35739 The Glebe V221228 190405 Stage 4.doc Version 1.20 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 and 10 Individual care plans were produced from the assessment of needs so that staff were aware of the action to be taken to ensure all needs of residents were met. Respect for residents privacy and dignity was upheld by the clear policies and procedures in the home and through the program of staff training and supervision. The home had clear medication policies and procedures, but there were inconsistencies in implementation resulting in some potentially unsafe practices. THE GLEBE C52 CO2 S35739 The Glebe V221228 190405 Stage 4.doc Version 1.20 Page 10 EVIDENCE: Individual care plans were examined for two residents. One case file examined did not contain an up to date care plan. The care plans seen were detailed and had been reviewed monthly. One care plan seen referred to recent falls in the monthly reviews, but did not detail the action required by staff in the care plan. Risk assessments were included in all the case files seen. Also, assessments of tissue viability, continence, nutritional needs and moving and handling needs. All the case files seen contained records of GP visits and access to other services, such as chiropody and community nurses Residents spoken with all said that staff respected their privacy. One resident said that staff always knock on her door before entering. Case files seen recorded resident preferences such as how they wished to be addressed and activities likes and dislikes. One resident said that staff respected her choice not to join in with some activities. All the case files seen contained an agreement signed by the resident or their representative regarding the administration of medication. One resident had chosen to be self-medicating. Medication was stored appropriately and securely. Staff administering medication had all undertaken appropriate training. There were some inconsistencies in the implementation of the medication procedures. Not all of the Medication Administration Records (MARs) had photographs of residents attached. Where staff had handwritten MARs there was no signature or countersignature. Medication prescribed to a named individual was being used for other residents and staff confirmed that this was accepted practice at the home. Staff at the home do not see the prescriptions before they are dispensed and so are unable to check against the order records. THE GLEBE C52 CO2 S35739 The Glebe V221228 190405 Stage 4.doc Version 1.20 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,14 and 15 Activities and routines in the home were varied and flexible to suit the expectations, preferences and abilities of residents. The meals provided in the home were of a high standard ensuring that residents were offered appealing and wholesome choices. EVIDENCE: Residents spoken with confirmed that routines in the home were flexible and that their choices were respected, such as bedtimes, taking meals in their rooms, and taking part in activities. The home offered a range of activities to residents including group and individual activities. A record was kept of activities. Staff spoken with talked enthusiastically about the activities. Recent activities included make up and manicure sessions, dominoes, bingo, entertainers, and chair-based exercises. Residents bedrooms had been refurbished and residents were involved in the choice of décor and soft furnishings. All the bedrooms seen were personalised with residents own furniture, pictures and possessions. All the residents spoken with praised the standard of the meals in the home and said that choices were always offered. One resident was particularly THE GLEBE C52 CO2 S35739 The Glebe V221228 190405 Stage 4.doc Version 1.20 Page 12 pleased that there were always plenty of fresh fruit and vegetables included. The main dining room was bright and cheerful with fresh flowers on the tables, ensuring a pleasant setting for residents to enjoy their meals. THE GLEBE C52 CO2 S35739 The Glebe V221228 190405 Stage 4.doc Version 1.20 Page 13 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 standard(s) 16 and 18 Residents were protected by the policies and procedures in place in the home, and by the program of staff training and supervision. EVIDENCE: There was a clear complaints procedure in place in the home. One resident spoken with said she was confident that she could take any complaint to the manager and that it would be properly dealt with. There have been no formal complaints to the home since the last inspection. All staff at the home have had training in adult protection issues and procedures. Records were kept of incidents of aggression in the home. All staff had regular supervision sessions and records were kept of these. Clear records were kept of residents personal money held in the home. THE GLEBE C52 CO2 S35739 The Glebe V221228 