Inspection on 09/11/05 for 13 Norfolk Street

This inspection was carried out on 9th November 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 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

13 Norfolk Street 10/02/06

13 Norfolk Street 28/02/05

13 Norfolk Street 15/01/05

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 13 Norfolk Street 13 Norfolk Street Leamington Spa Warwickshire CV32 5YQ Lead Inspector Deirdre Nash Unannounced Inspection 9th November 2005 09:30 13 Norfolk Street DS0000004479.V265179.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 13 Norfolk Street DS0000004479.V265179.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. 13 Norfolk Street DS0000004479.V265179.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 13 Norfolk Street Address 13 Norfolk Street Leamington Spa Warwickshire CV32 5YQ 01926 832552 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) Eden Place Limited Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places 13 Norfolk Street DS0000004479.V265179.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th February 2005 Brief Description of the Service: Norfolk Street is part of the Eden Place group of homes. The home is registered for 4 younger people with enduring mental health problems. The service is designed for independent service users. Nursing support is provided from Eden Place nursing home and there is also housekeeper support for 20 hours per week. The home is approximately ½ mile from Leamington town centre and close to all amenities and town centre shopping. It is a midterraced house with 4 bedrooms, separate lounge and dining room, a bathroom and kitchen. There is a garden at the rear of the house that has been set to concrete. Each service user has a single bedroom. 13 Norfolk Street DS0000004479.V265179.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home was given one days notice of this inspection to make sure that the new manager could arrange to be present. The main focus of the inspection was to check on the things that were found to be not up to standard at the last inspection in February. The Inspector spent time talking with the manager, the care support worker and three residents. She also looked at some records and looked around the home. What the service does well: What has improved since the last inspection? The home has benefited from some financial investment and a new manager since the last inspection. Every room has been redecorated and new carpet and flooring has been laid. The house is brighter and cleaner and the courtyard garden has been tidied up. The job of ‘housekeeper’, the only member of staff in the house daily, has been changed to ‘support worker’. This emphasises the professional level of the care needed to help each resident to look after himself safely. 13 Norfolk Street DS0000004479.V265179.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 13 Norfolk Street DS0000004479.V265179.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 13 Norfolk Street DS0000004479.V265179.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 The home does not have a statement of purpose that accounts for the particular service that it offers. Prospective service users would not get clear information about the home. EVIDENCE: The statement of purpose has undergone some amendment since the last inspection but still does not address the things set out in the requirement that was made. Particularly, it does not detail the ethos of Norfolk St and what it offers. The statement of purpose is from another of the company’s homes is used with some piece meal alterations. This is now overdue and must be done. 13 Norfolk Street DS0000004479.V265179.R01.S.doc Version 5.0 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, 9 The home produces plans of care for individuals that are regularly reviewed and include risk management. Residents are supported to safely manage their own lives. EVIDENCE: Residents have plans of care developed by the home that integrate risk assessment. The resident at each regular review signs them. No resident has a ‘Care Management Assessment/Care Plan’ to support the role of the home for each individual. All residents spoken to said that they are very happy at the home and the manager reports improvement in health and well being for each. However, social services should exercise an interest in their lives that is outside of the care provider organisation. The manager must approach social services for a review of each residents needs and a care plan. A requirement is made The ‘housekeeper’ role has been turned into a support worker with direct daily contact with each resident and responsibilities for contributing to their well being. The manager is the named nurse for each resident and meets with each one individually every four weeks to conduct a review of his care. 13 Norfolk Street DS0000004479.V265179.R01.S.doc Version 5.0 Page 10 Residents confirmed that fortnightly house meetings take place and their views are taken seriously. 13 Norfolk Street DS0000004479.V265179.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 17 Staff know the residents well and take time to support them with family, leisure and therapeutic links. Residents benefit from being able to broaden their lives in safety. EVIDENCE: Written records show that each resident has an active life. Comments from residents and possessions in bedrooms showed this. It is clear that staff take a real interest in working with residents to improve their family links and support them to make decisions about developing their lives. One resident said ‘ I’m really happy here, we all get on well, we’re like a family. The staff are great’. Most residents shop and prepare their own meals. The support worker keeps an eye on nutritional balance and one residents care plan includes safeguards around this. Eden Place, a larger home that is run by the same provider company, act as an extra resource and residents can have meals there if they wish. 13 Norfolk Street DS0000004479.V265179.R01.S.doc Version 5.0 Page 12 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, 20, The home provides support to individuals to deal with the tasks of daily living and to stay well. Residents are safeguarded from isolation and self neglect. EVIDENCE: Current residents need no direct help with personal care but it is clear from speaking to them that they get the level of prompting and encouragement that they need to help themselves and improve their self-care skills. Each bedroom now has a lockable safe box where residents keep their medication. Residents confirmed that they have a key and that the manager for safety keeps one. All medicines are now properly labelled. 13 Norfolk Street DS0000004479.V265179.R01.S.doc Version 5.0 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 encourages residents and relatives to speak out, takes concerns and complaints seriously and is aware of its responsibilities to protect from abuse. Residents are safeguarded by a responsibly inclusive service. EVIDENCE: The home has received no complaints since the last inspection and the Commission has received none about the home. The manager reports that he has spoken to all relatives of residents to make sure that they know that any concerns would be taken seriously. This is to be followed up by a letter. Residents confirmed that they feel able to complain if they need to and that they are asked at every house meeting if they have any complaints. The house support worker is undertaking a short course in Vulnerable Adult Protection in January 2006. 