Inspection on 19/01/06 for 13-15 Constitution Hill

This inspection was carried out on 19th January 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

13-15 Constitution Hill 23/01/09

13-15 Constitution Hill 01/02/08

13-15 Constitution Hill 03/08/06

13-15 Constitution Hill 16/08/05

13-15 Constitution Hill 25/02/05

13-15 Constitution Hill 02/09/04

Similar services:

Chesham House

Argyll House

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

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

CARE HOME ADULTS 18-65 13-15 Constitution Hill Norwich Norfolk NR3 4HA Lead Inspector Kim Patience Unannounced Inspection 19th January 2006 09:30 13-15 Constitution Hill DS0000027382.V279377.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 13-15 Constitution Hill DS0000027382.V279377.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. 13-15 Constitution Hill DS0000027382.V279377.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 13-15 Constitution Hill Address Norwich Norfolk NR3 4HA 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) 01603 789450 NO FAX # Mr M Talbot Mrs J Talbot Mr M Talbot Care Home 16 Category(ies) of Learning disability (4), Mental disorder, registration, with number excluding learning disability or dementia (12) of places 13-15 Constitution Hill DS0000027382.V279377.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th August 2005 Brief Description of the Service: Constitution Hill is a Care Home that provides services and single room accommodation to 16 residents, 12 falling into the category of Adults with a Mental Disorder and 4 falling into the category of Learning Disability.It is located close to the city centre and its amenities and within easy walking distance there are a number of pubs, shops and takeaways.The home itself is made up of two semi-detached Victorian houses joined together to form one house, resulting in spacious communal accommodation and large gardens. 13-15 Constitution Hill DS0000027382.V279377.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took approximately 3.5 hours to complete. The manager/proprietor was available throughout and was helpful in facilitating the process. During the inspection, staff were spoken to and the inspector tried to engage in conversation with service users, observation of interaction between staff and service users was made. In addition, records relating to service users, staff and the running of the business were inspected. Comment cards were left for relatives and service users to make comments at a later stage if they wish. What the service does well: What has improved since the last inspection? What they could do better: The home needs to make some improvements to the environment such as redecorating the communal areas and refurbishing the bathroom. However, they have a plan of maintenance and renewal, which will be implemented this year. There were two requirements made at the last inspection that were made for the second time and those requirements have still not been met. The proprietor must respond to requirements made by the Commission, as these are designed to ensure that the home acts in the best interests of its service users. The requirements were made in respect of a training programme and a plan of supervision and are made for the third time. An additional requirement is made in respect of a recognisable quality assurance process, which the home does not have. 13-15 Constitution Hill DS0000027382.V279377.R01.S.doc Version 5.1 Page 6 It is expected that all three requirements are met within the timescales set, the Commission may consider taking enforcement action, if necessary to achieve compliance. 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. 13-15 Constitution Hill DS0000027382.V279377.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 13-15 Constitution Hill DS0000027382.V279377.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): 0 Standards not assessed on this occasion. EVIDENCE: 13-15 Constitution Hill DS0000027382.V279377.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): 0 Standards not assessed on this occasion. EVIDENCE: Standards not assessed on this occasion. 13-15 Constitution Hill DS0000027382.V279377.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): Standards not assessed on this occasion. EVIDENCE: Standards not assessed on this occasion. 13-15 Constitution Hill DS0000027382.V279377.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 The home has systems in place to ensure that service users receive personal support in the way that they prefer and their physical and emotional needs are met. EVIDENCE: Service user care plans were inspected and the manager was available for a discussion in respect of how service users needs are met. People are admitted to the home through a well-planned multidisciplinary approach. Care needs assessments are provided by the Community Mental Health services and provide a very detailed care plan that includes service users expectations in respect of the way care is to be delivered. The plans include the support and promotion of self-care through observation and prompting. The homes focus is on rehabilitation and therefore people determine their own patterns in respect of daily routines such as getting up and going to bed, what they wear and how they wish to look. Where conflicts arise and staff feel that a change in the pattern is detrimental to their health and well-being, other professionals such as the Community Psychiatric Nurse or Social Worker are informed so a multi-agency approach can be taken to protect the individuals concerned. 13-15 Constitution Hill DS0000027382.V279377.R01.S.doc Version 5.1 Page 12 The service users accommodated do not require any additional equipment to maximise independence, however, the need for aids and equipment is taken into account at the pre-admission planning meetings and would be sourced by the appropriate agency at this stage. Record keeping in respect of each service user is good and identifies any changes in need or any issues that need to be reported to and dealt with by other agencies. Regular multi-disciplinary meetings take place to review progress and the Care Management Assessment. Records show that people are supported to manage their own health care needs. People can choose to remain with their own GP or change to a local practice if staying at the home for a longer period. Those able to manage their own medication do so within a risk assessment framework. People are given support to attend medical appointments if necessary, but encouraged to do this independently if possible. Health needs are monitored on a daily basis and records are well maintained. The home is mindful of monitoring change as a way of identifying deterioration or improvement of the individual’s state of mind. 13-15 Constitution Hill DS0000027382.V279377.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): 22, 23 The home provides opportunities for people to voice their opinion on the service. The home has systems in place that aim to protect people from abuse. EVIDENCE: The home has a complaints procedure that is included in the service users guide. Residents meetings are held on a quarterly basis and provide people with the opportunity to express their view of the service and any areas for improvement. This is a small home and staff have a close working relationship with residents, which also provides them with many opportunities to raise issues that concern them on a day-to-day basis. No complaints have been received by the home or the Commission since the last inspection. The home has a policy and procedure for the protection of vulnerable adults. All staff are in the process of receiving in-house training in adult protection. A support worker has been given the lead role in training and has developed a training programme for adult protection using BVS videos and workbooks. Whilst the nominated trainer demonstrates competence in overseeing the training and reinforcing learning through support sessions, it would still be recommended that some formal training in abuse awareness, train the trainer, is undertaken. See recommendations. 