Inspection on 28/02/07 for 14 Norfolk Road

This inspection was carried out on 28th February 2007.

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

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

Other inspections for this house

14 Norfolk Road 30/09/09

14 Norfolk Road 15/10/08

14 Norfolk Road 16/06/06

14 Norfolk Road 02/02/06

14 Norfolk Road 19/09/05

14 Norfolk Road 21/03/05

14 Norfolk Road 16/08/04

14 Norfolk Road 19/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 14 Norfolk Road Carlisle Cumbria CA2 5PQ Lead Inspector Cath Wilson Unannounced Inspection 28th February 2007 10:00 14 Norfolk Road DS0000022573.V327633.R01.S.doc Version 5.2 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 14 Norfolk Road DS0000022573.V327633.R01.S.doc Version 5.2 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. 14 Norfolk Road DS0000022573.V327633.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 14 Norfolk Road Address Carlisle Cumbria CA2 5PQ 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) 01228 592515 www.c-i-c.co.uk. Community Integrated Care Mrs Fiona Byers Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 14 Norfolk Road DS0000022573.V327633.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 6 service users to include: up to 6 service users in the category of LD (Adults with learning disabilities) The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 16th June 2006 Date of last inspection Brief Description of the Service: 14 Norfolk Road is a detached three-storey property. Community Integrated Care provides the care and services. The home is registered to provide care for six people with a learning disability. Service users only use the ground and first floors, with staff accommodation on the top floor. It is situated in a residential street approximately one mile from the City of Carlisle and is indistinguishable from other properties in the area. A staircase provides access between the floors. There is a private and enclosed garden area to the rear of the building and car parking to the front. The current scale for charging is £1,181.27p. There are additional charges for such items as toiletries, hairdressing and magazines. 14 Norfolk Road DS0000022573.V327633.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second Key Inspection to the home following a previous random visit and first Key Inspection. This was in order to follow up the requirements that had been made. This visit took place over the morning period when service users, the manager and staff were met. During this time all the key standards of the National Minimum Standards were re-examined. Service users, their relatives and members of staff had given opinions regarding the services provided by Norfolk Road to the inspector. Their comments and views have guided the judgements made in this report. A pre-inspection questionnaire was completed by the registered manager and received prior to this visit. This visit included a look around the home and an assessment of the home’s administrative policies and procedures. What the service does well: The home has documentation available to introduce new residents to the home. This is currently under review to ensure that up-to-date information is provided. There are well-developed links established between the home and health and social care personnel and the inspector received very positive comments. It was stated that people in the home ‘received excellent care’ and ‘staff are approachable, friendly and professional’. The manager and staff are very committed and focussed in their provision of care and do this in a sensitive, encouraging and kindly manner. The manager and staff are constantly looking at ways to improve their services and be progressive in the ways they can deliver these. They support and encourage people in their every day lives. There are robust recruitment procedures in place and welldeveloped staff training and development programmes. 14 Norfolk Road DS0000022573.V327633.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. 14 Norfolk Road DS0000022573.V327633.R01.S.doc Version 5.2 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 14 Norfolk Road DS0000022573.V327633.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good procedures, paperwork and care practices in place to ensure individual need is assessed, promoted and appropriately acted upon. EVIDENCE: The information available to prospective service users, their family or representatives is well documented. Assessments of people’s needs are comprehensively detailed as is the care planning documentation in use. Records show that a very holistic approach is taken in planning for people’s care and their needs, wishes and aspirations and show how these have been achieved. The Statement of Purpose and Service User Guide are currently being updated. 14 Norfolk Road DS0000022573.V327633.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and staff are very focussed on achieving the individual outcomes for people. This is carefully monitored through the system of care planning. Risk taking is well managed and a good balance is achieved between promoting independence and ensuring the well being and safety of people. EVIDENCE: There are individual care plans for people that continue to be developed and strengthened so that people’s achievements are identified. Individual ways of communicating are included and staff are constantly seeking ways of furthering people’s involvement in their daily lives. Furthering means of communication is being explored and this includes the advice and guidance of specialists. Information is kept up-to-date and very person centred. The information is regularly monitored and assessed and reviewed. Risk assessments had been 14 Norfolk Road DS0000022573.V327633.R01.S.doc Version 5.2 Page 10 undertaken and are integrated into the everyday life experiences of people. This allows people to be appropriately supported to be included in events in their lives in a safe, manageable and balanced manner. 