Inspection on 09/02/06 for Glebelands

This inspection was carried out on 9th February 2006.

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 21/09/05

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 Announced Inspection 9th February 2006 09:30 Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 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.V275243.R01.S.doc Version 5.1 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.V275243.R01.S.doc Version 5.1 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.V275243.R01.S.doc Version 5.1 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). 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.V275243.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection was conducted between the hours of 9.30 a.m. and 6.00 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 interviews with the registered manager, observations of care practices and a tour of the premises. A number of staff participated in the inspection process including two practice supervisors and six support workers. All seventeen residents were at home during varying stages of the inspection. Some were happy to speak with the inspector and either gave consent, or showed the inspector their bedrooms. Formal interviews were not appropriate and the inspector chatted to informally to seven residents. 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, the pre-inspection questionnaire, and an action plan submitted by the home following the last inspection. Nine relatives/visitors completed pre-inspection comment cards which the manager had proactively sent to home addresses in order try and obtain a response. Fifteen residents completed comment cards. What the service does well: There is a strong emphasis on supporting residents to take control of their own lives and in achieving individually appropriate life styles. Residents are given opportunities to maintain and develop social, emotional and independent living skills. There are good links with the local community and residents are able to choose community based activities. Residents’ health and wellbeing is fully promoted by ensuring there are nutritious, varied and well balanced meals. Staff continue to support residents to access health care facilities and there is good monitoring so that any potential complications are quickly identified. There are robust procedures in place in order to offer residents protection from abuse. All residents who completed comment cards stated that they felt safe living at the Glebelands. The premises is furnished to a high standard thereby providing residents with a comfortable and homely place to live. All communal areas are light and airy with modern furniture. Bedrooms are decorated and furnished according to resident’s wishes. They contain lots of personal possessions such as televisions, hi-fi centres and videos. Residents benefit from a home that is well managed and are supported by a team of staff who are aware of their roles and responsibilities. Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 Page 6 Overall there were very positive comments made by relatives, including: “We are more than happy with the standard of care, parents like ourselves rest assured that their loved ones are happy, content, and have friendships amongst each other”. Throughout the inspection staff were seen to interact positively with residents, who looked happy and relaxed in their surroundings. All residents who completed comment cards stated that they knew who to approach if they were unhappy or wished to complain. What has improved since the last inspection? What they could do better: The level of support and care given to residents is not reflected in the current care planning system. Management have already started to address this as an issue although progress has been slow. Risk assessments also need expanding to ensure all potential hazards to residents are identified. Residents need to be offered more opportunities for participating in the running of the home and in some cases, in exercising control over the care that they receive. Different approaches need to be developed so that all residents can actively participate in this process such as person centred planning. Improvements are needed to make systems more safe with regard to the control and administration of medication. The majority of residents feel that their privacy is respected but are still requesting that the telephone is moved to a more private area. Glebelands is still experiencing staffing shortages and although agency staff are employed to cover any shortfalls, this can impact upon the continuity of care for residents and means that progress is some areas is slow. Little progress has been made towards introducing a quality assurance system in order to enable residents an opportunity to help shape and develop the service. Unfortunately, the manager is awaiting approval before distributing excellent questionnaires which had previously been devised. Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 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.V275243.R01.S.doc Version 5.1 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): These standards were not evaluated at this inspection. EVIDENCE: Since the last visit the manager has updated the statement of purpose as requested and this document now contains up to date details of staffing levels. The home is fully occupied; there have been no new admissions since the last inspection. Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 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): 6, 7 and 9 The system for care planning still needs improvement as it does not provide staff with the necessary information in providing the care required by service users. Continued progress is being made in assisting residents to participate in making their wishes known with regard to care delivery. Risk assessments are in place but not for all of the risks which are posed in delivery of care; an improved system would offer more protection to service users. EVIDENCE: The level of support and care provided by staff is currently not reflected in the existing care planning system. It is acknowledged that the manager has already identified this as a shortfall and a new system is currently being introduced. A sample of care plans were examined. In some cases, care plans introduced in 2003 had not been reviewed and updated accordingly to reflect changes in residents’ dependency levels and needs. For example, there were no care plans in place for epilepsy, continence management, nutrition or mobility. One resident has a care plan in place for tissue viability but this requires updating Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 