Inspection on 20/12/05 for The Glen

This inspection was carried out on 20th December 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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Glen 21/04/07

The Glen 02/06/05

The Glen 30/11/04

The Glen 04/05/04

The Glen 05/02/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 The Glen 162 Folkestone Road Dover Kent CT17 9SN Lead Inspector June Davies Announced Inspection 20th December 2005 10:00 The Glen DS0000023601.V264443.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Glen DS0000023601.V264443.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. The Glen DS0000023601.V264443.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Glen Address 162 Folkestone Road Dover Kent CT17 9SN 01304 330133 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) Learning Disabilities Care (Dover) Ltd Mrs Jennifer Penelope Marsh Care Home 8 Category(ies) of Learning disability (8) registration, with number of places The Glen DS0000023601.V264443.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd June 2005 Brief Description of the Service: The Glen is a large detached house standing in Folkestone Road, Dover, a local bus service runs along this road, and the main line train station is situated approximately half a mile down the road. Dover town centre is approximately two miles from the home. The house stands on a fairly large plot, with a large garden area to the rear of the property, the car parking facilities are also situated outside the garden area to the rear of the property. The Glen is registered to provide accommodation and care to 8 adults with a learning disability. Accommodation in the home is situated over three floors, the ground floor offers a communal lounge, dining room and kitchen, and two bedrooms, one with en suite facilities. Bedrooms are located on all three floors. One of the bedrooms on the second floor is en-suite. The Glen DS0000023601.V264443.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out over a period of eight hours. The inspector spent time speaking to and observing communications between the residents and the staff on duty. Residents were excited about the prospect of Christmas, and were keen to point out the Christmas decorations internally and externally. Evidence was also gathered from documentation relating to residents, staff and policies and procedures within the home. The inspector was also shown where redecoration and replacement carpets and flooring had taken place in the home. What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose, Service User Guide, Contract/Statement of Terms and Conditions need to be reviewed to inform all residents their relatives/representatives, what items will be charged as extra over and above the fees payable. This needs to be a comprehensive list and include such items as newspapers, magazines, confectionary, hairdressing, clothing, The Glen DS0000023601.V264443.R01.S.doc Version 5.0 Page 6 travelling, personal electrical items, etc. The inspector has made a requirement for these documents to be reviewed. The management of the home need to ensure they meet the gender needs of the residents at night, on a two week rota, there are two male staff working three nights per week on each rota, as the home has mainly female residents, the inspector has made a requirement that the home actively seeks to employ at least one female member of staff to ensure there is a gender mix of staff over the two week rota, which can meet the needs of the residents in the home. 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 Glen DS0000023601.V264443.R01.S.doc Version 5.0 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 The Glen DS0000023601.V264443.R01.S.doc Version 5.0 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): 1, 2, and 5 The home’s Statement of Purpose, Service User Guide, and contract/statement of terms and conditions, need to be reviewed to give prospective residents, their relatives/representatives, with information they need, to make a decisions about moving into the home. EVIDENCE: The Glen’s, statement of purpose and service user guide need to be updated to ensure that the fees charged clearly state what areas of the residents care will be incorporated in these fees. Any extra charges for, clothing, personal electrical items, hairdressing, toiletries, sweets, newspapers, travelling etc should also be clearly stated, to ensure that residents, their relatives/representatives are quite clear that there will be extra charges to be paid for out of the residents personal monies. The inspector has made a requirement that these documents are amended for future use. The home has a comprehensive pre-admission assessment, which has recently been reviewed to incorporate any previous forensic evidence prior to a resident coming to loive at the home. It is important that care managers and other external professionals, provide this evidence on request of the provider/registered manager, to ensure that appropriate risk assessments are completed to minimise risk to that potential resident and other residents living in the home. The contract/statement of terms and conditions needs to be reviewed to ensure that the providers are quite clear as to the fees charged and what they will cover, and cost the cost of facilities not covered by the fees, a requirement has been made under NMS 1. The Glen DS0000023601.V264443.R01.S.doc Version 5.0 Page 9 The Glen DS0000023601.V264443.