Inspection on 17/01/07 for 3 Herrick Road

This inspection was carried out on 17th January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3 Herrick Road 22/01/09

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Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 3 Herrick Road Taverham Norwich Norfolk NR8 6SQ Lead Inspector Mrs Lella Andrews Key Unannounced 17th January 2007 04:00 3 Herrick Road DS0000068111.V327830.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 3 Herrick Road DS0000068111.V327830.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. 3 Herrick Road DS0000068111.V327830.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 3 Herrick Road Address Taverham Norwich Norfolk NR8 6SQ 01603 861076 01603 869713 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) New Boundaries Community Services Limited Mrs Sally Cumbers Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 3 Herrick Road DS0000068111.V327830.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: N/A Date of last inspection 28th February 2006 Brief Description of the Service: 3 Herrick Road is a three bed roomed bungalow in Taverham providing care to three people with learning disabilities. The Home is located approximately four miles outside the city of Norwich in a quiet residential area with access to local facilities and shops. There is a small garden at the rear of the Home and shingle parking to the front. There is a communal bathroom, kitchen and lounge/diner. 3 Herrick Road DS0000068111.V327830.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report contains information about the Home that has been gathered since the last Inspection and includes an unannounced visit to the Home on the 17th January 2007 between 4pm and 6.15pm. During the visit the inspector was shown around the communal areas of the Home, spoke to the member of staff on duty, observed staff supporting the clients, looked at records and observed medication administration. The clients have communication difficulties and this makes it difficult for the Inspector to gather information directly from the clients themselves. Two completed comment cards were received from relatives and these both contained positive responses with additional comments being made: “… always appears to be well cared for and happy” “…the staff are very welcoming to me when I visit” The report also contains information gathered during a meeting on the 30th January 2007 with the Manager where management issues were discussed and a selection of records seen. The Manager had not returned the Pre inspection Questionnaire and so it was not possible for the Commission to seek the views of health/social care professionals involved with the clients. The fees for the Home are individually assessed for each client, depending on their needs. Currently the fees range from £800.00 to £2,400.00 per week. What the service does well: The Home provides homely, comfortable accommodation which meets the needs of the clients The Home is well managed and the clients and staff receive support from the Manager The care plans contain information for staff about how to meet the needs of the clients Staff receive induction and training to enable them to carry out their roles effectively 3 Herrick Road DS0000068111.V327830.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. 3 Herrick Road DS0000068111.V327830.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 3 Herrick Road DS0000068111.V327830.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, 2 and 5 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Documents provide detailed information about the Home but there is a need for some additions to ensure that they meet regulations The organisation has appropriate assessment procedures which would be put in place to ensure that the Home could meet the needs of any prospective clients. EVIDENCE: The Home has a Statement of Purpose which provides information about the Home. There are some minor additions which need to be made for this document to meet regulations. See requirements A Statement of Terms and Conditions (contract) is provided to the clients but these need to be personalised with details of individual fees and it is recommended that these are available in alternative formats to improve the opportunities for the clients to understand them. See requirements and recommendations. 3 Herrick Road DS0000068111.V327830.R01.S.doc Version 5.2 Page 9 No new admissions have been made to the Home recently but there are appropriate admission procedures in place which would ensure that the Home was able to meet prospective clients needs. 3 Herrick Road DS0000068111.V327830.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. 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 member of staff on duty has a good understanding of the content of the care plans and of how to meet the needs of the clients. In general, risks are recognised and assessed with written guidance available about how to manage the risks although there is a need for a risk assessment to be carried out for the use of bedsides. Despite the communication difficulties, the clients are encouraged to make their own choices as far as is possible. EVIDENCE: One of the care plans was looked at in detail and one more briefly. The organisation are in the process of altering the format of the care plans but the 3 Herrick Road DS0000068111.V327830.R01.S.doc Version 5.2 Page 11 ones seen during the visit are still in the old format. The care plans contain detailed information for staff about how to meet the needs of the clients. They also contain information about identified risks and the steps in place to reduce the risks. It is required that a risk assessment is carried out for the use of bedsides. The member of staff on duty was aware of the content of the care plans and was able to describe the care required by the clients. The care plans contain information about the clients personal preferences and choices which is important and none of the clients have good verbal communication. The member of staff gave examples of how the individual choices of the clients are sought and it is clear that this is given a high priority despite the communication difficulties. The Responsible Individual for the organisation is the appointee for the clients financial affairs. The Manager is responsible for overseeing the system on a day to day basis whilst staff are responsible for ensuring accurate records are receipts are kept for expenditure. The individual records relating to clients money were not seen during this Inspection process. 3 Herrick Road DS0000068111.V327830.