Inspection on 10/02/06 for Great Glens Facility Limited

This inspection was carried out on 10th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Great Glens Facility Limited 05/06/09

Great Glens Facility Limited 24/08/07

Great Glens Facility Limited 13/06/06

Great Glens Facility Limited 18/01/05

Great Glens Facility Limited 26/08/04

Great Glens Facility Limited 29/01/04

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

CARE HOME ADULTS 18-65 Great Glens Facility Limited 149/151 Midland Road Wellingborough Northants NN8 1NB Lead Inspector Mrs Sarah Smart Unannounced Inspection 10th February 2006 09:55 Great Glens Facility Limited DS0000012789.V276451.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 Great Glens Facility Limited DS0000012789.V276451.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. Great Glens Facility Limited DS0000012789.V276451.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Great Glens Facility Limited Address 149/151 Midland Road Wellingborough Northants NN8 1NB 01933 274570 01933 224729 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) Mr Frank Leslie Foulds Mr Darryl Foulds Mr Darryl Foulds Care Home 22 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (22) of places Great Glens Facility Limited DS0000012789.V276451.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. To accommodate18 service users at 149/151 Midland Road, Wellingborough, NN8 1NB, PC by reason of mental disorder for the age of 25 years and over To accommodate 4 service users at 153a and 153b Midland Rd, Wellingborough in need of PC by reason of mental disorder, for the age of 25 years & over Date of last inspection Brief Description of the Service: Great Glen is a Home providing personal care for up to twenty-two young adult service users who have long-term mental health needs and have ongoing involvement with community based psychiatric support services. Accommodation is provided in the main building on two floors, in single bedrooms, each with an en-suite facility, and in a separate detached house next door, providing three single bedrooms for the more independent service users. Originally, Great Glen was registered as a ‘core & cluster’ establishment, with both houses managed by Mr Foulds. Facilities in both properties include recreation lounges, communal living rooms on both floors, with facilities for making hot drinks. There are limited adapted facilities to cater for physical disability, although currently the category of registration is only for service users with mental health needs with no physical disability needs. Externally, there are landscaped gardens with a large patio area. Great Glen is also well situated in a relatively quiet residential street not far from the centre of Wellingborough. Great Glens Facility Limited DS0000012789.V276451.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced inspection was undertaken between the hours of 9.55 and 1pm. Preparation for the inspection included, review of the previous inspection report, requirements and recommendations, and took approximately 1.5 hours. The primary method of inspection used was ‘case tracking’. This involves selecting a number of service users and tracking their care and experiences through review of their records, discussion with them, the care staff and observation of care practices. The following areas were covered during the inspection: case tracking, medication, sample of policy review, staff rota, staff files, tour of the premises, and staff and service user interviews. Two service users were case tracked. Two staff members, plus the manager, were interviewed at length, and several others briefly, whilst three service users were spoken to in detail. What the service does well: What has improved since the last inspection? What they could do better: Great Glens Facility Limited DS0000012789.V276451.R01.S.doc Version 5.1 Page 6 The confidentiality policy could contain further information. The medication policy should contain further information. The manager should consider introducing healthcare assessments as the homes service users age. The provision for the handling of service users death should be managed more effectively. Staff files did not contain sufficient information to protect service users. The recruitment policy did not give adequate information. Some concerns relating to health and safety were raised at the time, for example, fire, first floor windows. 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. Great Glens Facility Limited DS0000012789.V276451.R01.S.doc Version 5.1 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 Great Glens Facility Limited DS0000012789.V276451.R01.S.doc Version 5.1 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 the following standard(s): 3 Service users needs are met. EVIDENCE: Through case tracking (see summary), observation, and discussion with staff and service users during the inspection, the inspector was satisfied that service users needs were being met at the time of the inspection. The home had a very pleasant and calm atmosphere which was most conducive to successful care of the service user group. Service users and staff had appropriate communication between them. Service users spoken to during the inspection gave very positive feedback to the inspector. Great Glens Facility Limited DS0000012789.V276451.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,10 partially Service users needs and choices are respected, although the policy requires further information. EVIDENCE: Service users care plans were written in detail, and included a record of past medical and behavioural history. The care plans gave sufficient information for the service users needs to be met. The service user records also contained consent forms, indicating which household chores the service user wished, or was willing, to be involved in. The confidentiality policy contained limited information, but did not cover telephone calls, contact by the media, or conversations between staff outside the working environment. Great Glens Facility Limited DS0000012789.V276451.R01.S.doc Version 5.1 Page 10 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): These standards were not assessed during this inspection. EVIDENCE: These standards were not assessed during this inspection. Great Glens Facility Limited DS0000012789.V276451.R01.S.doc Version 5.1 Page 11 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): 18,19,20,21 Service users personal and healthcare needs are met, although policies should be updated. EVIDENCE: Service users stated that they are adequately supported by staff to be as independent as possible. They stated that they have key workers of the same sex and opposite sex to them, to ensure that all the service users needs are met, and they feel able to speak to staff openly, knowing that information will be treated confidentially. The existing service users at the home have very minimal physical health needs, however the manager acknowledged that the group are becoming older, and consideration should be given to when it would be appropriate to introduce healthcare assessments. A sample of medication was viewed. Records were maintained to a high standard, as was the storage of the medication. The medication policy did not state that the GP must be advised of drug errors immediately, or the Commission for Social Care Inspection. This document did also not state that medication must be retained for 7 days following the death of a service user. Great Glens Facility Limited DS0000012789.V276451.R01.S.doc