Page 11 to describe the current methods employed for pressure relief including equipment which is being used. Attempts have been made at introducing a person centred planning system but further work is needed including exploring different strategies for those residents who are unable to vocalise their wishes and aspirations. Some of the person centred planning booklets are not fully completed. The manager is hopeful that a new consultant employed by the Local Authority will be able to assist in progressing this requirement. Care plans need to be developed with regard to how residents are supported with managing their finances. All residents have access to advocacy services as and when necessary. There was positive feedback from one professional advocate who completed a preinspection comment card who stated, “my contact with Glebelands is as an advocate, I would like to emphasize the excellent job they have done in encouraging the resident to do new things. They (the resident) has developed greatly in the last few years”. As identified at previous inspections, more opportunities could be provided to residents 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. Although there are residents’ meetings, these are not always occurring on a frequent basis. For example, in one unit, the last recorded residents’ meeting was in May 2005. During interview one of the residents confirmed that meetings were not occurring. Risk assessments have recently been reviewed as is good practice. It is pleasing to see that copies are held on all four units so that staff have ready access to these important tools. Some elements of risk management require expansion. For example, one resident uses a wheelchair for negotiating long distances in the community. There was no risk assessment in place. All the risks associated with this equipment and as highlighted by the Medicines and Healthcare Products Regulatory Agency must be assessed. There were no risk assessments in place for incontinence management or epilepsy. Whilst there were risk assessments in place for use of the bath hoist this needs expansion to include the number of staff who assist the resident in using this equipment. There was a risk assessment in place for one resident who is prone to pressure sores but this requires expansion and detailed guidelines included for staff in how to identify potential pressure sores. Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 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): 12, 13, 16 and 17 Service users are assisted to participate in a range of leisure and social activities in the home and in the community, which is supportive in helping them lead stimulating and meaningful lives. More efforts are needed however in ensuring that activities which are provided, reflect individual residents’ needs and preferences. Service users’ rights are respected with regard to their daily routines. The home provides a varied and well balanced diet; service users enjoy their meals and meal times. EVIDENCE: Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 Page 13 There are ample opportunities for service users to develop and maintain their independent living skills. For example during the inspection service users were observed undertaking their own household chores. Residents frequently offered to make the inspector a drink during a tour of the premises. There are rotas outlining tasks allocated to residents on a daily and weekly basis as encouragement in participating in the day to day running of their units. The majority of service users attend specialist day centres or colleges to participate in fulfilling activities. Some residents are involved in work placements and are undertaking relevant qualifications. Service users spoke enthusiastically to the Inspector about their enjoyment in undertaking activities such as horse riding, going shopping and going out for lunch with their key worker. Since the last inspection reviews of activity programmes have been undertaken as requested. The management have introduced a new strategy for recording activities in order to demonstrate that these are varied and stimulating. As refusals are also recorded, this will prove a useful evaluation tool. As yet, staff are not always completing the new records on a regular basis. Feedback from residents was mixed with regard to the provision of stimulating activities provided by the home. Eight residents confirmed that they felt enough activities were provided, however seven residents felt more could be offered. This finding was reflected during interviews with residents. Some residents expressed satisfaction with their activities and leisure pursuits whilst others were less enthusiastic. One resident stated that they were bored during the week when not attending their day care provision and at the same time also stated that they felt dissatisfied with attending one of their day centres, as all they do is play bingo. Another resident stated “they used to take us out at weekends but they don’t bother with our unit so much now”. Whilst it is acknowledged that with such a large and varying service user group, it may present as difficult to meet everyone’s preferences, nevertheless, strategies such as residents’ meetings, person centred planning and improved quality assurance systems may assist further in this process. Observations and discussions with staff, management and service users identified that daily routines are flexible to suit the needs of individual residents. The majority of residents are self advocating and are able to exercise choice for example with regard to opening of their mail. Staff were seen interacting positively with service users throughout this inspection process. All service users have keys to their own bedrooms and to the front door of their individual flats. The majority of residents who completed comment cards felt that their privacy was respected there was a small number of exceptions. During interviews one resident complained that staff accessed his bedroom in his absence without his permission and this was discussed with the manager. Another resident stated that staff did not always knock on the Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 Page 14 door before entering the unit and was concerned that staff from another unit used it as thoroughfare when disposing of their household waste. There has been an outstanding requirement to relocate the telephone as this is currently located in the main communal lounge. Despite attempts at making this a more private facility with an acoustic hood (which was agreed with residents), during interviews residents still complained about the lack of privacy. The manager has agreed to look into this further. Residents