13 Norfolk Street DS0000004479.V265179.R01.S.doc Version 5.0 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, 30. The interior appearance of the house is improved through decoration but its amenity is still limited by lack of space. Residents enjoy being cosy. EVIDENCE: A number of requirements to improve the physical environment of the home were made at the last two inspections early this year. Most have been complied with. The house is clean and has been redecorated and re carpeted throughout and the heating system has been changed. A considerable amount of work has been done in a short space of time. Residents say they are pleased with the décor and chose the colours for their own rooms. However, the premises remain below standard on room sizes and bathroom and toilet facilities. The house is on three levels, one of which is below pavement and the stairs, hallways and landings are cramped. The kitchen is basic and the fittings are tired, worn and have become unhygienic with age. There are algae growing inside the Perspex knobs on the kitchen taps. The kitchen fittings must now be replaced. The bathroom is also basic and needs a bit more ‘comfort’ added to it including more shelves for toiletries. Despite these significant shortcomings the outcome for service users remains positive. They like the house, they say they do not mind the basement accommodation and do not find their living cramped. 13 Norfolk Street DS0000004479.V265179.R01.S.doc Version 5.0 Page 15 The house is typical of its kind in central Leamington where period property is very expensive and what it lacks in internal amenity may be made up for by its close proximity to the town centre. These residents can get out and about and do so. The registered provider must remain on top of décor and maintenance and continue to improve the internal amenity of the home as much as possible to compensate for structural shortfalls against national standards. The manager took a list of small items needing repair or replacement as the Inspector toured the house. For example there were some missing and broken window coverings and light shades and the manufacturers labels were still stuck to the front of the washbasin and pedestal in the bathroom. Put together, small things like this develop an atmosphere of neglect and that is not good for service users. A good practice recommendation was made at the last inspection for the provider to consider the long term plan for this home given that it does not meet so many of the National Standards for Environment. This recommendation remains but the Commission may make this a requirement if the interior of the home is allowed to deteriorate again to the state that it was in at the beginning of this year. A new requirement is made to produce a maintenance plan for the home and submit a copy to the Commission. 13 Norfolk Street DS0000004479.V265179.R01.S.doc Version 5.0 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): 31, 32, 33, 35 The home provides sufficient staff to offer residents the level of care and support that they need. Residents are able to develop levels of independence in safety. EVIDENCE: Referred to above the role of ‘Housekeeper’, the only staff in the home, has been changed to ‘’Support Worker. She has recently acquired her professional Award at level 2 and records show that she takes part in a rolling programme of training with the staff group at Eden Place. Residents also have 24-hour access to the team at Eden Place and the manager who also manages Eden Place and one other ‘satellite’ homes and is the named nurse for Norfolk St residents is on 24-hour call. 13 Norfolk Street DS0000004479.V265179.R01.S.doc Version 5.0 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): 37, 38, 39, 42 Great progress has been made this year on improving the home and the service. Resident’s benefit from a management approach to the home that is responsible but inclusive. 1 EVIDENCE: The manager has been in post since the early summer and has applied to be registered with the Commission. He also manages a larger home and one other small homes nearby. A survey was made of the views of residents and their relatives in March but the findings were not put together and reported on. The new manager says that a further quality review is set to take place during December and will include other ‘stakeholders’ such as residents G.Ps. A summary of the findings must be sent to the Commission. The support worker for the house is linked to a programme of statutory health and safety training at Eden Place. Fire extinguishers and portable appliances are regularly tested and serviced. A hand towel must be kept in the bathroom for staff and visitors so resident’s personal towels do not get used. 13 Norfolk Street DS0000004479.V265179.R01.S.doc Version 5.0 Page 18 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 x x x x Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 x 2 2 N/A x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 x 16 x 17 Standard No 31 32 33 34 35 36 Score 3 3 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 13 Norfolk Street Score 3 x 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 x x 2 x DS0000004479.V265179.R01.S.doc Version 5.0 Page 19 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 YA1 Regulation 4 Requirement The registered person must produce a statement of purpose that properly describes the service offered at 13 Norfolk St. (not met from last inspection) The registered person must approach social services on behalf of each resident for a community care assessment and care plan. The registered person must produce a development plan for the home and submit a copy to the Commission. The registered person must replace the sofas in the lounge (not met from last inspection) The registered person must extend the safety rail to properly cover the stairwell outside of the back door (not met from the last inspection). The registered person must refurbish the kitchen and replace the fittings with new. (The date can be negotiated if structural work is intended.) The registered person must increase the shelving in the bathroom and improve the DS0000004479.V265179.R01.S.doc Timescale for action 01/01/06 2 YA6 14 01/01/06 3 YA24 23 01/02/06 4 5 YA24 YA24 16 13 25/12/05 01/01/06 6 YA24 13 01/04/06 7 YA24 16 01/02/06 13 Norfolk Street Version 5.0 Page 20 general comfort of the room. 8 YA39 24 The registered person must 01/04/06 introduce a quality assurance system for the home, report its findings and send a copy to the Commission (part met from last inspection) The registered person must 01/12/05 provide a means in the bathroom for staff and visitors to wash and dry their hands without using residents toiletries and towels. 9 YA42 13 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 YA25 YA42 Good Practice Recommendations The registered person should consider the long term plan for this home with regards to the standards required and service users needs. The registered person should develop policy and procedures on lone working. 13 Norfolk Street DS0000004479.V265179.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Leamington Spa Office Imperial Court Holly Walk Leamington Spa CV32 4YB 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 Norfolk Street DS0000004479.V265179.R01.S.doc Version 5.0 Page 22 - 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. 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