Inspection on 12/07/06 for 3 Norwich Road

This inspection was carried out on 12th July 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

3 Norwich Road 24/02/06

3 Norwich Road 14/10/05

3 Norwich Road 07/02/05

3 Norwich Road 26/05/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

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 Norwich Road Long Stratton Norwich Norfolk NR15 2PG Lead Inspector Mr Roger Andrews Unannounced Inspection 12th July 2006 04:00 3 Norwich Road DS0000027559.V304319.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 Norwich Road DS0000027559.V304319.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 Norwich Road DS0000027559.V304319.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 3 Norwich Road Address Long Stratton Norwich Norfolk NR15 2PG 01508 536059 01508 536103 manager.nrl@prospects-uk.org 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) Prospects Carole Margaret Thompson Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 3 Norwich Road DS0000027559.V304319.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th February 2006 Brief Description of the Service: 3,Norwich Road is a semi-detached house situated in the village of Long Stratton several miles to the south of the city of Norwich. The registered accommodation consists of three single bedrooms, a kitchen/diner, a lounge and a staff office. There is a large rear garden and car parking to the front of the house. 3 Norwich Road DS0000027559.V304319.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from the providers, the service users as well as others who work at the service. This has included two recent visits to the service, one unannounced and a follow up announced visit to look at records. This report gives a brief overview of the service and the current judgements for each outcome group. What the service does well: What has improved since the last inspection? What they could do better: On a few occasions the staff forget to sign the record that shows they have given out medication. The manager needs to look at this to make sure when this happens it is picked up quickly and dealt with. The smoke detectors need to be checked regularly and the checks need to be recorded to make sure they are in good working order. The manager needs to do a check of the building to make sure any risks to residents and staff are minimised and this should include looking at the risk of fire. 3 Norwich Road DS0000027559.V304319.R01.S.doc Version 5.2 Page 6 The manager does report incidents involving residents to other people such as the social worker. However, she also needs to make sure The Commission is told about these things. The information kept in staff files could be tidied up so that they are easier to read. 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. 3 Norwich Road DS0000027559.V304319.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 Norwich Road DS0000027559.V304319.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 The quality outcome for this area is good. Residents individual support needs are assessed and have information about the services available to them. EVIDENCE: A Statement of Purpose and Service User Guide are in place. The Service User Guide is written in easy to understand language. There have been no new admissions and all three-service users have lived at this address since the home was set up. It is not envisaged that any of the residents will be replaced, though currently the organisation is looking for a more suitable property for all three residents to move to. A comprehensive and user-friendly folder called “All About Me” has been constructed for each person, which contains information about all aspects of residents’ current and previous lives. One section of this folder contains templates for a full pre-admission assessment to take place for future residents users prior to admission. 3 Norwich Road DS0000027559.V304319.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 The quality outcome for this area is good. Support plans are informative and include areas of risk. EVIDENCE: The support plans for all three residents were looked at during this inspection visit. These contained a good level of detailed information about matters such as personal and healthcare needs, preferences and support needs. Support plans also identified positive attributes such as ‘sense of humour’, ‘sociable’, and ‘enthusiastic’. There was a good emphasis on encouraging residents to do tasks, (e.g. making a cooked breakfast), for themselves. The views of residents are gathered informally and mealtimes are an obvious opportunity to have discussions about issues and forthcoming events. The residents and their families are also given the opportunity to complete a questionnaire Risk assessment areas are covered and topics such as road safety, understanding the value of money and the ability to make, for example, hot drinks were observed in the support plans. Discussion took place about the need to have an environment risk assessment. See further comments below on this issue. 3 Norwich Road DS0000027559.V304319.R01.S.doc Version 5.2 Page 10 Records are held in a small upstairs office with lockable filing cabinets. There is a computer system in the office. 3 Norwich Road DS0000027559.V304319.