190405 Stage 4.doc Version 1.20 Page 14 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 standard(s) 19,24 and 26 The home was suitable for its stated purpose and well maintained ensuring that residents lived in a safe, comfortable, homely environment. EVIDENCE: The home was clean and pleasant on the day of the inspection. All rooms seen were well decorated and comfortably furnished. The manager said that a program of repairs and maintenance was always ongoing and that two new windows had recently been installed. The manager said it was planned for other windows to be replaced, the lighting in one of the corridors to be upgraded, and a carpet replaced in one of the bedrooms. The garden of the home was large, well maintained and fully accessible to residents. One resident spoken with said she particularly enjoyed the garden and made good use of it in the summer months. The case files seen contained a record of residents wishes with regard to the furniture and fittings in their bedrooms. Where residents had chosen not to have items provided in line with Standard 24, this was recorded and signed by THE GLEBE C52 CO2 S35739 The Glebe V221228 190405 Stage 4.doc Version 1.20 Page 15 the resident or their representative. All the bedrooms seen were pleasant and comfortable with lockable doors. THE GLEBE C52 CO2 S35739 The Glebe V221228 190405 Stage 4.doc Version 1.20 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 The home provided sufficient staff with appropriate experience, skills, and training to ensure residents were protected and that their needs could be met. EVIDENCE: The staff duty rotas were examined and showed that sufficient numbers of staff were on duty throughout the day. The manager explained that she had recently been able to recruit more staff to provide additional hours throughout the day Monday to Friday and from 7.30am to 10.30am at weekends. The staff spoken with all felt that this had helped with the workload, but also felt that more hours at weekends would be beneficial. Two staff files were examined and both contained all the required information. Records were seen of staff training, including induction training, statutory training, NVQ and specific training such as dementia awareness. More than 50 of the care staff had achieved NVQ level 2. THE GLEBE C52 CO2 S35739 The Glebe V221228 190405 Stage 4.doc Version 1.20 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,35,36 and 38 The home had an effective quality assurance system in place to ensure that the stated aims and objectives of the home were being met. The registered manager ensured the health, safety and welfare of residents and staff by promotion of, and compliance with the policies and procedures in place. EVIDENCE: A recent quality assurance report was seen which contained the views of residents, their relatives, visitors and staff. The manager explained that a local advocacy service had assisted residents to complete questionnaires where necessary. Records were seen of residents personal money held in the home. Records were clear and accurate with signatures and receipts. THE GLEBE C52 CO2 S35739 The Glebe V221228 190405 Stage 4.doc Version 1.20 Page 18 Records were seen of staff training relating to fire safety, food hygiene, infection control, first aid, and moving and handling. THE GLEBE C52 CO2 S35739 The Glebe V221228 190405 Stage 4.doc Version 1.20 Page 19 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 3 COMPLAINTS AND PROTECTION 3 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x 3 3 x 3 THE GLEBE C52 CO2 S35739 The Glebe V221228 190405 Stage 4.doc Version 1.20 Page 20 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. 2. Standard 7 7 Regulation 15 15 Requirement An individual care plan must be available for every resident. All care plans must contain details of action to be taken by staff to meet all assessed needs of residents. Medicines must only be administered to the person for whom they have been prescribed, labelled and supplied Prescriptions must be seen and checked against the items ordered before being submitted to the pharmacy Timescale for action 31/05/05 31/05/05 3. 9 13 31/05/05 4. 9 13 31/05/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 9 Good Practice Recommendations A handwritten Medication Administration Record, (MAR), should be signed by the member of staff who wrote it and countersigned by a member of staff who has checked that it is correct. A photograph of the resident should be attached to the MAR to ensure correct identification. C52 CO2 S35739 The Glebe V221228 190405 Stage 4.doc Version 1.20 Page 21 2. 9 THE GLEBE Commission for Social Care Inspection Cardinal Square Nottingham Road Derby DE1 3QT 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 THE GLEBE C52 CO2 S35739 The Glebe V221228 190405 Stage 4.doc Version 1.20 Page 22 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!