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 Residents know that their personal goals are reflected in their individual care plans and that potential risks are managed. Residents know that their views are listened to and that their records will be kept securely maintaining their confidentiality. EVIDENCE: The inspector viewed one care plan, which had been comprehensively written and clearly stated the assessed care needs, goals and aspirations of the resident, together with the input and support that is forthcoming from other multi disciplinary agencies. The care plan was well cross referenced, and also contained good risk assessments in regard to activities, and the daily life of the resident. Throughout the visit the inspector was able to witness different styles of communication being used by care staff between the residents. During the morning three of the residents went into Dover, to do some shopping and have a coffee, two residents remained in Dover for lunch, and returned to the home early in the afternoon. During conversation with the residents both collectively and individually, residents were able to tell the inspector how happy they were at the home, and it was easy to observe that the residents are given choices in regard to their daily living and social activities. The inspector observed that policies and procedures relating to the The Glen DS0000023601.V264443.R01.S.doc Version 5.0 Page 11 residents in the home are written in a simple and pictorial way to ensure that the residents can understand what is expected of them. Residents are able to take risks, within a risk assessment framework, so that the likelihood of risk is reduced. Where possible residents are involved in writing up their own risk assessment to give them some empowerment, and a better understanding of protecting their own safety. The Glen DS0000023601.V264443.R01.S.doc Version 5.0 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Links with education and the community are good and enrich the resident’s educational and social opportunities. The meals in the home are chosen by the residents, and offer good choice and variety. EVIDENCE: Each resident is given the opportunity to identify and pursue a college course of their choice, which would also be risk assessed to identify any areas of serious risk. Where residents attend a college course they would be escorted and supported by members of care staff. Residents have access to the local community on a daily basis, visiting the local shops, going into the main shopping centre of Dover, or just going for walks in the locality of the home. They also attend local discos, and eat out one night per week. Other activities on offer are visits to local pubs, theatre and concerts. Residents also enjoy when weather permits using the trampoline and are also looking forward to using the new above ground swimming pool in the garden of the home. None of the residents in the home have paid employment due to the severity of their learning disability. Residents are able to use public transport as and when they wish, but the provider/manager has ensured that there is always a car available for the residents use when they wish to go out. The Glen DS0000023601.V264443.R01.S.doc Version 5.0 Page 13 On the day of the inspection the residents were very excited about Christmas, and much of the conversation with the inspector centred on the Christmas decorations in the home and garden, and Christmas cards that had been received by the residents. Some of the residents are visiting the families for the Christmas period, and were looking forward to this. Two residents are remaining at the home for the Christmas period and their family will visit them for Christmas lunch in the home. The inspector was shown the Christmas week menu, which had been written by a resident with choices and ideas being given by the other residents in the home. Residents have also been involved in selecting a four-week rotating menu, and have made choices via pictures from magazines, and advertising to illustrate the meals on offer. These pictures have then been used to demonstrate each daily menu, to ensure that residents know what food is on offer from day to day. All the residents said they enjoyed the food in the home, but also look forward to eating out as and when the opportunity for this arises. The Glen DS0000023601.V264443.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 19. The health care needs of the residents’ are well met with clear evidence of good multi disciplinary working taking place on a regular basis. EVIDENCE: All residents in the home need some degree of support with personal health care and personal hygiene needs and care staff ensure that this is given in such a way as to ensure the privacy and dignity of the resident is maintained. All support given with health care and personal hygiene is recorded in each resident’s care plan. Residents have access to their G.P as and when they wish, and the home has good working relationships, with psychiatrists, behaviour specialist, and speech and language therapists. Residents also have access to dentists, opticians, and chiropodists at regular periods throughout the year, or as and when the need occurs. Four residents have regular access to the sensory unit at Cairn Ryan on a weekly basis. The Glen DS0000023601.V264443.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Complaints made are acted upon appropriately and in a timely way. Residents know that their complaints will be listened to and acted upon. Staff have excellent knowledge and understanding of adult protection issues, which protects the residents from abuse. EVIDENCE: Since the last inspection there has been one complaint, and the inspector witnessed through observation of documentation that this had been dealt with appropriately and in a timely way. The complaints policy and procedure, has been specifically written with the residents’ in mind, and is demonstrated by pictures to assist residents understanding, if they wish to make a complaint. The home has up to date policies and procedures for the protection of vulnerable adults. The inspector viewed the home’s training matrix and this showed that the majority of staff have undertaken POVA training, mop up training is to be organised early in the New Year for staff who have been recently employed. The Glen DS0000023601.V264443.