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 The quality outcome for this area is good. Residents participate in a variety of activities and are helped to maintain contact with family and friends. There is a varied menu and residents are involved in preparing food. EVIDENCE: Discussion with staff, residents and looking at support plans gave a good sense of residents being involved in interesting activities. The residents regularly attend their local church and participate in leisure pastimes such as swimming, ten pin bowling, attending evening clubs, walking, listening to music and watching television. Each of the residents attends daytime work placements during the week which include a local college and working at BHS. One of the residents was observed helping in the garden alongside a volunteer worker who regularly visits the home. The residents allowed access to their bedrooms, which were nicely personalised and reflected particular interests. One resident had many posters 3 Norwich Road DS0000027559.V304319.R01.S.doc Version 5.2 Page 12 reflecting his interest in the local football team. Staff respect the privacy of resident’s rooms and one comment in a support plan reminded staff to knock on bedroom doors. Residents maintain contact with family members and there are regular visits home to parents on a weekly basis. One support plan reflected that the resident’s mother had been involved in helping to compile it. Two of the residents have an advocate. Efforts are underway to secure a new advocate for another resident. The weekly menu reflects a good variety of food dishes. One of the support plans contained details on the resident’s healthy eating programme. Residents said they enjoyed their meals and that they were going to have a meal at a restaurant after going ten pin bowling to celebrate one of the residents’ birthday. Support plans reflect residents participating in food preparation including cooking meals such as scrambled eggs on toast. Residents also help by joining in the domestic routine such as laying tables. The residents will also be involved in shopping trips. 3 Norwich Road DS0000027559.V304319.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 The quality outcome for this area is adequate. Personal and healthcare needs are supported, though medication recording needs a system in place to quickly pick up on errors. The daily medication records need a system that promptly highlights errors. EVIDENCE: The residents enjoy a good degree of independence in managing personal care tasks and mainly require encouragement and prompting and daily routines are set out in support plans. There was also evidence of healthcare needs being attended to including optician and chiropody services. Where incidents involving residents have occurred these have been properly documented and referred on to the social worker if appropriate. However, the manager should also make sure the Commission are notified of events in line with regulation 37 of the Care Homes Regulations 2001. See requirement. The staff look after medications and have all completed the Boots Medication course, though residents are encouraged to be part of the process and a comment in one of the support plans highlights that the residents “see this as a sign of being an adult”. Each medication record contains a picture of the resident concerned. The administration records were checked and in some 3 Norwich Road DS0000027559.V304319.R01.S.doc Version 5.2 Page 14 instances the staff had forgotten to initial the record. The staff must be vigilant to ensure they complete the record and the manager must put into place a system whereby the next person completing the record informs her as soon as possible if they discover the previous medication round has not been initialled so that she can follow this up speedily. See requirement. 3 Norwich Road DS0000027559.V304319.R01.S.doc Version 5.2 Page 15 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 quality outcome for this area is good. Residents feel safe in their home and staff have received training in adult protection procedures. EVIDENCE: There have been no formal complaints. Relatives and residents said they know how and whom to complain to. One resident said they liked living here and that they felt safe. A complaint procedure and recording form is in place and this incorporates remedial action if required. From observations the residents appeared to interact in a relaxed manner with members of staff and there was a good sense that they would feel able to tell staff if something was upsetting them. They are also able to speak to day centre staff, one of who helped a resident fill in her questionnaire prior to the inspection visit. All staff have completed Protection of Vulnerable Adults training and have also completed the in-house training on the prevention of abuse. The financial records of residents were looked at. Receipts are kept for large expenditures, though not for every day purchases such as drink, ice creams, etc. The record is checked regularly and there is also a detailed register of the amounts that the residents pay to Prospects as part of their contribution towards the fees and a record of weekly personal allowances. Residents have additional funds in bank accounts and only reasonable amounts of money are kept on the premises. 