13-15 Constitution Hill DS0000027382.V279377.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, 30 Service users live in a safe, homely environment that is kept clean and tidy however, some areas of the home are in need of redecoration. EVIDENCE: A tour of the premises was completed. On entering the building it was clear that this home creates an environment that people can feel relaxed and comfortable in, as they would in their own home. There is an entrance hall, which has a notice board to display any correspondence for residents and relatives. Once in the main part of the home, there is a large kitchen, large lounge/dining room and a large conservatory that stretches the width of the rear of the building. The lounge has comfortable sofas and other furniture that is congruent with the service user group accommodated. The conservatory is the designated smoking room and the majority of residents smoke. However, there are a small number of people who do not and the home must be mindful of protecting these people from passive smoking. The manager states that extractor fans are to be installed in the conservatory to reduce the risk to others, however in the meantime the doors between the conservatory and main lounge should remain closed when people are smoking. See recommendations. 13-15 Constitution Hill DS0000027382.V279377.R01.S.doc Version 5.1 Page 15 The majority of service user accommodation is situated on the first floor, each service user has a key to their room and a master key is held by the manager, in case of emergencies. One room was entered with the permission of the service user and was found to be pleasantly furnished and decorated. The communal areas of the home are in need of redecoration, some rooms need a fresh coat of paint to brighten them up and the paint is peeling off the woodwork in areas that have frequent use. The home has a programme of maintenance and renewal that is due to be reviewed and updated in February 2006. The plan will include the redecoration of communal areas, the replacement of the carpet in the main lounge and the refurbishment of one bathroom. All areas were found to be clean and tidy, part of the carers duties include cleaning routines and laundry encouraging service users to participate where possible. Service users are responsible for keeping their own rooms clean and tidy, however, are encouraged and supported to so. 13-15 Constitution Hill DS0000027382.V279377.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): 35, 36 The manager cannot demonstrate staff are trained to meet peoples needs due to the lack of a formal training programme. The manager cannot demonstrate that staff are adequately supervised due to the lack of formal supervision sessions. EVIDENCE: The home still does not have a formal training plan to show what training will be provided throughout the year. The training plan is essential and should provide evidence that the manager has considered the core training needs for the team, sourced with who and where training will be provided and has planned finances to ensure that the training will take place. A requirement was made in relation to this at the last inspection and is therefore made for the second time. See requirements. As mentioned in standard 23, the manager has given the responsibility of training to a support worker who will be developing a training programme. The support worker will also deliver some training in the home, however needs to receive some formal training to ensure that he is competent to deliver the training effectively. See recommendations. However, there was evidence of some training such as that described in standard 23 and some in respect of fire safety and food hygiene and two 13-15 Constitution Hill DS0000027382.V279377.R01.S.doc Version 5.1 Page 17 members of staff are due to attend medication training at the University of East Anglia. In respect of staff supervision, the home has a small team of staff who work very closely and as such have lots of ongoing day-to-day work practice supervision. The manager/proprietor lives on the premises and has daily contact with staff. However, there is still no formal one-to-one supervision and the manager must provide the opportunity for such supervision at least 6 times per year. A requirement was made in relation to this at the last inspection and is therefore made for the second time. See requirements. 13-15 Constitution Hill DS0000027382.V279377.R01.S.doc Version 5.1 Page 18 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): 39, 42 The home cannot fully demonstrate that service user views underpin the development of the service provided. The home promotes the health safety and welfare of service users and staff. EVIDENCE: During discussion with the manager, it was evident that service users are consulted on a daily basis about the quality of the service. Observations of interaction between staff and service users also show that there is a very open consultative approach. Daily records are maintained and show the discussions that take place and any action taken in response to comments made. Residents meetings are held on a quarterly basis and provide another forum for service users to express their views. However, the home does not have a recognisable system for monitoring quality in the home and this must be developed in accordance with the National Minimum Standards. See requirements. As part of this process, the home must comply with the requirements made by the Commission. 13-15 Constitution Hill DS0000027382.V279377.R01.S.doc Version 5.1 Page 19 In respect of health and safety, the home has a policy and procedure in place. Staff are trained in health and safety during their induction and provided with refresher training on an annual basis. Risk assessments are completed on the premises and COSHH. Equipment such as small electrical are tested annually and emergency lighting is tested 6 monthly. Fire safety records show that weekly alarm checks and evacuations are completed. Fire equipment is checked every six months and staff and service users are provided with training when joining the home and updated annually. 13-15 Constitution Hill DS0000027382.V279377.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 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 X 33 X 34 X 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X 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 X X X X 2 X X 3 X 13-15 Constitution Hill DS0000027382.V279377.R01.S.doc Version 5.1 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA35 Regulation 18(1) Requirement The registered person must produce a staff training and development programme. This is repeated for the third time. The registered person must introduce a plan of formal supervision. This is repeated for the third time The registered person must have a recognisable quality assurance system in place. The results of the quality assurance monitoring must be produced in a report, a copy of which must be provided to service users and the Commission. Timescale for action 01/03/06 2. YA36 18(2) 01/03/06 3 YA39 24 01/07/06 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 YA35 Good Practice Recommendations It is recommended that the support worker with the responsibility for training be provided with training in order to fulfil this role effectively. DS0000027382.V279377.R01.S.doc Version 5.1 Page 22 13-15 Constitution Hill 2 YA24 It is recommended that the home take measures to protect non-smoking residents from the effects of passive smoking. 13-15 Constitution Hill DS0000027382.V279377.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 13-15 Constitution Hill DS0000027382.V279377.R01.S.doc Version 5.1 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!