Inspection on 21/03/07 for Glenholme Residential

This inspection was carried out on 21st March 2007.

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

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

Other inspections for this house

Glenholme Residential 16/02/09

Glenholme Residential 18/10/05

Glenholme Residential 27/04/05

Glenholme Residential 13/12/04

Glenholme Residential 04/05/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Glenholme Residential 20/22 Cabbell Road Cromer Norfolk NR27 9HX Lead Inspector Maggie Prettyman Unannounced Inspection 21st March 2007 09:00 Glenholme Residential DS0000049178.V334265.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Glenholme Residential DS0000049178.V334265.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Glenholme Residential DS0000049178.V334265.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glenholme Residential Address 20/22 Cabbell Road Cromer Norfolk NR27 9HX 01263 511101 01263 517098 davidhales@halesdavid.fsnet.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) D & D Care Services Ltd Mrs Debbie Hales Care Home 17 Category(ies) of Learning disability (17) registration, with number of places Glenholme Residential DS0000049178.V334265.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Seventeen (17) people of either sex with learning disabilties may be accommodated. 18th October 2005 Date of last inspection Brief Description of the Service: Glenholme is a care home providing personal care and accommodation for 17 adults with learning disabilities. The home is owned by Mr David Hales and Mrs Debbie Hales. The manager is Debbie Hales. The home is located in the coastal town of Cromer and is close to the sea and all other local facilities including pubs, shops and local transport. The home comprises of a pair of large three storey Edwardian terraced houses that are connected to make one home. There are in practice two distinct groups of residents that are only linked at ground floor level. Each group has their own communal areas. The home has 9 single rooms and 4 double rooms. Some of these rooms have en suite facilities. The current range of weekly fees is £330 - £501 Glenholme Residential DS0000049178.V334265.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the provider, some residents and their relatives as well as other who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and current judgements for each outcome group. What the service does well: What has improved since the last inspection? The home is working to improve its practice in many ways. In particular a new system of medication has been introduced and the way that staff are recruited has been improved. Residents, their families and staff have been asked what they think of the home and changes have been made as a result of comments that were made. Glenholme Residential DS0000049178.V334265.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Glenholme Residential DS0000049178.V334265.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glenholme Residential DS0000049178.V334265.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 2 Prospective service users have the information they need to make an informed choice about the service. Prospective service users individual aspirations and needs are assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Service User Guide is comprehensive, available in accessible formats and a copy is placed in the hallway of the home in both written and auditory forms. Evidence in service user files demonstrated that a comprehensive needs assessment takes place prior to someone coming to live at the home. Glenholme Residential DS0000049178.V334265.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 Service users changing needs are reflected in individual care plans. Service users are supported to make decisions about their lives. Service users are supported to take risks as part of an independent lifestyle. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Inspection of individual care plans demonstrated that they are comprehensive and reviewed according to service user changing needs and developing skills. Evidence of service user plans supporting self-management of behaviour was seen. Risk assessments are in place, including those protecting service users from abuse. Glenholme Residential DS0000049178.V334265.R01.S.doc Version 5.2 Page 10 Following the recent quality audit, service users now have a meeting each evening to enable them to discuss and plan many aspects of the home. Information is given to enable informed choice; meeting records demonstrated active involvement from the group in this process. Inspection of records, discussion with service users and observation on the day showed that service users actively participate in both individual and group decision-making and influence the running of the home. Risk assessments and care plans as well as daily records and observation on the day of inspection demonstrate that planned risk is a part of service users’ daily lives. Service users were confident and talked openly about likes, dislikes and the wide variety of activities that they are involved in. Staff demonstrated appropriate concern and support whilst enabling service users in life skill development. Glenholme Residential DS0000049178.V334265.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17 Service Service Service Service Service users users users users users take part in a wide range of enjoyable activities. are part of the local community. enjoy good relationships with others. rights and responsibilities are supported. have a healthy diet and enjoy their meals. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Glenholme Residential DS0000049178.V334265.R01.S.doc Version 5.2 Page 12 EVIDENCE: Discussion with service users and inspection of records demonstrated that a wide range of stimulating occupational activities is offered to service users. They have raised some issues relating to poor external day care services. This has resulted in service users choosing to stay at home or to access other facilities. One service user is on an action group to try and improve external day care provision. The home is situated in the centre of Cromer. Service users described using local pubs, shops, clubs and other facilities. Bus passes enable free transport to the wider area. Service users exercise their rights to vote if they wish. Inspection of records and discussion with service user demonstrated that the home works well enabling people to make and maintain ongoing personal relationships. Family relationships are supported. Specialist guidance is sought, as appropriate, to support life partnerships. Evidence in records as well as observation on the day of inspection demonstrated that the routines of the home are flexible and promote freedom and choice. Staff interacted with service users in a warm, respectful and courteous manner. Individual rooms were respected as private places, mail is handed directly to people, household chores are delegated and work is being undertaken to ensure that new smoking regulations are met with the understanding of service users. Service users both as individuals and as a group choose meals daily. The food prepared on the day of inspection was nutritious and much enjoyed by the group in relaxed and pleasant dining areas. One service user made a meat pie for the group, which was clearly well made and tasty. The home is working on new approaches to healthy eating with service users, particularly those with ongoing health needs. Glenholme Residential DS0000049178.V334265.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 Service users receive support in the way that they require. Service users physical and healthcare needs are met. A new system of medication has been introduced. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observation of the home and discussion with service users demonstrated that personal support is offered in a respectful and dignified way. Personal routines are flexible. People choose their clothes and hairstyle. Key working supports people’s individuality and choice. The home is introducing individual healthcare plans for service users. Medication is reviewed and healthcare needs are supported well on a day-today basis. It is recommended that the good work being put in to individual healthcare plans be completed. Glenholme Residential DS0000049178.V334265.R01.S.doc Version 5.2 Page 14 Since the last inspection a new MDS system, of medication is in place. This was inspected and found to be well maintained, with records up to date. Some Mar sheets did not detail specific reasons for non-administration of medication. It is recommended that the annotation system provided on MAR charts be used as directed. Some service users choose to lie in and this can prevent their taking prescribed medication. The home is asking advice from the pharmacist in this matter. Glenholme Residential DS0000049178.V334265.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 Service users feel their views are listened to and acted upon. Service users are protected from abuse, neglect and self harm. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No formal complaints have been received by the home since the last inspection. The complaints procedure is clearly displayed for service users in an accessible form. Feedback from the recent quality audit has resulted in service user meetings where comments and concerns can be raised. Service users have been supported in making complaints about external services. Minor complaints and comments are not audited. It is recommended that the home records and audits minor complaints, concerns and compliments about the service to identify patterns and trends. Examination of service user records and notifiable incidents reported to the commission and adult protection services demonstrate that this home actively protects its service users from abuse. The manager is a trainer for adult protection. Staff are trained at induction and have refresher training regularly. All areas of risk including service user personal relationships and money are included. Glenholme Residential DS0000049178.V334265.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24 and 30 The home is comfortable and homely. The home is clean, pleasant and hygienic. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises demonstrated that the home is clean, tidy and well maintained. All areas of the home are fresh and cheery. Individual rooms are decorated to the style and taste of individual. Fir regulations are adhered to. The home is a normal house, and is not identified as a care home by any external signs, so protecting the privacy and dignity of service users. Antibacterial hand gel is available throughout the building. Protective equipment was seen in areas where personal care is given. The laundry area is clean, tidy and has good quality equipment. A rota is in place to ensure service users developing life skills can use the facility at a time to suit them. Glenholme Residential DS0000049178.V334265.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 34, 35 and 36 Staff are supported by competent staff. The home is working to improve its recruitment practice. Staff receive regular training. Staff could receive more regular individual supervision. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observation of people working during the inspection showed that staff are accessible, approachable, interested and committed. Service users spoke positively about the people that support them. They demonstrated knowledge of service user needs and a good understanding of ways to help people to develop lifestyle skills. Records showed that the home continues to encourage staff to gain NVQ qualifications. Four staff files were inspected and found to meet the standards. The home has worked during the last year to improve the quality of information gained for staff, and some examples of excellent recruitment practice were seen. Glenholme Residential DS0000049178.V334265.R01.S.doc Version 5.2 Page 18 However, more work could to be done in to include further good practice. It is recommended that the home follow the further good practice guidelines detailed in the good practice guide “Safe and Sound”. Training records for staff were examined. Ongoing training is clearly offered by the home. A new detailed induction programme has been introduced to the home. The home would benefit from a clearer system of auditing staff training. It is recommended that the home introduces a clear system of training audit to ensure all training needs and requirements are met. Some records of staff supervision were seen. This system has not been maintained recently. The home has recognised this shortfall and has taken steps to resolve the matter. It is recommended that the system of supervision be maintained by the home in future. Glenholme Residential DS0000049178.V334265.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42 Service users benefit from a well run home. Service users views underpin the running of the home. The health, safety and welfare of service users are promoted and protected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Glenholme Residential DS0000049178.V334265.R01.S.doc Version 5.2 Page 20 EVIDENCE: The manager of the home demonstrated throughout the inspection that she is a competent, experienced and caring person. As the joint owner of the home she is responsible for achieving the aims and objectives of the home, as well as all aspects of the running and management of the home. The home has recognised the need for additional management support, and a well qualified, competent and experienced deputy manager has been appointed. The home has recently undertaken a service user, staff and relative satisfaction survey. Matters raised in these surveys have directly influenced and changed the way that the home is run. During the inspection it was clear that many aspects of good practice are taking place but are not audited centrally. It is recommended that the home develop an audit system to ensure that good practice; accidents and incidents are recorded, so that the manager can identify any patterns, trends, shortfalls or extra training needed. The tour of the home demonstrated that safe working practices are employed by the home. Records of health and safety compliance were seen. Training records should be better kept to ensure that staff have received all relevant training and that it is up to date. Accidents and incidents are recorded, but not always audited by the home. Notifiable incidents are reported in detail and promptly to relevant authorities. Glenholme Residential DS0000049178.V334265.R01.S.doc Version 5.2 Page 21 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 4 2 3 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 3 23 4 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Glenholme Residential DS0000049178.V334265.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 2 3 4 5 6 Refer to Standard YA19 YA19 YA22 YA34 YA35 YA36 Good Practice Recommendations The good work put in to developing health care plans should be completed. Mar charts should be annotated as directed. It is recommended that an audit of minor complaints, comments and compliments be maintained. It is recommended that further good recruitment practice identified in “Safe and Sound” is implemented It is recommended that a clear system of training audit be kept by the home. It is recommended that the system of supervision is reinstated by the home. It is recommended that the home develop a system of audits to enable the manager to identify good practice, accidents and incidents, so that trends and patterns, shortfalls and developing training needs within the home can be addressed. DS0000049178.V334265.R01.S.doc Version 5.2 Page 23 7 YA39 Glenholme Residential Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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