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26 and 30 The standard of both the internal and external environment of the home is good providing the residents with an attractive and homely place to live. EVIDENCE: The Glen is well decorated and furnished, there is an on going decorating and maintenance programme to ensure that the home is kept in good order, taking into account the residents’ safety. One resident told the inspector that he really enjoyed living at ‘The Glen’. Recently the home has invested money in a new conservatory. Redecoration has taken place in the following areas, ground floor and second floor bathroom, shower rooms, communal toilets, kitchen, two bedrooms, lounge and dining areas. There has been new carpet fitted throughout the home, with new non-slip wooden flooring fitted in the communal dining area, and other communal areas where carpet would be inappropriate. The garden at the rear of the property has new security fencing, and an above ground swimming pool has been installed. A new 42” plasma T.V. has been fitted in the residents’ communal lounge. One bedroom and en suite on the ground floor has been adapted for a wheelchair user. Documentation was available to show that the home meets the requirements of the local Fire safety officer and the Environmental health officer. The Glen DS0000023601.V264443.R01.S.doc Version 5.0 Page 17 Each resident’s bedroom reflects his or her own interests and personal taste. Residents are able to select the furniture of their choice, and all bedrooms are furnished in a homely domestic style. Residents are able to reflect their own personalities in their bedrooms, and there was evidence of this in bedrooms seen by the inspector. On the day of the inspection the home was clean, tidy, and free from any offensive odours. The inspector noted that in all communal hand washing facilities, universal hand washing precautions were displayed. The Glen DS0000023601.V264443.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34 and 35 Staff morale is high resulting in an enthusiastic workforce that works positively with the residents to improve their whole quality of life. Since the last inspection the standard of vetting and recruitment practice has improved. EVIDENCE: The inspector was able to speak to staff on duty in the home on the day of inspection. All staff said that they work very much as a team, that all residents have key workers who take on certain responsibilities pertaining to the assessed needs and wishes of the residents’ in the home. One resident requires twenty-four hour one to one care and this is reflected on the care staff rota in the home. At the present time 65 of the staff working in the home have NVQ level two and above, and some of the care staff have also completed A1 assessors award. During the inspection the inspector witnessed that staff have developed personalised communication for each resident in the home. The inspector also witnessed a member of staff using good de-escalating techniques with a resident who was showing signs of stress. Staff on duty corresponded with the duty rota for the day. The inspector witnessed via the duty rota, that on some occasions over a two-week period there are two male night carers on duty. This was discussed with the provider, and the provider confirmed that she is actively seeking appropriate female members of staff to prevent this from happening, therefore the inspector has made a requirement that the provider/registered manager continues to pursue this to ensure that there is appropriate staff on duty to meet the gender needs of the residents. The Glen DS0000023601.V264443.R01.S.doc Version 5.0 Page 19 The inspector viewed personnel files of the newest members of care staff, and found that files contained POVA first checks, CRB, two references and two forms of identification. Documentation was available to show that staff had received appropriate induction, and had received mandatory training. The inspector was also able to verify this through communication with staff on duty on the day of the inspection. The Glen DS0000023601.V264443.R01.S.doc Version 5.0 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The acting manager has a good understanding of what needs to improve in the home, and residents benefit from a well run home. The systems for resident consultation are good with a variety of evidence that indicates resident’s views are sought. EVIDENCE: The provider/registered manager has many years experience at management level. There is evidence that the proivider/registered manager regularly updates her skills and competence to ensure that she is able to meet the assessed needs of the residents in the home. During the course of the inspection the staff spoke positively about the management of the home, and how the residents wishes must always come first. The home carries out quality assurance procedures, and residents are asked for their views on the home, the questionnaires used for this quality assurance survey are simple and in picture format, to make them easily understood by the residents. Evidence was also available to ensure that appropriate building risk assessments, and health and safety assessments are carried out to ensure the safety and security of the residents within the home. The Glen DS0000023601.V264443.R01.S.doc Version 5.0 Page 21 The inspector was shown in date maintenance certificates for all equipment used in the home; this included a recent test of all portable appliances in the home. The fire logbook showed that fire points are checked weekly and emergency lights are tested on a monthly basis. The Glen DS0000023601.V264443.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 2 X X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 3 X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 2 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Glen Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000023601.V264443.R01.S.doc Version 5.0 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 YA1 Regulation 5, 6, 16 Requirement Statement of Purpose and Service User Guide clearly states what extra charges will made to residents over and above the fess charged by the home. The staff team reflects the cultural/gender composition of the residents. Timescale for action 01/02/06 2 YA33 12 01/02/06 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 YA2 Good Practice Recommendations The homes pre-admission assessment is reviewed to ensure that any previous forensic evidence is disclosed prior to a resident coming to live in the home. The Glen DS0000023601.V264443.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Kent and Medway Area Office 11th Floor International House Dover Place Ashford Kent TN23 1HU 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 The Glen DS0000023601.V264443.R01.S.doc Version 5.0 Page 25 - 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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