Version 5.1 Page 12 Service users preferences in the event of death were not recorded, however the manager acknowledged the need to gather such information. The death policy did not appear to relate to this particular home as it referred to older people and shared rooms, of which the home have none. Great Glens Facility Limited DS0000012789.V276451.R01.S.doc Version 5.1 Page 13 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): These standards were not assessed during this inspection. EVIDENCE: These standards were not assessed during this inspection. Great Glens Facility Limited DS0000012789.V276451.R01.S.doc Version 5.1 Page 14 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): 24,25,26,27,28,29,30 The environment was satisfactory. EVIDENCE: The home had a pleasant atmosphere, and was appropriately maintained both internally and externally. Two service users bedrooms were viewed with their permission. The service users had been involved in the choice of colour scheme, and purchase of bed linen etc. Service users spoken to by the inspector stated that they were happy with their rooms. Both of the bedrooms viewed were personalised by the individual occupying that room. Two bathrooms were viewed, in addition to the service users ensuite facilities. One bathroom had broken tiles around the bath, which could be sharp. A requirement has been made in relation to this. Otherwise these rooms were satisfactory. Housekeepers were present in the home at the time of the inspection. The home appeared clean and tidy, and was free from odour. Although a majority of the service users smoke, the home retains a non-smoking lounge. Extraction devices are available in the areas where smoking is permitted. The kitchen was clean at the time of the inspection, and the inspector was advised that all of the equipment was in working order. Great Glens Facility Limited DS0000012789.V276451.R01.S.doc Version 5.1 Page 15 Great Glens Facility Limited DS0000012789.V276451.R01.S.doc Version 5.1 Page 16 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): 33,34 Recruitment practices were not satisfactory. EVIDENCE: The staffing rota was viewed. This indicated that there are three staff members working a full early shift, with a fourth working a part shift, and two staff working a full late shift with a further working a part shift. During the night there is one waking staff, and one sleeping. The manager stated that provisions are put in place if the sleeping staff is wakened, and cannot then cover their shift the following day. Staff and service users spoken to stated that there are sufficient staff on duty. A sample of staff files were viewed. None of the three files contained any references, and the manager was unable to give an explanation for this, but felt that had the administrator been on duty, they would be available. The inspector had concerns that the manager should have been aware of their whereabouts. A requirement has been made. The recruitment policy did not contain any information as such, but referred the reader to an Employment Law Handbook which was kept in the managers office, however the manager appeared to have no knowledge of this book. This policy must be reviewed in light of the omissions seen in the staff files. Great Glens Facility Limited DS0000012789.V276451.R01.S.doc Version 5.1 Page 17 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): 42 The safety of the residents is not promoted in some areas, which could potentially result in an accident. EVIDENCE: Advice must be sought from the fire officer in relation to the disabled automatic fire door closure on the kitchen door. Other doors had the appropriate door closures in place. ( one paragraph removed) Cleaning chemicals were noted to be stored in unlocked cupboards. Staff advised the inspector that this had been discussed with the Health and Safety Inspector, however the home must ensure that written risk assessments are in place in relation to this, if it is a practice which the home intend to continue. The risk assessments must also consider visitors to the home. Service users care plans and other documentation indicated that they are involved in the household chores around the home. Some first floor windows did not have restrictions on them to reduce the risk of a service user climbing of falling out of them. There was evidence that such devices were once fitted, but the staff advised that they are frequently broken off. The manager must carry out a risk assessment in relation to the lack of Great Glens Facility Limited DS0000012789.V276451.R01.S.doc Version 5.1 Page 18 restrictors, and if necessary as a result, fit appropriate restrictors to the windows. The manager is recommended to obtain the fire officers comments upon proposed management of this. Records indicated that fire drills are carried out very regularly, and some service users fail to evacuate the building. The manager felt that this may be due to the frequency of such drills, and agreed that by having the drills less often may mean that service users are more likely to respond appropriately. The records did not state which staff attended the drills. This is recommended, and should include staff signatures as well as names. The manager was unable to locate records relating to regular fire equipment checks, and was unclear as to whether they have been carried out or not. Such records must be held. Great Glens Facility Limited DS0000012789.V276451.R01.S.doc Version 5.1 Page 19 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 3 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 x ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 1 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 2 X X X X X 1 x Great Glens Facility Limited DS0000012789.V276451.R01.S.doc Version 5.1 Page 20 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA34 Regulation 19 Requirement Two satisfactory references must be obtained before any staff member commences employment at the home. Advice must be sought from the fire officer in relation to the disabled fire door closer. A copy of the fire officers feedback must be forwarded to the Commission for Social Care Inspection. A risk assessment must be undertaken in relation to the unrestricted opening of the first floor windows, and identified action taken. A copy of the risk assessment must be forwarded to the Commission for Social Care Inspection. Timescale for action 10/03/06 2 YA42 23 15/03/06 3 YA42 12 10/03/06 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 YA10 Good Practice Recommendations The confidentiality policy should contain additional DS0000012789.V276451.R01.S.doc Version 5.1 Page 21 Great Glens Facility Limited 2 3 4 5 6 YA21 YA42 YA24 YA34 YA42 information. The death policy should be reviewed, and service users wishes in the event of their death should be recorded. Staff members should sign to acknowledge attendance at fire drills. The broken bathroom tiles must be replaced. The recruitment policy must cover every aspect of recruitment to ensure that service users are protected. Fire equipment checks must be carried out timely, and records maintained and available for inspection. Great Glens Facility Limited DS0000012789.V276451.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Northamptonshire Area Office 1st Floor Newland House Campbell Square Northampton NN1 3EB 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 Great Glens Facility Limited DS0000012789.V276451.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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