Inspection on 25/04/07 for 2-10 Norfolk Road

This inspection was carried out on 25th April 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 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

2-10 Norfolk Road 17/01/06

2-10 Norfolk Road 23/09/05

2-10 Norfolk Road 22/02/05

2-10 Norfolk Road 10/08/04

2-10 Norfolk Road 17/03/04

Similar services:

Whiteley House

Tyndale Avenue

Bennfield House Nursing Home

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

CARE HOME ADULTS 18-65 2-10 Norfolk Road 2-10 Norfolk Road Sheffield South Yorkshire S2 2SX Lead Inspector Andrea Leverett Key Unannounced Inspection 25th April 2007 9:30 DS0000002992.V330536.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 DS0000002992.V330536.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. DS0000002992.V330536.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 2-10 Norfolk Road Address 2-10 Norfolk Road Sheffield South Yorkshire S2 2SX 0114 272 2245 0114 279 8246 norfolkroad@together-uk.org www.together-uk.org Together Working for Wellbeing 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) Mrs Rachel Jane Sleney Care Home 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11) of places DS0000002992.V330536.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17th January 2006 Brief Description of the Service: Norfolk Road (Together) is registered to provide a service for 11 people between the ages of 18 - 65 who have functional mental health problems. The home has 4 domestic style self-contained bungalows, each with a lounge, kitchen, bathroom and bedrooms. Norfolk Road is close to the Sheffield tram route. Meadowhall is easily accessible. All city centre shopping and entertainment facilities are local. DS0000002992.V330536.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 25th of April 2007. Four service users were spoken with as well as 5 staff members and the manager. A tour of two of the bungalows was undertaken during the site visit and service user and staff files were inspected. Judgements about quality of life and choices were taken from direct conversations with service users and observation on the day followed by discussion with support staff and evidencing records held at the home. Feedback from Health professional, staff and Service user surveys was also taken into consideration and comments have been reflected in this report. The inspector concluded that the service users continue to be given an excellent service at Norfolk Rd. A high standard of support and access to health services is provided here and progress has been made towards meeting recommendations made at the last inspection. Two requirements regarding amendments to service user contracts and the safe refuse storage area have been made and two further recommendations regarding toilet facilities and medication risk assessments. Lowest fee £ 1024.00 per Month Highest fee £ 1056.00 per Month Cost of item (£) Items not covered by fee Hairdressing Chiropody Magazines, News Papers Holidays. Subsidised Various £12.00 Various Service user choice DS0000002992.V330536.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Service users rights would be better protected if old tenancy agreements were amended to reflect the organisations change in name. The safety of service users and the security of the Home would be improved by ensuring that the refuse bin areas are enclosed making them less susceptible to being vandalized or set alight. Service users access to toilet facilities would be improved if the toilets in the bungalows were sited separately from the bathrooms. DS0000002992.V330536.R01.S.doc Version 5.2 Page 7 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. DS0000002992.V330536.R01.S.doc Version 5.2 Page 8 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 DS0000002992.V330536.R01.S.doc Version 5.2 Page 9 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, 2, 3 and 5. People who use the service experience excellent quality outcomes in this area. Prospective Service users can be confident that they will receive good information to make an informed choice to move into the Home and that their needs will be comprehensively assessed before they do so. All service users benefit from tenancy agreements but their rights would be better protected if some of these were amended to reflect the organisations change in name. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Home has a statement of Purpose and service user guide, which includes comprehensive information that is clear and includes all the information required by standards. The inspector met and talked with the most recently admitted service user and inspected care assessments. The service user was able to visit the Home and records showed that a detailed community care assessment was obtained before the service user moved in. The homes own assessment also included likes and dislikes, social and emotional needs and risk assessments. Discussion with the service user and records seen showed DS0000002992.V330536.R01.S.doc Version 5.2 Page 10 that the Home worked closely with health professionals to ensure a smooth transition to the Home. Service users files sampled during the site visit included Tenancy agreements and Local Authority Placement Contracts although some of the older tenancy agreements have not yet been amended to reflect the organisations change in name. The need to do this so that service users rights are protected was discussed with the manager and a requirement has been made regarding this. DS0000002992.V330536.R01.S.doc Version 5.2 Page 11 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. People who use the service experience excellent quality outcomes in this area. Assessments and care plans reflect service users needs and aspirations in terms of leading an independent life style and service users are supported to take risks as part of this. