Inspection on 21/09/05 for Glebelands

This inspection was carried out on 21st September 2005.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 22 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glebelands 28/05/08

Glebelands 05/06/07

Glebelands 25/07/06

Glebelands 09/02/06

Glebelands 02/02/05

Glebelands 17/08/04

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

CARE HOME ADULTS 18-65 Glebelands Kempton Way Off Heath Farm Road Norton, Stourbridge West Midlands DY8 3AZ Lead Inspector Jayne Fisher Unannounced Inspection 21st September 2005 09:30 Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 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 Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Glebelands Address Kempton Way Off Heath Farm Road Norton, Stourbridge West Midlands DY8 3AZ 01384 813590 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) Chadd Housing Association Russell Kent Care Home 18 Category(ies) of Learning disability (17), Learning disability over registration, with number 65 years of age (1) of places Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Three services users in the category Learning Disability (LD) may also have a physical disability (PD). One service user in the category of learning disability (LD) may also have a mental disorder (MD). 2nd February 2005 Date of last inspection Brief Description of the Service: Glebelands is an 18 bedded care establishment which is provided through a partnership of the Churches Housing Association of Dudley District (CHADD) and Dudley Metropolitan Borough Council (MBC) Social Services Department. The property is owned and managed by CHADD who are the Registered Providers. Dudley MBC provides staffing to support service users. The Home was originally built in 1970 but was totally refurbished in 2000. The unit is a two storey property which is separated into four flats: two with five beds and two with four beds. All bedrooms are single occupancy. Each flat has its own laundry, lounge and dining room with adjoining kitchen and an additional area for making snacks. There are bathing and toilet facilities on both floors which include level access showers. There is 1 assisted bath on the ground floor in flat 2. Each flat has its own private entrance with a secure entry phone system. There is a large meeting room on the ground floor which also acts as an activities room for service users with a television and pool table. A shaft lift and stairway give access to both floors There is a garden with an enclosed courtyard. Glebelands has a large car park to the side of the premises. The Home is situated in a residential area of Stourbridge, the town centre being within easy access. The Home provides care for 18 adults who have a learning disability, one of whom is over the age of 65 years. Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted between the hours of 9.30 a.m. and 3.30 p.m. The purpose of the inspection was to assess progress towards meeting the national minimum standards and towards addressing items identified at previous inspection visits. A range of inspection methods were used to make judgements and obtain evidence which included: formal and informal interviews with the manager and five staff who were on duty. There was also a tour of the premises. Glebelands provides care for eighteen younger adults who have a range of learning disabilities, who may exhibit challenging behaviour, who have communication needs and associated health care problems. Seven residents were at home for varying parts of the inspection. It was not possible to have an open dialogue with all residents therefore the inspector used a variety of communication methods including brief chats and discussions, observation of body language and gestures, plus observed interactions between residents and staff. A number of records and documents were examined. Other information was gathered prior to the inspection from reports of visits undertaken by the owner’s representative and an action plan submitted by the home following the last inspection. The inspector was made to feel very welcome and would like to thank service users, the manager and staff for their assistance and co-operation during the visit. What the service does well: There is an emphasis on promoting independence so that residents can reach their full potential and make their own decisions regarding daily living. The building is designed to enhance this principle of care. There are four flats each with a front door and separate access. All flats have their own kitchens and communal lounges/dining areas. There is no restriction upon residents’ movement within the building. Residents were seen either relaxing in their own bedrooms, watching television in communal areas or participating in daily living skills tasks with support from staff. Residents were happy to show the inspector their bedrooms which were individually decorated and furnished to reflect their own tastes. Residents chatted about their favourite activities; one resident had recently starting horse riding, another resident had recently been on holiday to France, a third resident spoke about their volunteer work. During interviews residents confirmed that they could receive visits from their relatives and could visit friends and family if they wished. There was positive interaction observed between staff and residents. There was a happy and relaxed atmosphere with friendly banter and joking. Staff were overhead asking residents what they would like to eat for lunch and practice was observed which promoted dignity. There are regular residents’ Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 6 meetings at which they talk about preferred foods and outings. There is plenty of information for new residents regarding the service so that they can make an informed choice about whether they wish to live at the