Inspection on 27/04/05 for Glenholme Residential

This inspection was carried out on 27th April 2005.

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

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

Other inspections for this house

Glenholme Residential 16/02/09

Glenholme Residential 21/03/07

Glenholme Residential 18/10/05

Glenholme Residential 13/12/04

Glenholme Residential 04/05/04

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Coopers Mill Ltd

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Paradise Lodge

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Upaya Ananda

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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 Ann Catterick Unannounced 27 April 2005 15:00 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Glenholme Residential I55 s49178 Glenholme v222480 270405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Glenholme Residential Address 20/22 Cabbell Road Cromer Norfolk NR27 9HX 01263 511101 01263 517098 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) D & D Care Services Ltd Mrs Debbie Hales Care Home 17 Category(ies) of Learning disability (17) registration, with number of places Glenholme Residential I55 s49178 Glenholme v222480 270405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Seventeen (17) people of either sex with learning disabilities may be accommodated. Date of last inspection 13 December 2004 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. On the day of inspection 17 service users were accommodated. 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 11 single rooms and 3 double rooms. Some of these rooms have en suite facilities. Glenholme Residential I55 s49178 Glenholme v222480 270405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 4.75 hours. The manager was off site and the inspector was able to speak to the deputy manager, staff, including a newly appointed member of staff, most of the service users as well as have a tour of the building and read some care plans and files. There was also opportunity to join service users for their evening meal. There have been no complaints or concerns since the last inspection. What the service does well: What has improved since the last inspection? Since the last inspection one of the lounges has been designated a nonsmoking lounge and has been totally refurnished and redecorated. This now offers a non-smoking lounge that can be used by service users on either side of the home. Glenholme Residential I55 s49178 Glenholme v222480 270405 Stage 4.doc Version 1.30 Page 6 Since the last inspection more staff have been offered National Vocational Training and this will mean that the competence and expertise of staff will continue to develop. The home continues to improve and refurbish areas of the home and this is monitored within the homes maintenance and renewal programme. Air purifiers have been placed in the communal lounges to ensure that the rooms do not get too smoky. 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. Glenholme Residential I55 s49178 Glenholme v222480 270405 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Glenholme Residential I55 s49178 Glenholme v222480 270405 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3 and 5 The Statement of Purpose and Service User Guide give clear details and information about the home thus enabling service users, their families and professionals to have the information needed to make an informed decision on whether or not and individual’s need would be met. Staff are offered appropriate training and supervision to ensure that they can meet the specific needs of the service users. Service users are issued with a statement of terms and conditions of their placement within the home. EVIDENCE: The Service User Guide has recently been revised and is offered in the written form, makaton and audiotape. The document is informative and includes the Statement of Purpose. The home receives many positive comments from service users and it is planned to include some of these comments in the Service User Guide. The home has a stable staff group who are offered appropriate training and supervision to ensure that they can meet service users needs. This was confirmed by looking at evidence of training on file as well as with talking to staff on duty. No service users had been admitted to the home since the last inspection. Glenholme Residential I55 s49178 Glenholme v222480 270405 Stage 4.doc Version 1.30 Page 9 Several care plans were inspected and some service users files were inspected. Signed contracts of the statements of terms and conditions of placement were seen on file. Glenholme Residential I55 s49178 Glenholme v222480 270405 Stage 4.doc Version 1.30 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 standard(s) 6, 7 and 8 Care plans are available to staff and service users and this ensures that service users specific needs are reflected in their care plans. All service users spoken to confirmed that they were supported and encouraged in making decisions about their own lives and were empowered by this process. Service users are very involved in the day-to-day running of the home and are consulted and involved in any issues that affects their day-to-day lives. EVIDENCE: Several care plans were seen and these include all of the information needed. The care plans seen were user friendly and easy to understand. The home has recently started to include a new lifestyle plan within its care plan and all service users should have this inclusion in their care plans by the next inspection. Service users are involved in the creation of the care plans. Service users were spoken to about how involved they felt within the home and how much they were able to involved in decisions that affected their dayto-day lives. All of those service users living in the home have lived their for Glenholme Residential I55 s49178 Glenholme v222480 270405 Stage 4.doc Version 1.30 Page 11 some time and said that they felt very much part of the decision making processes in the home and involved with those issues that affected them on a daily basis. Regular resident meetings take place and service users were confident to express their views and preferences to staff at any time. Individuals spoke about the way staff enabled them to make personal decisions about their own lives and on how they were supported by staff in these areas. Service users said that they trusted staff completely and spoke very highly of all staff, including the management. Glenholme Residential I55 s49178 Glenholme v222480 270405 Stage 4.doc Version 1.30 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 standard(s) 14, 15, 16 and 17 Service users are able to choose from a range of leisure activities that gives them opportunity to follow hobbies and develop new ones. Service users are able to develop friendships and keep in touch with friends and family if and when they choose. Service users rights are respected and this has enabled service users to feel empowered and in control of their own lives. Service users are provided with nutritious meals that they enjoy. EVIDENCE: Service users are encouraged to pursue any hobby or activity that they enjoy and are supported in this if need be. They are also encouraged to say no to leisure activities or pursuits if they choose and this was evidenced by some Glenholme Residential I55 s49178 Glenholme v222480 270405 Stage 4.doc Version 1.30 Page 13 service users choosing to go on a planned holiday and other choosing to stay at home and pursue other options. Service users families and friends are always welcomed within the home and staff at the home ensure that service users visit family members if this is preferred. A service user spoke of the support she received from staff in this area when a family crisis occurred and she felt the need to be with family. The manager ensured that the service user was taken to be with her family as soon as possible. Service users within the home are well able to make decisions about their own lives and a supported and empowered by staff to do this. Service users very much