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three service user assessments and care plans have inspected. Assessments are detailed and include risk, general care, Pen pictures, relevant life history and health assessments. Care plans seen reflect service users needs as detailed in their assessments and records showed that both these documents are regularly reviewed. The ethos of the service is to promote independence in all aspects of daily life and discussions with service users and observation during the site visit DS0000002992.V330536.R01.S.doc Version 5.2 Page 12 evidenced this approach. Service users plan their own menus and shop and cook their own meals with support as needed. Regular service user meetings are facilitated and rota’s for cleaning and general house rules are agreed amongst themselves. Service users are encouraged to go out independently and take responsible risks but support is also provided in line with service users needs and wishes. Typical service user comments included: “You get help in this place, I get shopping money and can do what I want” “I go out when I like, staff always ask me what I want and I feel supported by staff, we have house meetings” DS0000002992.V330536.R01.S.doc Version 5.2 Page 13 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. People who use the service experience excellent quality outcomes in this area. Service users take part in a range of activities including community activities and their rights are respected and responsibilities recognised in their daily lives. Time is taken to encourage and support service users to maintain personal and family relationships. Service users are encouraged and supported to maintain a healthy diet and their needs and wishes are sort and respected in this regard. This judgement has been made using available evidence including a visit to this service. DS0000002992.V330536.R01.S.doc Version 5.2 Page 14 EVIDENCE: Records seen and discussions with service users and staff evidenced that service users undertake a range of activities in the community both independently and with support from staff. In addition service users are encouraged to take holidays, which are subsidised by the organisation. It was evident from discussions with service users that they maintained relationships with family and friends and visitors are welcomed in the Home. An inspection of two of the bungalows kitchens and food storage areas evidenced that a range of healthy food was available including fresh fruit and vegetables. Service users plan, shop for and cook their own meals with support from staff if needed. Service user’s told the inspector that: “I feel supported by staff and I have been on holiday to Scotland. I am part of a Men’s Group and I go to a day centre. Staff are helping me to find a college to go to.” “I go out with my mom and go shopping with staff. Staff are nice and I choose what I want. I clean up in the bungalow. I don’t go on holiday, I don’t want to.” “ I go for walks and to the Salvation Army, I can do what I want and you get help in this place.” “ I have been here a year and I love it. You get lots of help and support, help with shopping and that. I have a key worker and can phone for help at any time.” Feedback from relatives included: “They give our relative good advise and support, they keep family well informed so we can work together to keep our relative as well as possible.” DS0000002992.V330536.R01.S.doc Version 5.2 Page 15 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. People who use the service experience excellent quality outcomes in this area. Service users receive a high standard of support to maintain their personal care in the way they prefer and require. Service users can be confident that their physical and emotional health needs will also be met to a high standard. Service users retain, administer and control their own medication where appropriate and are protected by the homes policies and procedures for dealing with medicines. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Records of assessments and care plans seen and observation and discussion with staff and service users showed that service users receive personal care and support in the way they prefer and require. Records included guidelines for undertaking aspects of personal care and daily records and observation on the DS0000002992.V330536.R01.S.doc Version 5.2 Page 16 day of the site visit evidenced that preferred choices in daily living were respected. Although most service users can support themselves independently with personal care, sensitive individual support is provided as needed. Records seen and discussion with service users and staff showed that access to routine and specialist health services was facilitated. It was clear that the Home had strong links with specialist Mental Health services and feedback from Health Professionals was overwhelmingly positive about the service provided by Norfolk Rd. Typical comments included: “They treat clients as individuals and work well with colleagues outside of the organisation. They offer appropriate support for clients in a dignified and caring way. I wish there were more units like this.” “It is a small service so they know each person very well and have a high level of understanding of complex mental health issues. The service is viewed by the Community Mental Health Team as highly competent and we have positive working relationships.” An inspection of the Homes medication storage and administration systems showed that medication was being stored administered and recorded appropriately. Although service users files contain information regarding medication protocols for each service user and signed agreements stating how medication will be given, assessments do not include a specific medication risk assessment and a recommendation has been made that this is done. Associated Chemist undertakes a quarterly medication review of the homes systems and records showed that staff training is in place. New staff are monitored before they administer medication and two staff administer medication at all times. DS0000002992.V330536.R01.S.doc Version 5.2 Page 17 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. People who use the service experience good quality outcomes in this area. Service users and their families know that their concerns will be listened to and acted upon. Service users are protected from abuse, neglect and self-harm. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Home has a complaints procedure, which meets all the requirements of this standard. Discussion with service users and feedback from relatives demonstrated that concerns and complaints would be taken seriously, although no complaints have been made in the last 12 months. Records showed that staff work hard to establish service users wishes and needs. The Home has appropriate adult protection procedures and policies and staff spoken to and records seen also confirmed that Adult Protection training is undertaken. DS0000002992.V330536.R01.S.doc Version 5.2 Page 18 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): 24, 27 and 30. People who use the service experience good quality outcomes in this area. Service users live in a clean, comfortable and on the whole safe environment although more could be done to improve security and access to toilets. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of two of the bungalows was undertaken and these are clean, well presented and furnished to a good standard. The bungalows kitchens and lounge flooring have been upgraded and have recently been redecorated and have some new furniture. Information taken from the homes pre inspection record and observation on the day of the site visit showed that the Home is maintained appropriately. Service users clean their own bungalow and a rota is in place for this. In addition records showed that staff carry out routine maintenance checks. DS0000002992.V330536.R01.S.doc Version 5.2 Page 19 Each bungalow has one shared bathroom and toilet between three service users, which, although this is appropriate in terms of numbers sharing, because the toilet is sited inside the bathing area, access to the toilet is not always unrestricted. Examples were given of service users having to ask to use toilets in the other bungalows because other service users bathing occupied the bathroom. A recommendation has been made that the service explores ways of redesigning the bathroom space so that the toilet can be separate. The refuse bins are currently kept exposed at the front of the bungalows and have been vandalised and set on fire in the past. The manager informed the inspector that this has happened to other homes in the area and because the bungalows have some wood facing, this could present a serious fire risk. A requirement has been made that the practice of keeping the refuse bins exposed be risk assessed and action taken to reduce the risk as necessary. DS0000002992.V330536.R01.S.doc Version 5.2 Page 20 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. People who use the service experience excellent quality outcomes in this area. Service users are supported by a sufficient number of staff that are competent and qualified. Service users can be confident that they will be protected by the homes recruitment practices and that staff are supervised appropriately. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Three staff files were inspected and evidence from these and discussions with staff showed that appropriate recruitment practices are in place. Files included application forms two written references and evidence of Criminal Record Bureau checks. Records also showed that the Home provides appropriate induction procedures and training for staff. In addition to an in house induction staff undertake induction foundation training provided by the organisation. DS0000002992.V330536.R01.S.doc Version 5.2 Page 21 Records and discussions with staff also evidenced that a range of training is provided including NVQ level 3. As well as a range of appropriate mandatory training the staff also undertake extensive service specific training such as medication, sexual health, anxiety and depression, drugs and alcohol, dual diagnosis, mental health and self-harm. All service users and staff spoken to and feedback from questionnaires evidenced that sufficient staff are provided to meet needs and records showed that staff were appropriately supervised. As well as 1:1 supervision staff also attend regular staff meetings and shift hand over meetings. Staff told the inspector that they are encouraged to contribute to the agenda’s and felt that the management team listened to their views. Service users spoke highly of the staff team and felt supported by them. DS0000002992.V330536.R01.S.doc Version 5.2 Page 22 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. People who use the service experience excellent quality outcomes in this area. The care of service users is enhanced by a staff team that is led by a competent and experienced manager, who ensures that the home is run well. Service users can be confident that their views underpin all self-monitoring, review and development by the Home and their health, safety and welfare are promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Both the manager and deputy manager have undertaken the NVQ 4 Management and Care Award and have several years experience of working DS0000002992.V330536.R01.S.doc Version 5.2 Page 23 with this client group. Observation on the day, records viewed and discussion with service users and staff evidenced that the manager delivered an effective service user led service. They presented as motivated and enthusiastic and both service users and staff spoke highly of them and felt that they were approachable and inclusive in their management style. Records and observation during the site visit showed that the Home was maintained appropriately and service users health, safety and welfare was given a high priority. Regular service user reviews and service user and staff meetings take place and the organisation undertakes regular monthly regulation 26 quality assurance visits. In addition the Home has service user and environmental risk assessments in place and an Annual Audit review and Business Plan is also in place. DS0000002992.V330536.R01.S.doc Version 5.2 Page 24 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 4 3 4 4 X 5 3 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 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 4 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 X 4 X 4 X X 3 X DS0000002992.V330536.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 YA5 Regulation 5 Requirement Timescale for action 14/06/07 2 YA42 23 Service users tenancy agreements must be amended to reflect the organisations change in name. The practice of keeping the 14/07/07 homes refuse bins location at the front of the property must be risk assessed and action taken to reduce any risks identified. 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 YA20 YA27 Good Practice Recommendations It is recommended that all service users have a medication risk assessment document that supports the guidelines and medication agreements already in place. It is recommended that the service explore ways of redesigning the bathroom space in each bungalow so that the toilets can be separate. DS0000002992.V330536.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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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