take an active role in meals and menu planning. Residents help plan the menu, go food shopping and are involved in food preparation and cooking. Some residents will take it in turns to choose and cook the evening meal. During interviews residents confirmed that they helped choose the menu and chatted about how they liked to be involved in preparing the evening meal. Some residents require supervision whilst others are able to carry out these tasks independently. Fourteen out of fifteen residents who completed comment cards said that they liked the food provided. One resident had commented that sometimes they disliked the food but during interviews said that this was rare, and that overall they did enjoy their meals. During interview one resident said “I like the food but some things I don’t like such as sweetcorn. I help prepare meals”. Fridges, freezers and cupboards were seen to be well stocked. Staff were also seen wearing appropriate protective clothing when preparing and cooking food. There is only one recommendation with regard to record keeping. The home does not keep records of residents’ individual food choices from the daily menu. There are cooked food temperatures to confirm what meals have been provided and daily reports also include some food choices. However, on occasions residents do choose a number of alternatives from the daily menu and ideally these should always be recorded. Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 Page 15 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): 18 and 20 Residents receive personal support in the way they prefer and require. The systems for administration of medication still require improvement in order to provide greater protection. EVIDENCE: During interviews residents confirmed that staff provide assistance according to their preferences. They stated that they are able to go shopping and choose their own clothing. Fourteen out of fifteen residents who completed questionnaires stated that they felt well cared for and the majority of residents said that staff treated them well. All residents are self mobilizing and therefore at present no technical aids or equipment are required apart from a bath hoist. Progress was monitored towards meeting outstanding requirements with regard to health care. Some slight improvements are still necessary, for example with regard to ensuring that all residents are weighed on a monthly basis, which is fully recorded. Case tracking reveals that staff are continuing to provide appropriate support to residents in accessing appropriate health care facilities and take proactive action upon identifying any potential health complication. Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 Page 16 There were a number of items identified at the last visit with regard to the Whilst some progress has been control and administration of medication. made in some areas, there are still practices which require improvement. For example, staff are not always signing the medication administration record (MAR) sheet at the point of administration. Upon gaps being identified, staff are signing retrospectively and using a circle around their initials to denote this has taken place. This is not acceptable. On one occasion it was identified that the member of staff who had administered medication (the manager), had not signed their initials. Another member of staff had signed in their absence to confirm that medication had been administered, but in addition to signing retrospectively, had used someone else’s initials. This not legal practice. Some initials of staff were not discernable to confirm administration, as staff had crossed out the original signatures as these had been inadvertently recorded in error and tried to record their own initials. On occasions residents go out during the evening and their medication is administered slightly later. Staff are using a letter code ‘D’ to denote that they are on ‘social leave’ which is not the case. Senior support staff secondary dispense the medication and leave it for the night staff to administer. Night staff if administering the medication must therefore sign the MAR sheet. It also transpires that not only are night staff occasionally administering medication, they are routinely administering pain relief to one resident who requires medication later in the evening when the senior support staff have gone off duty. Night staff have not received accredited training in the safe handling of medication and must do so without delay. It was concerning to note that in one resident’s case staff were ignoring the instructions of the prescriber. One resident is required to have 15 mls of Lactulose on a daily basis. However, the majority of staff are only administering 10 mls. Previously the home has ceased to use over the counter medicines. One resident has recently returned from visiting their family with some household remedies which are occasionally being administered. This must be discussed and agreed with the General Practitioner and written records maintained, prior to administration. Please see the Requirements section of this report for further items discussed during this inspection. Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 Page 17 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): 23 The home is making good progress in ensuring policies, procedures and practice offer residents robust safeguards from abuse. EVIDENCE: All residents who completed feedback questionnaires stated that they feel safe living at the Glebelands. During interviews the Manager demonstrated good knowledge regarding adult protection strategies and the Protection of Vulnerable Adult (POVA) scheme. There are copies of relevant legislation and procedures on the premises and available to staff. There are excellent procedures in place with regard to the safe handling of residents’ finances. The administrator keeps thorough records of expenditure and income, which upon sampling balance accurately with monies held. Residents are actively encouraged to take responsibility for their own money and all have individual bank accounts. Where possible they will sign to confirm financial transactions have taken place. Residents’ monies and personal expenditure sheets are audited on a daily basis. There is only one outstanding requirement in relation to these standards which is to provide all staff with training in vulnerable adult abuse. Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 Page 18 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): 24 and 30 The standard of the environment within this home is good providing service users with an attractive and safe place to live. The premises are clean and hygienic throughout. EVIDENCE: A tour of all communal areas was undertaken and with their consent and invitation, the inspector also visited some residents’ bedrooms Very good standards are maintained. The communal areas are bright and airy with comfortable and homely furnishings. All bedrooms are decorated and furnished to a high standard and individualised with personal possessions, photographs and stereo equipment. It is pleasing to see that colour schemes, décor and furnishings reflect service users’ individual tastes. Since the last inspection a new perimeter fence has been erected to increase security. Carpets have been replaced in one of the flats. The worn suite and dining furniture in flat no. 3 still require replacement. It was observed that whilst downstairs the noise from the loose floorboards on the first floor was quite noticeable. This requires attention. The premises was clean and odour free through out. There are only a couple of minor improvements necessary. Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 Page 19 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): 34 The home is maintaining a robust recruitment and selection procedure which offers protection to residents. Slight improvement is necessary however with regard to retaining documents for inspection. EVIDENCE: Progress was monitored towards outstanding requirements. There are twenty-nine support staff employed. Only seven staff are qualified to NVQ II or above. Problems have been incurred in the past with a lack of senior staff who are able to provide support as NVQ assessors. The manager is hopeful that this situation will be resolved in the near future. There are seven staff who are currently undertaking this qualification. The home continues to experience staffing problems through turnover and sick leave. Whilst it is reassuring that staffing levels are maintained through the use of agency staff, this can impact upon continuity of care for residents despite the best efforts made to only use regular agency staff. During interviews one resident commented “I don’t like the agency staff, I like the ‘ordinary’ (permanent) staff better, we can have a joke with them and they know us”. Three out of nine relatives who completed feedback cards felt that there weren’t always sufficient staff on duty. One relative stated that occasionally due to leave, sick leave and study days, staffing levels are below the ‘norm’, but that they do not see this as a major problem at present. Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 Page 20 Examination of a staff personnel file confirms that recruitment and selection procedures for new staff continue to be robust. All pre-employment checks were undertaken prior to commencement of duties. There is only one area which requires improvement. The criminal record bureau disclosure and POVA check was not available for inspection. The manager had received confirmation from the human resources department of the Local Authority that this check had been satisfactory but a copy had not been retained on the premises. It is required that copies of CRB and POVA checks for new staff must be made available for inspection unless otherwise agreed and ratified by the Commission for Social Care Inspection. It was reassuring to hear that finally some progress is starting to be made in providing staff with specialist induction and foundation training. The manager and senior staff are undergoing training to be ‘learning supporters’ to therefore provide assessment for staff undergoing this training. The manager plans to ensure that all new staff will commence this training as from April 2006 and will then proceed to train existing staff. There is an outstanding requirement to provide evidence of a staff training budget. This has been withdrawn. However, the central staff training and development plan requires updating. During interviews some staff confirmed that they are not receiving regular formal recorded supervision sessions. Unfortunately shortages in senior staff have had a direct impact upon the frequency of supervision sessions. Please see the Requirements section of this report for any other items discussed. Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 Page 21 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): 37 and 39 The manager is supported well by a senior team of staff and together they provide clear leadership through out the home with individual staff demonstrating an awareness of their roles and responsibilities. Quality assurance systems require development so that residents and other users can be confident their views underpin the development of the service EVIDENCE: Glebelands has a competent and qualified manager. Interviews demonstrate that the manager keeps up to date with relevant changes in legislation and good practice guidelines. Any serious issues identified during this visit received prompt attention by the manager to address any shortfalls. There is a team of senior support staff. During interviews staff confirmed that they could approach their management team if they were unsure or wanted advice on any issues. Unfortunately little progress has been made towards implementing a comprehensive quality assurance system. At the last visit the manager had Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 Page 22 devised excellent questionnaires to elicit feedback from residents, relatives and other professionals. It is disappointing that the manager is still awaiting corporate approval before being able to distribute these questionnaires. It is essential that residents are given an opportunity to help shape the development of the service and air their opinions to senior management. Food hygiene practice was sampled during a tour of the premises. Concerns were raised with regard to fridge and freezer temperature checks undertaken by staff. On occasions these were high and exceeding the safe limits being 8 o C, and on one occasion 12 o C. There were no records to demonstrate what action (if any) staff had taken to redress temperatures which are too high or too low. On the day of the visit the temperature of the fridge in one of the units was recorded as 8 o C but staff had failed to identify this as an issue. New maximum and minimum thermometers have been purchased and it is suggested guidelines are devised for staff regarding how to use these thermometers and what action to take if temperatures are too high or low. Upon repeated testing the fridge was later found to be functioning properly. However, high temperatures were recorded in most of the flats and it is recommended that staff receive further guidance. Any other items discussed during this visit are contained within the requirements section of this report. Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 Page 23 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 Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 X 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 X 1 x 3 X 1 X X X X Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 Page 24 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 YA6 Regulation 15(1) Requirement To develop a rigorous and robust 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 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). 2. YA8 12(3) To offer more opportunities for 01/06/06 service users to participate in the DS0000024984.V275243.R01.S.doc Version 5.1 Page 25 Timescale for action 01/06/06 Glebelands 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). 3 YA9 13(4)(c) To review and expand risk 01/06/06 assessments to ensure that there are written risk assessments established for all aspects of service users lives which pose a risk, for example: wheelchair use, epilepsy, incontinence etc. To review and expand weekly 01/06/06 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 partly met). To provide a telephone facility 01/06/06 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 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). To make the following DS0000024984.V275243.R01.S.doc 4. YA14 16(2)(n) 5. YA16 16(2)(b) 6. YA18 17(1)(a) 01/06/06 7. YA19 12(1)(a) 01/06/06 Version 5.1 Page 26 Glebelands improvements to health care: 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). 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. (Previous timescale of 1/12/05 is not met). 8. YA20 13(2) To make the following improvements to the control and administration of medication: 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). To ensure that there is more consistent recording of the administration of creams and ointments on MAR sheets held in service users’ bedrooms. (Not assessed at this visit). To improve administration of medication and recording on the medication administration record (MAR) sheets. All gaps must be explored with written explanations obtained. Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 Page 27 01/05/06 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. (Previous timescale of 1/12/05 is not met). 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. (Previous timescale of 1/12/05 is not met). To ensure that risk assessments are carried out for any service user who self medicates including vitamins and creams. (Not assessed at this visit). To ensure that keys to drugs cupboards are held separate to any other master keys. To ensure that night staff who administer medication are provided with accredited training in the safe handling of medication. To ensure that prior to administration, any household remedies are formally discussed and agreed with the General Practitioner, with written records maintained. To ensure that staff fully adhere to the dosage instructions for administration of medication such as Lactulose, as specified by the prescriber. Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 Page 28 To ensure that individual care plans contain guidelines for the administration of any variable dosages of medication such as Mebeverine. 9. 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). To amend complaints procedure 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). 11. YA23 13(6) To provide all staff with training in vulnerable adult abuse awareness. (Previous timescale of 1/1/04 is not met). 01/06/06 01/06/06 10. YA22 22(8) 01/06/06 12. YA24 23(2)(b) To replace worn and stained 01/06/06 settees and dining room furniture in flat no. 3. (Previous timescale of 1/12/05 is not met). To address noisy floorboards in flat nos. 3 and 4. To make the following improvements to infection control: 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). 13. YA30 13(3) 01/05/06 Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 Page 29 To ensure that all bathrooms are kept free of communal items such as plastic jugs used for rinsing hair. 14. 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 timescale of 1/1/06 is not met). To provide all staff with training in understanding and managing challenging behaviour. 15. YA34 13(6) To ensure that criminal record 01/06/06 bureau disclosure and Protection of Vulnerable Adult (POVA) checks for new staff are held available on the premises for inspection. To amend induction/foundation 01/06/06 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 - to be held on the premises and available for Inspection. (Previous timescale of 1/1/04 is partly met). Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 Page 30 01/06/06 16. YA35 18(1)(a) To provide all staff with training in equal opportunities and disability equality. (Previous timescale of 1/1/04 is not met). 17. YA36 18(2) 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). 18. YA39 24 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 not 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) infection control. (Previous timescale of 1/1/04 is partly met). 3) training in emergency Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 Page 31 01/06/06 01/06/06 19. YA40 12(1)(a) 01/06/06 20. YA42 18(1)(a) 01/06/06 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). 21. YA42 12(1)(a) To ensure compliance with 01/06/06 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 staff take appropriate action which is fully recorded, when fridge or freezer temperatures are found to be either too high or low upon daily testing. 22. YA43 26 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. (Previous timescale of 1/11/05 is not met). 01/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA17 Good Practice Recommendations To consider providing written records of residents’ chosen food options when these differ from the main menu. DS0000024984.V275243.R01.S.doc Version 5.1 Page 32 Glebelands 2 YA20 To continue to monitor and record temperature of staff room containing the drugs cupboards which should not exceed 25 C. A more suitable location should be considered if temperatures exceed this limit. 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. (Not assessed at this visit). 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. To establish written guidelines for staff when testing fridge and freezer temperatures using the new maximum/minimum thermometer. These must include actions to be taken if temperatures are too high or low (which must be fully recorded). 3 4 5 YA32 YA42 YA42 Glebelands DS0000024984.V275243.R01.S.doc Version 5.1 Page 33 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.V275243.R01.S.doc Version 5.1 Page 34 - 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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