see ‘Glenholme’ as ‘their home’ and feel the focus is resident led and not staff led. A service user said that they had lived there for a number of years and loved living there. All other comments about the home and staff were positive. The home has no designated kitchen staff and meals are cooked and prepared by the care staff. All have a food hygiene certificate. The main meal of the day is provided in the home at tea- time and on the day of inspection the meal looked nutritious and appetising. A choice of simple deserts was on the menu but the general opinion was that desert was something that was eaten, more at weekends. Fruit was not generally provided within the home but many of the service users said that they bought their own and they preferred to do this. Glenholme Residential I55 s49178 Glenholme v222480 270405 Stage 4.doc Version 1.30 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 standard(s) 19and 20. Service users physical and emotional health needs are identified and met and this aims to ensure that service users reach their full health potential. The home has a policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines but this was not being fully followed and therefore was not fully protecting service users. EVIDENCE: Service users said that they were able to have their health needs met. The service users had access to all of the community health care services and were given information and advice from staff. Some service users said that their health had improved since becoming resident at Glenolden. All staff have received Boots medication training although errors in procedures were seen on the day of inspection. Not all of the medical administration sheets had been completed correctly. A service user had been given a homely remedy but this had not been recorded at the time of administration. Glenholme Residential I55 s49178 Glenholme v222480 270405 Stage 4.doc Version 1.30 Page 15 Secondary dispensing was observed at teatime. Boxes of laxative sachets were stored above the medication cupboard as there was not room for them the medication cupboard. Other practice relating to medication that was observed was carried out correctly. Glenholme Residential I55 s49178 Glenholme v222480 270405 Stage 4.doc Version 1.30 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 standard(s) 23 Staff and service users were aware of adult protection and felt confident that if they had any concerns they would be able to address these with the management of the home. They were aware of the role of the CSCI. EVIDENCE: The staff spoken to were very clear about their roles and responsibilities relating to adult protection. They had received training in this area and evidence of this was seen on file. Service users were clear about their rights to be protected from abuse and were clear on how to ‘whistleblow’ if need be. All of the service users spoken to said that they were very well cared for and protected and had never had concern regarding the care provided by staff. Glenholme Residential I55 s49178 Glenholme v222480 270405 Stage 4.doc Version 1.30 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 standard(s) 24 and 30 The home is suitable for its purpose being, generally, a homely comfortable safe environment for people to live. Some decoration and replacement of furniture has taken place since the last inspection and further replacement of furniture and some decoration is planned. EVIDENCE: When walking around the home it was noted that some of the communal areas had been redecorated and furnished. An example of this was the newly designated non-smoking lounge within the home that had been decorated and refurbished to a high standard. The Home has a maintenance and renewal programme and part of this plan will be to re-upholster the settees in the smoking lounge in Number 20. Those service users rooms that were seen were all homely and reflected the preferences and personalities of the service users. A problem with the roof had caused a damp area in the ceiling of one of the bedrooms, however, this was being repaired at the time of the inspection. Glenholme Residential I55 s49178 Glenholme v222480 270405 Stage 4.doc Version 1.30 Page 18 On the day of inspection the home was clean and tidy with no offensive odours. Glenholme Residential I55 s49178 Glenholme v222480 270405 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,34 and 35 Staff are offered appropriated training to enable them to fulfil their roles as residential carers and offer a good quality of care to service users. Staff were seen interacting with staff and this was done in a way that encouraged good interaction and communication. The home has a policy and procedures for the recruitment and selection of staff and evidence of the use of this procedure was seen on file. Staff are offered appropriate induction and foundation training and are encouraged to complete NVQ level 2 or 3. This ensures that staff have the relevant skills to fulfil their roles as carers. EVIDENCE: Staff files were seen and there was evidence of induction and foundation training as well as evidence of NVQ training. Those staff spoken to confirmed that training was encouraged within the home and staff were seen to have the skills to carry out their tasks. Service users expressed views that suggested staff were well trained. On the day of inspection one of the staff members on duty was an additional member of staff who was being inducted. She said that she was very satisfied Glenholme Residential I55 s49178 Glenholme v222480 270405 Stage 4.doc Version 1.30 Page 20 with the training offered. She had an induction pack to complete and was working alongside more experienced staff. She had a good understanding of the ‘whistleblowing’ policy and was planning to complete NVQ level 3. The processes around the recruitment of staff were seen on files and these were detailed and thorough. A recommendation would be that the manager ensure that she has comprehensive details of a prospective employees work history as this had not been obtained on all of the staff files inspected. Service users were very clear about the positive care they received from staff. They were satisfied with all aspects of their care and said that the service they received from staff was very good. This was the case on the day of inspection. Glenholme Residential I55 s49178 Glenholme v222480 270405 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 38 An experienced well-trained manager who has the support of a competent deputy manages the home and the consequence of this is that the service users receive a good quality well managed service. EVIDENCE: The verbal feedback from service users was overwhelmingly positive about all aspects of their care within the home. They spoke very positively about the manager saying that she was supportive and approachable and a good listener. When a service user has received some bad news the manager was particularly sensitive and supportive at this time. This information was offered as an example of how good the management and staff were. Those staff spoken to spoke positively about the management of the home and the support they received from the manager a deputy. Glenholme Residential I55 s49178 Glenholme v222480 270405 Stage 4.doc Version 1.30 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 4 x 3 x 3 Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x x x 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Glenholme Residential Score x 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x x x I55 s49178 Glenholme v222480 270405 Stage 4.doc Version 1.30 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 20 Regulation 13.2 Requirement The registered provider must ensure that staff follow the correct procedures when dealing with medicines. Timescale for action 01/05/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 24 1 Good Practice Recommendations That the registered provider continue to replace worn furniture and decorate when appropriate. That comments from service are included in the Service Users Guide. 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