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Clients are involved with a range of activities when at day services but due to the staffing levels are unable to have much choice about what they do at weekends. The clients rights are respected Relatives are satisfied with the care provided EVIDENCE: The clients all attend the day service in North Walsham owned and managed by the organisation for four days per week. The Home has a large white minibus as the mode of transport for the clients. Whilst it is positive that the Home has its own transport the particular style of vehicle is rather obtrusive. 3 Herrick Road DS0000068111.V327830.R01.S.doc Version 5.2 Page 13 The Manager said that the clients find it difficult to use an ordinary car and there are risk assessments in place for the use of this vehicle . There is only one member of staff on duty at a time at the Home which limits the activities that the clients can take part in. The care plans show that the clients like different activities and that one of the clients would prefer to spend the majority of their time at home. This means that the individual choices and preferences of the clients about how they spend their time are regularly restricted. It is recommended that additional staff are on duty at weekends and days in which the clients are not attending day services so that that they are able to access community facilities more easily and to take part in activities of their choosing. The member of staff on duty at the time of the visit is very aware of the rights of the clients and of the need to respect their privacy and dignity. The member of staff spoke to the clients in a respectful, kind manner and the atmosphere within the Home was relaxed and calm. The care plans contain information about the arrangements in place for the clients to maintain contact with relatives. Two comment cards were received from relatives and these both contained positive responses. They indicate that both relatives are satisfied with the care provided and that the staff make them feel welcome when they visit and keep them informed about changes affecting their relative. The care plans contain information about the dietary needs of the clients. One of the clients has a particular need in this area and the member of staff gave examples of how interpreting signs and body language is used by staff to ascertain issues relating to the clients diet. The clients are not involved in the shopping as this is mainly done through ordering through the “cash and carry” warehouse. Menus are available but staff have flexibility within these and try to ensure that the clients have choices about what they eat. There are currently only three chairs in the dining area and it is recommended that additional chairs are available so that staff can sit with the clients at mealtimes. 3 Herrick Road DS0000068111.V327830.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. 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. The personal and healthcare needs of the clients are met. Medication is managed effectively but there is a need to update the medication procedure so that it provides clearer guidance for staff. EVIDENCE: The care plans contain details about the health and personal care needs of the clients. Clients have regular appointments with dentists and opticians as well as with other health care professionals as required. The member of staff on duty at the time of the visit gave examples of how staff would ascertain if the clients are unwell despite the communication difficulties. As the pre-inspection questionnaire was not returned it was not possible to gather the views of the health and social care professionals involved with the clients. 3 Herrick Road DS0000068111.V327830.R01.S.doc Version 5.2 Page 15 The medication system was inspected. Medication is stored appropriately and records are kept of medication received and administered. There is written guidance available for the use of PRN medication. It is required that the medication procedure is reviewed to ensure that it is accurate as currently it states that two staff are involved in the administration of medication. Staff receive training from the organisations training department prior to being able to administer medication alone. The Manager said that they are told that agency staff have received medication training but that they do not have the details of this. As agency staff work alone at the Home it is recommended that the Manager has details of the format and content of the training that they have received. 3 Herrick Road DS0000068111.V327830.R01.S.doc Version 5.2 Page 16 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. Staff receive training about protecting the clients from abuse but there is a need for the procedure to be updated so that it provides clear guidance in the event of an allegation of abuse being made. The Home has a complaints procedure but it would be difficult for the clients to use this personally due to their communication difficulties. The Manager needs to ensure that relatives and other stakeholders are aware of the procedure. EVIDENCE: The Home has a complaints procedure. One of the relatives comment cards states that they are not aware of the content of the complaints procedure and so it is recommended that a copy of this is sent to all stakeholders. The Commission has not received any complaints about the service and the Manager said that she has not received any complaints. The staff try hard to gather the views of the clients but the opportunities for this are reduced due to their communication difficulties. The staff receive training with regard to the protection of vulnerable adults within their induction to the organisation. As previously mentioned in this 3 Herrick Road DS0000068111.V327830.R01.S.doc Version 5.2 Page 17 report it is recommended that the Manager knows more about the format and content of training that agency staff have. The organisation is in the process of reviewing and updating policies and procedures but it is required that the Safeguarding Adults procedure is available to staff in a timely way as currently the procedure is out dated and will not provide good advice to staff. 3 Herrick Road DS0000068111.V327830.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 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Home provides homely, comfortable accommodation for the clients EVIDENCE: The Home provides comfortable, homely accommodation for the three clients who live there. The clients have their own bedrooms and there is a shared lounge/diner, kitchen and bathroom. The bath has a hoist which staff said meets the needs of the clients. The Home does not have enough space for a separate sleep-in room for the clients and so the bed for staff use is in the lounge which does rather detract from the homely appearance. 