Glebelands. On a brief tour all parts of the premises were seen to be very clean, well maintained and free from any odours. What has improved since the last inspection? What they could do better: Care planning needs further improvement particularly with regard to involving residents in the development of their own care plans. Although residents are involved in day to day decisions regarding their care, more effort is needed to offer opportunities to participate and influence key decisions regarding the running of the home and development of the service. Weekend and evening activities need more planning and structuring particularly for those residents who are less independent and require more assistance. Reviews of care plans and activity programmes together with residents would assist in this process. Although there is good health care monitoring not all residents are receiving regular weight checks. Systems for the administration and control of medication also require improvement in order to offer residents greater protection. Residents expressed concerns regarding the fence around the building which does not afford privacy and in some instances they are being taunted and teased by local children. A higher fence would afford more security. Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 7 More effort is needed to ensure that policies, procedures and practice are learning disability orientated rather than older persons, which is the main service provision of the Local Authority, who are in partnership with the provider (and who are responsible for the employment of staff). For example, providing appropriate policies and in varying formats suitable for residents and providing specialist induction and foundation training for staff. 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. Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 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 Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The Statement of Purpose and Service User Guide are very good providing service users and prospective service users with details of the services the home provides enabling an informed decision about admission to be made. EVIDENCE: There is a well written and comprehensive statement of purpose. Some slight amendments were identified at the last announced inspection in August 2004 which still require action. For example, up to date staffing details and inclusion of the complaints procedure. A service user guide has also been produced in a pictorial format which covers the key issues. Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 8 and 10 Service users are consulted on some aspects of life within the home, however more opportunities need to be offered in order for them to be able to influence key decisions regarding the home and service they receive. Progress is being made in ensuring that service users are made aware that information about them is handled sensitively. EVIDENCE: A sample of care plans were examined as part of case tracking which revealed that progress is still required to afford a more effective system. This is acknowledged by the manager who is in the process of introducing a more efficient care planning approach which is learning disability orientated. For example using a recognised person centred planning system. Although this was attempted a few years ago it was never fully integrated or completed. There are regular review meetings held however care plans are not necessary updated or amended. For example some care plans were established in May 2003 and have not been formally reviewed. Some care plans examined did not contain up to date information. Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 11 There are strategies for ensuring that service users participate and have control regarding some elements of care delivery mainly in respect of their daily lives. Interviews with service users confirmed that they have regular meetings in their flats. There were records of minutes which confirmed a range of topics are discussed such as preferred outings, food etc. However as acknowledged by the manager more progress is needed in offering service users opportunities to become proactively involved in the running of the Home. For example, although service users meet prospective new staff, there is no formal procedure for participation in staff interviews. Service users are not represented in management structures and do not attend staff meetings. As discussed at previous inspections, in order for service users to successfully participate in the running of the Home, this must be carefully planned with all parties aware of their roles and responsibilities accompanied by written protocols and training sessions. At previous inspections it has been required that service users are provided with written information as to how they can access their own personal records. The manager states that a protocol has been devised and this is currently being read and signed by service users. Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 14 and 15 Although there is a range of leisure pursuits, more structured planning and evaluation would ensure that all service users have opportunities to participate in stimulating activities. Staff offer support and encouragement so that service users are able to maintain family and personal relationships. Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 13 EVIDENCE: As identified at previous inspections, although there are structured weekly activity planners detailing which college courses and day centres that residents attend during the week, leisure activities at evenings and weekends remain blank. Whilst it is accepted that service users may wish to undertake a range of either spontaneous and unstructured activities, the activity sheets should at least recognise this aspect which would allow for planning, monitoring and evaluation. In addition although the majority of residents are able to exercise their own choice and are able to support themselves in following their own hobbies and leisure pursuits, there are a small number of less independent service users who need assistance, and therefore this requires some planning and structure. It was difficult to determine what activities are taking place for those residents needing more support. Examination of personal daily reports during a 14 day period for one service user revealed that apart from attending their day centre, they had either watched television, seen a film on DVD and participated in a residents’ meeting. Their care plan for social inclusion stated that ‘occasional trips out would be offered when the opportunity arises as 2 members of staff are needed’. Another resident’s care plan stated that regular swimming sessions should be offered. Staff who were interviewed thought these were occurring on a weekly basis although there were no records to confirm that this was taking place. A number of outings identified by residents during their meetings had not taken place. Residents stated that they were unaware as to why these had not occurred. Management said that there had been reduced outings as residents had been going on their annual holidays. The manager accepts that improved planning, evaluation and recording of activities is necessary. During interviews residents confirmed that they could visit their families and friends when they wished. Records demonstrated that this was taking place on a regular basis. For example, some residents regularly go to visit and stay with their families at weekends. Residents are still complaining that the telephone in the main communal lounge does not afford them privacy. The manager has reinforced during meetings that residents can use the cordless phone facility. This will be evaluated at the next visit. Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 14 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 the following standard(s): 19 and 20 The health needs of service users are well met with evidence of good multidisciplinary working taking place on a regular basis. Slight improvements would further benefit residents. The systems for administration of medication require improvement in order to provide greater protection. EVIDENCE: Service users are offered personal support in a way which maximises their independence and promotes their dignity. Since the last inspection more male staff have been recruited. The new care planning system will hopefully ensure that their preferences are fully recorded including those with regard to ageing and terminal care. It was pleasing to see that improvements have been made with regard to health care monitoring and recording. Health care appointments charts were up to date and demonstrated that residents receive regular dental, chiropody, ophthalmic and medication checks. The ‘priority screening for health care’ booklets are currently being reviewed as previously requested. There is improved recording with regard to urine testing. Staff closely monitor service users’ health care needs and any issues identified are acted upon. For example one resident prone to ulcerated legs had been made an appointment to see the practice nurse as staff were concerned regarding a deterioration in their condition. There was evidence that service users had been referred to Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 15 appropriate specialists regarding changes in behaviour. During interviews staff demonstrated good knowledge regarding residents’ specialist dietary needs. A couple of improvements are necessary. For example, a comprehensive care plan regarding all aspects of diabetic care is required. Weight checks for residents is somewhat erratic. Residents in one flat receive monthly weight checks which are fully recorded. Service users in other flats had not been weighed regularly, some for over ten months. This needs to be addressed particularly as some residents are prone to eating and weight problems. Although there have been some improvements in some areas of the control and administration of medication, there has been a deterioration in other aspects. It was pleasing to see comprehensive guidelines in place regarding the administration of ‘as and when necessary’ (PRN) medication for all residents. Household remedies are no longer used. Staff have received appropriate training including instruction in the monitored dosage system. Although a key holding policy and signed handover sheet was introduced, staff have not been signing for the handover of medication keys since May 2005. There were a number of gaps in the medication administration record (MAR) sheets where there was no staff initial to confirm administration had taken place, or a recognised letter code to explain why this had not occurred. It was encouraging to see that the manager had already identified this as an issue earlier in the week and was taking appropriate action. As before, not all medication received is being fully recorded on receipt mainly short courses of antibiotics. It appeared from the computerized MAR sheet that one resident had recently been prescribed a 7 day course of 28 antibiotic tablets. There was no confirmation as to how many tablets had been received. There were 30 staff signatures which indicates that either the resident had been prescribed 2 extra tablets or that staff had signed for medication which had not been in place or administered. Although it is commendable that service users are encouraged to take responsibility for their own medication, written risk assessments were not in place with regard to self administration. Staff are not always recording the administration of creams and ointments. Any other items discussed during this inspection are identified in the Requirements section of this report. Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 16 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 the following standard(s): 22 The complaints process ensures that users views are listened to and acted upon although further improvements are necessary to offer residents greater accessibility to this process. EVIDENCE: There have been no complaints received regarding the service during the last twelve months. In the past any complaints which have been received have been dealt with in a fair and consistent manner and resolved to the satisfaction of the complainant. There is a complaints procedure which is a corporate policy established by Dudley MBC. As identified at previous inspections, this requires amendment as it does not inform users that they have the right to make a complaint direct to the Commission for Social Care Inspection if they wish. In addition it would be beneficial if the complaints procedure was reproduced in varying formats such as pictorial and audio in order to meet the needs of the service user group. The manager reports that a new complaints officer has been appointed who is looking at these shortfalls. Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 17 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 the following standard(s): 0 These standards were not assessed at this inspection. EVIDENCE: A brief tour of the premises was undertaken during this inspection. Some improvements have taken place with regard to infection control and fire safety. For example, the laundry door in flat 2 is no longer propped open and a suitable door closer has been fitted. It was pleasing to see that appropriate sealed laundry bags and baskets have now been obtained. A couple of items remain outstanding with regard to infection control. As at the last inspection some residents complained about the lack of adequate fencing around the home. They were concerned about the intrusion from local youths and children (particularly as the home adjoins open playing fields and football pitch). There are plans to replace the fence with the building of some new bungalows in the grounds however, this must receive more urgent attention due to the level of anxiety expressed by residents. Any additional items discussed during this inspection are contained within the Requirements section of this report. Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35 and 36 Training and supervision is improving thereby ensuring staff have the skills in order to undertake their duties although induction and foundation training is still outstanding, which is necessary in order for staff to have the underpinning knowledge regarding the specialist needs of residents. EVIDENCE: Since the last inspection the number of staff who have undertaken a vocational qualification has increased. 33 staff are currently employed, 12 staff are qualified to NVQ II or above. A further 6 staff are undertaking an NVQ qualification. There is a central staff development and training plan although the manager states that this may not be up to date as the training co-ordinator is temporarily seconded. Examination revealed that statutory training is ongoing and this was confirmed during interviews with staff. The manager is still trying to ascertain details of a training budget as previously requested. It is disappointing that no further progress has been made with regard to specialist training including providing staff with induction and foundation training which is provided by an accredited learning disability awards framework provider. This training is essential for staff who are new to the field of learning disabilities. There is evidence of improvements with regard to the frequency of formal staff supervision. This was previously impeded by the lack of senior staff which has Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 19 now been rectified. It was pleasing to see from a sample of supervision records that staff are receiving regular supervision sessions although further progress is still necessary. Annual appraisal systems are starting to be implemented. Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 40 and 42 Improvements are being made to systems for user consultation thereby offering residents an opportunity to participate in the development of the service. Policies and procedures require review to ensure that they comply with recognised professional standards ensuring the best interests of residents are safeguarded. The health, safety and welfare of service users and staff is so far as is reasonably practicable promoted by management. EVIDENCE: Progress is being made with regard to improving the quality assurance mechanism. Satisfaction surveys have been designed to seek feedback from stakeholders in the community and staff. Policies and procedures covering topics which meet all of the requirements of the National Minimum Standards still need to be established. These must reflect the individual service rather than the corporate business. Good progress has been made in respect of improving health and safety standards. At the last inspection serious concerns had been raised regarding Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 21 fire safety training and the lack of fire evacuation drills. These received prompt attention and progress is on-going. There is regular fire safety training for all staff by the manager and senior staff who have undertaken a fire safety training course. There are regular fire safety drills and the fire alarm system and emergency lighting is more consistently checked. All fire safety equipment has been serviced and inspected. The manager reports that the home recently received an inspection from the fire safety officer and that no concerns were identified. There is an up to date fire safety risk assessment. All maintenance and service checks were found to be up