3 Norwich Road DS0000027559.V304319.R01.S.doc Version 5.2 Page 16 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 & 30 The quality outcome for this area is good. Although the premises are not entirely suitable, residents enjoy a homely environment. EVIDENCE: The house has a sizeable garden, which gives good opportunity for residents to sit out and have barbeques and to help in garden maintenance. On the ground floor there is a good size comfortable lounge, which looks on to the back garden. There is a kitchen/dining area and one of the residents has his bedroom on the ground floor. There are toilet and washing facilities on both floors. The house has its limitations and comments have been made in previous reports on the small size of the kitchen and need for attention to decoration. Some decoration has been taking place recently and there is certainly a homely and lived-in feel to the house. The bedrooms do not have en-suite facilities and there are limited facilities for the staff for sleeping-in. Prospects is currently seeking to move premises to a larger property, though so far this has been problematic. Advocacy support has been initiated for the residents to make sure their views are taken into account on this matter. The home was clean and tidy during both of the inspection visits. 3 Norwich Road DS0000027559.V304319.R01.S.doc Version 5.2 Page 17 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): 32, 34 & 36 The quality outcome for this area is good. Staff receive appropriate training and supervision and have access to policies and procedures. EVIDENCE: At least one member of staff is present when any of the residents are at home and one member of staff sleeps in at night. Two staff files were viewed at random. These contained appropriate information such as evidence of a Criminal Records Bureau check, (including the volunteer), application forms, two written references for which there is a pro-forma document and a photograph. The files were rather disordered and could benefit from being re-organised to make finding information easier. See recommendation. The staff have received a good range of training which includes health and safety, food hygiene, first aid and fire training. Other examples of training include Boots Medication, epilepsy training, basic makaton and administration training. Two members of staff have completed NVQ 3, (Promoting Independence). Staff are also due to undertake a course in challenging behaviour. As noted, all staff have completed protection of vulnerable adults 3 Norwich Road DS0000027559.V304319.R01.S.doc Version 5.2 Page 18 training. Induction training is in place for new staff and part of this is undertaken at the regional office. Staff have access to a recently revised set of policies and procedures provided by Prospects. This is a well referenced and accessible tool so that staff can find specific polices easily. Staff receive supervision from the manager, usually on a two monthly basis. The manager has support meetings with her line manager on a monthly basis. 3 Norwich Road DS0000027559.V304319.R01.S.doc Version 5.2 Page 19 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, 39 & 42 The quality outcome for this area is adequate. The manager seeks residents’ views and the views of staff, family and friends. Fire checks should be undertaken regularly and documented and a risk assessment of the premises should be carried out. EVIDENCE: The manager has been in place for some time and is currently undertaking the Registered Manager’s Award. Residents are able to complete a questionnaire, which asks for their views on a variety of topics such as the friendliness of staff, having the opportunity to discuss issues and concerns, whether they feel their views are listened to and if they receive sufficient support. A questionnaire is also in place for the staff and for the friends and family of residents. 3 Norwich Road DS0000027559.V304319.R01.S.doc Version 5.2 Page 20 The fire records were checked. The last fire drill took place on 21st June 2006. One of the smoke detectors on the ground floor had no battery and was not working. This has now been rectified. The smoke detectors need to be checked regularly, (i.e. weekly), and the check should be documented and signed. A risk assessment of the premises is also required and this should be carried out by a competent person looking at the house on a room-by-room basis and should also include a fire risk assessment as part of this process. See requirement. 3 Norwich Road DS0000027559.V304319.R01.S.doc Version 5.2 Page 21 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 2 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 2 X 3 Norwich Road DS0000027559.V304319.R01.S.doc Version 5.2 Page 22 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 YA19 Regulation 37 Requirement The manager should also make sure the Commission are notified of events in line with regulation 37 of the Care Homes Regulations 2001. The manager must put into place a system whereby the next person completing the medication record informs her as soon as possible if they discover the previous medication round has not been initialled so that she can follow this up speedily. A premises and fire risk assessment needs to be carried out by a competent person. Timescale for action 01/09/06 2 YA20 13 01/09/06 3 YA42 23 01/10/06 3 Norwich Road DS0000027559.V304319.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA34 Good Practice Recommendations It is recommended that staff files be tidied up into a more orderly system. 3 Norwich Road DS0000027559.V304319.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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