14 Norfolk Road DS0000022573.V327633.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s rights are very much promoted and their individuality respected. Meal times are also catered for on an individual basis both in the home and through using community. facilities. EVIDENCE: People’s leisure and community involvement are detailed in their personal record and staff are very encouraging and supportive of people attending these. Staff attended to these in a manner that respected people’s individuality and planned people’s inclusion with this in mind. Family members are encouraged to have involvement. Mealtimes are arranged to meet individual need whether this be in the home or community. Staff encouraged people to make their own decisions and their rights and choice are recognised and promoted. It is clear that this is one of the underpinning values of Norfolk Road. 14 Norfolk Road DS0000022573.V327633.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health care matters are well managed and documented. Medicines management is good. EVIDENCE: Staff are informed of people’s healthcare needs and these are clearly recorded. Staff work positively with local health care professionals when required to offer an attentive and supportive approach to ensure people’s health needs are met and planned for. There is access to specialist advice and guidance. As indicated earlier in this report, there is very clear evidence that staff work diligently in promoting positive outcomes for people. There are policies and procedures for medicines management and staff informed of these. All medicines were securely stored and medication records are appropriately kept. 14 Norfolk Road DS0000022573.V327633.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s complaints system is available to both service users and their family and arrangements for vulnerable adult procedures are well managed. EVIDENCE: Information is available regarding complaints and service users, relatives or representatives have access to this. Staff are informed of the policies and procedures relating to adult protection matters and how to safeguard the health and welfare of people in the home. Protecting vulnerable adults is integrated into the training and development plan for each member of staff. The manager and staff are familiar with the multi-disciplinary guidance and include arrangements for training to be appropriately renewed. 14 Norfolk Road DS0000022573.V327633.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home now provides a comfortable and pleasant environment to suit individual life styles. EVIDENCE: Requirements were made regarding the environment at the previous inspection and these have now been implemented. The home is pleasant and shows much improvement in the furnishings and decorations. Communal rooms continue to be improved and there has been much attention given to the soft furnishings creating a homely environment. The work planned on refurbishing the kitchen now needs to be completed as does the planned finishing touches to the utility room. Arrangements are in place for the health and safety of people in the home and for their environment. Guidelines are followed and records are kept up-to-date regarding environmental health and fire safety. Specialist equipment is regularly serviced and the home had access to advice and guidance regarding environmental matters. 14 Norfolk Road DS0000022573.V327633.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a motivated and committed manager and staff team that meet the comprehensive needs of people in the home. EVIDENCE: Staff continue to be provided with a good training and development programme and the manager and staff are pursuing additional training issues so that they can enhance the lives of people in the home. A high percentage of staff have NVQ qualifications. The manager and staff I met during the inspection are well informed of the needs of people and certainly have great commitment to placing their needs first and provide them with life enhancing experiences. New staff to the home had had a clear induction period into the home and they are appropriately supervised during this. Their training needs are identified and they are supported and encouraged in their work. Looking at ways to make information user-friendly and more accessible is an ongoing process for them but these are all examples of good care practices. The home follows the recruitment procedures of Community Integrated Care. Staff had all the appropriate checks and references completed prior to taking up their post and all appointments are subject to a probationary period. 14 Norfolk Road DS0000022573.V327633.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People continue to benefit from a service that places their personal need first and where they are valued as individuals. EVIDENCE: There are health and safety policies and procedures available in the home and staff are informed of these matters. The records assessed on the day of the inspection were organised, up-to-date, accessible and confidentially stored. The acting manager is organised and focussed in his responsibilities and maintained systems in the home that benefited the service users. Arrangements in the home were very focussed on meeting the needs, wishes and aspirations of the people living here. 14 Norfolk Road DS0000022573.V327633.R01.S.doc Version 5.2 Page 17 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 3 2 3 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 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 4 34 4 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 3 X X 3 X 14 Norfolk Road DS0000022573.V327633.R01.S.doc Version 5.2 Page 18 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 14 Norfolk Road DS0000022573.V327633.R01.S.doc Version 5.2 Page 19 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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