to date. A Legionella risk assessment has been completed which identifies the premises as low risk. Recommendations have been largely complied with although a written Legionella management plan needs to be established. There is good accident reporting and an excellent monthly monitoring of all accidents. There is also good recording of any challenging behaviour incidents for the purpose of monitoring as is good practice. Once again the Registered Provider is failing to comply with the requirements of the Care Homes Regulations 2001, Regulation 26. This requires a representative from the provider to visit and provide a monthly report as to the conduct of the home. This responsibility is alternated between the landlord (CHADD) and the Local Authority. Although there are regular reports from visits undertaken by representatives from CHADD which are forwarded to the Commission for Social Care Inspection, there are no reports available from visits undertaken by the Local Authority for over 12 months. This needs to be addressed. Any additional items discussed during this inspection are contained within the Requirements section of this report. Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 X X X X Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X 2 X 2 Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 2 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X X 2 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Glebelands Score X 2 1 X Standard No 37 38 39 40 41 42 43 Score X X 2 2 X 2 x DS0000024984.V251795.R01.S.doc Version 5.0 Page 23 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 YA1 Regulation 4 Timescale for action To amend the statement of 01/01/06 purpose to ensure that all details are included as required by Schedule 1 of the Care Homes Regulations 2001. To produce a service user’s guide containing details as required by standard 1.2. This must also be in a format suitable for service users. A copy to be forwarded to the Inspector upon completion. (Previous timescale of 30/9/03 is partly met). To develop a rigorous and robust 01/01/06 care planning system and ensure that it incorporates all aspects of care/support required for individual service users. This must also cover healthcare and social and recreational activities to ensure a holistic approach to care planning (Previous timescale of 1/1/04 is partly met). The service user must be involved in this process (person centred planning), and all care plans must be signed by the service user. Reviews of care Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 24 Requirement 2 YA6 15(1) plans must be undertaken at least every six months. (Previous timescale of 1/1/04 is partly met). Care plans must also be produced in a format suitable for service users. (Previous timescale of 1/1/04 is partly met). To offer more opportunities for service users to participate in the day to day running of the Home through joining staff meetings, representation in management structures, recruitment and selection of staff. (Previous timescale of 1/1/04 is partly met). To provide written information to users on how to access their personal information and to keep written evidence that users have received this information. (Previous timescale of 1/1/04 is partly met). To review and expand weekly activity planners to ensure that they are fully completed for all service users and are extended to cover weekend activities (planned and spontaneous). To undertaken a documented review staffing levels at weekends to ensure that they are appropriate to meet the needs of service users. (Previous timescale of 1/6/05 is not met). To provide a telephone facility for service users which affords more privacy. (Previous timescale of 1/3/04 is not met). To ensure that preferences and restrictions on residents’ choices be negotiated, included in service user plans and reviewed regularly: decision to not provide DS0000024984.V251795.R01.S.doc 3 YA8 12(3) 01/01/06 4 YA10 12(4)(a) 01/01/06 5 YA14 16(2)(n) 01/12/05 6 YA16 16(2)(b) 01/01/06 7 YA18 17(1)(a) 01/01/06 Glebelands Version 5.0 Page 25 certain items of furniture as required by Standard 26, personal care given by opposite gender staff, preferred bed times, bath times etc. (Previous timescale of 1/1/04 is partly met). 8 YA19 12(1)(a) To make the following 01/12/05 improvements to health care: 1) To ensure that the ‘priority screening for health care’ booklets are kept up to date (and reviewed), and all sections are fully completed by the Home. (Previous timescale of 1/10/04 is partly met). 2) To ensure that care plans are expanded for diabetic service users. These must include guidelines for management of diabetes, screening, monitoring and potential complications. (Previous timescale of 1/10/04 is not met). To ensure that all service users receive more regular and consistent weight checks which are fully recorded. To make the following improvements to the control and administration of medication: 1) To review and expand the medication policy to include all subjects: staff training, drug hazard alert notices, key holding etc. (Previous timescale of 1/3/04 is not met). 2) To introduce a key holding policy and handover sheet. (Previous timescale of 1/10/04 is partly met). Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 26 9 YA20 13(2) 01/12/05 3) To ensure that receipt of all medicines received into the Home is fully recorded including short course antibiotics. (Previous timescale of 1/6/05 is not met). 4) To ensure that there is more consistent recording of the administration of creams and ointments on MAR sheets held in service users’ bedrooms. (Previous timescale of 1/6/05 is not met). 