3 Herrick Road DS0000068111.V327830.R01.S.doc Version 5.2 Page 19 The Home was clean and free from offensive odours on the day of the visit. There are appropriate cleaning procedures in place. 3 Herrick Road DS0000068111.V327830.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, 33, 34 and 35 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The staff receive relevant induction and training to carry out their roles. The Home is using agency staff on a regular basis although these are usually staff who know the clients well as they are working at the Home regularly. Staffing levels are adequate to meet the basic needs of the clients but there are limited opportunities for clients on the days when they are not attending day services. The Home follows appropriate recruitment procedures. EVIDENCE: There are currently vacancies within the staff team, including that of Team Leader. The vacancies are being covered by agency staff who are working at the Home on a regular basis and therefore know the clients well. Recruitment for the Home is an ongoing process. 3 Herrick Road DS0000068111.V327830.R01.S.doc Version 5.2 Page 21 The Manager is aware of the need to ensure that staff who work at the Home do not become isolated due to working alone. Staff said that they see the Manager on a regular basis and that they are always able to contact the on-call manager if they need to. As previously mentioned in this report the fact that there is only one member of staff on duty restricts the opportunities that the clients have on the days that they are not attending day services. It is recommended that there are additional staff on duty when the clients are not at day services The member of staff on duty at the time of the visit communicated well with the clients and appeared to be confident in carrying out the support for the clients. Staff receive appropriate induction and ongoing training which is provided by the Training Manager who has been employed by the organisation. As previously mentioned it is recommended that the Manager is aware of the content and format of training that agency staff receive. Two of the staff files were seen and these contain the necessary information required by regulation. 3 Herrick Road DS0000068111.V327830.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, 38, 39 and 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The Manager provides good support to the clients and staff The ways in which the quality of the service is monitored and the results of this need to be brought together into an annual quality assurance report The health and safety needs of the clients and staff are considered with steps taken to reduce risks. However, a fire risk assessment needs to be carried out. EVIDENCE: 3 Herrick Road DS0000068111.V327830.R01.S.doc Version 5.2 Page 23 The Manager has managed this Home and two others within the organisation for several years. She has almost completed the Registered Managers award and attends other training offered within the organisation. The member of staff said that they see the Manager on a regular basis and that she provides good support. There is also an on-call manager available 24 hours a day. The team leaders post is currently vacant and so the Manager is currently carrying out more of the day to day management which the new Team Leader will take on once appointed. Due to the communication difficulties of the clients it can be difficult to obtain their views but the member of staff was seen to use alternative methods of communication to try to do so. The organisation has recently started to send questionnaires to relatives and health/social care professionals to seek their views about the service provided. The different quality assurance strands now need to be brought together into an annual quality assurance report and a copy sent to the Commission. A requirement is made about this. The organisation is not carrying out monthly visits to the Home as per Regulation 26 and a requirement is made about this. The Home has a smoke detector and emergency lighting and the records of regular checks on these were seen, as was the record of checks on the hot water temperatures. A requirement is made for a risk assessment to be carried out. 3 Herrick Road DS0000068111.V327830.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 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 3 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 2 X X 2 X 3 Herrick Road DS0000068111.V327830.R01.S.doc Version 5.2 Page 25 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA1 Regulation 4 Requirement It is required that the Statement of Purpose contains the information listed in Schedule One of the Care Homes Regulations It is required that the Service User Guide and the contract contain the information in Regulation Five It is required that a risk assessment is carried out for the use of bedsides It is required that the medication procedure is accurate It is required that the Safeguarding Adults procedure is accurate It is required that an annual quality assurance process is carried out and that the report is sent to the Commission It is required that monthly visits are carried out as per Regulation 26 and that a report is sent to the Commission It is required that a fire risk assessment is carried out Timescale for action 28/02/07 2 YA5 5 28/02/07 3 4 5 6 YA9 YA20 YA23 YA39 13 (4) 13 (2) 13 (6) 24 28/02/07 28/02/07 28/02/07 30/04/07 7 YA39 26 31/01/07 8 YA42 13 (4) 31/01/07 3 Herrick Road DS0000068111.V327830.R01.S.doc Version 5.2 Page 26 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 3 4 5 Refer to Standard YA5 YA33 YA17 YA20 YA35 YA22 Good Practice Recommendations It is recommended that the contract is available in alternative formats It is recommended that the staffing levels are increased on the days when clients are not attending day services It is recommended that additional chairs are purchased for the dining area It is recommended that the Manager is aware of the content and format of training that agency staff have received It is recommended that the complaints procedure is sent to all stakeholders 3 Herrick Road DS0000068111.V327830.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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. Extracts may not be used or reproduced without the express permission of CSCI 3 Herrick Road DS0000068111.V327830.R01.S.doc Version 5.2 Page 28 - 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!