5) To improve administration of medication and recording on the medication administration record (MAR) sheets. All gaps must be explored with written explanations obtained. Unauthorized letter codes such as ‘X’ must not be used. Staff must only sign the MAR sheet if they have administered and witnessed the taking of medication by the service user. 6) To ensure that when any changes of medication are made on the MAR sheets by staff, such as the addition of new medication, two staff initials are obtained to confirm accurate instructions have been recorded. 7) To clarify all ‘as directed’ doses with the prescriber. Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 27 8) To ensure that all creams/ointments are labelled with the date of opening. 9) To ensure that risk assessments are carried out for any service user who self medicates including vitamins and creams. 10 YA21 12(2) To ascertain the wishes of service users with regard to terminal illness and death (assisted by family or advocates if necessary). These to be fully recorded on care plans. (Previous timescale of 1/1/04 is partly met). 01/01/06 11 YA22 22(8) To amend complaints procedure 01/01/06 to include details of the CSCI local area office and a response timescale of 28 days. (Previous timescale of 1/7/03 is not met). To produce a complaints procedure in a format suitable for all service users. (Previous timescale of 1/1/04 is not met). To provide all staff with training 01/01/06 in vulnerable adult abuse awareness. (Previous timescale of 1/1/04 is not met). To erect a more suitable 01/12/05 perimeter fence to afford service users more privacy and protection. To replace worn and stained settees and dining room furniture in flat no. 3. To continue to progress plans to replace stained carpeting in communal areas in flat no. 2. 12 YA23 13(6) 13 YA24 23(2)(b) Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 28 14 YA30 13(3) To make the improvements to control: following 01/12/05 infection 1) To ensure that mop heads are laundered daily at thermal disinfection temperatures and are dried appropriately (inverted). (Previous timescale of 1/6/05 is not met). 2) To remove and replace any worn ironing board covers. (Previous timescale of 1/6/05 is not met). 15 YA32 18(1)(c) To ensure that all staff are working to obtain an NVQ II or III by an agreed date; or the Manager must provide evidence to demonstrate that through past work experience staff meet this standard. (Previous timescale of 1/5/04 is not met). To ensure that 50 of care staff achieve an NVQ II by 2005. (Previous recommendation). 16 YA35 18(1)(a) To amend induction/foundation 01/12/05 training to ensure it meets the Sector Skills Council specification. To ensure that this training is carried out by a Learning Disability Awards Framework accredited provider. To ensure that induction is completed within the first six weeks of employment and foundation, within the first six months. (Previous timescale of 1/7/03 is not met). To provide a staff training and development plan with a Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 29 01/01/06 dedicated budget – to be held on the premises and available for Inspection. (Previous timescale of 1/1/04 is partly met). To provide all staff with training in equal opportunities and disability equality. (Previous timescale of 1/1/04 is not met). To ensure that structured supervision of staff is carried out bi-monthly. (Previous timescale of 1/1/04 is partly met). To provide all staff with an annual appraisal. (Previous timescale of 1/1/04 is not met) To develop an effective quality assurance system to include feedback from service users, stakeholders in the community etc. (Previous timescale of 1/1/04 is partly met). To regularly review all policies and procedures. To establish and/or expand, update policies as detailed in Appendix II of the National Minimum Standards and including: infection control, vulnerable adult abuse, medication, infection control, complaints etc. The Manager must sign and date all policies. (Previous timescale of 1/1/04 is not met). To provide training for all staff commensurate with their duties in the following areas: 1) Moving and handling. (Previous timescale of 1/1/04 is partly met). 2) Health and safety. (Previous timescale of 1/1/04 is partly met). 3) infection control. (Previous Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 30 17 YA36 18(2)© 01/01/06 18 YA39 24 01/01/06 19 YA40 12(1)(a) 01/01/06 20 YA42 18(1)(a) 01/01/06 timescale of 1/1/04 is partly met). 4) training in emergency breakdown procedures (or to ensure staff read and sign a policy which describes what action to take in the event of a breakdown). (Previous timescale of 1/1/04 is not met). To ensure compliance with Control of Substances Hazardous to Health Regulations 1988 – to carry out and update individual risk assessment on products used. .(Previous timescale of 1/1/04 is partly met). To ensure that there is a written report on the conduct of the home completed by the providers representative who is carrying out monthly visits. A copy must be provided to the Registered Manager and a copy forwarded to the Commission for Social Care Inspection. 21 YA42 12(1)(a) 01/01/06 22 YA43 26 01/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard 20 Good Practice Recommendations To monitor and record temperature of staff room containing the drugs cupboards which should not exceed 25 C. To obtain an up to date copy of the Royal Pharmaceutical Society guidelines for the administration and control of medicines in care homes issued in June 2003. To provide awareness training for staff in cerebral palsy and diabetes awareness. To establish a documented Legionella control scheme as recommended following a Legionella risk assessment. DS0000024984.V251795.R01.S.doc Version 5.0 Page 31 2 3 32 42 Glebelands Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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 Glebelands DS0000024984.V251795.R01.S.doc Version 5.0 Page 32 - 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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