CARE HOME ADULTS 18-65
3 Norwich Road Long Stratton Norwich Norfolk NR15 2PG Lead Inspector
Mrs Susan Golphin Announced Inspection 24 February 2006 14:00p 3 Norwich Road DS0000027559.V264160.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 3 Norwich Road DS0000027559.V264160.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 3 Norwich Road DS0000027559.V264160.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service 3 Norwich Road Address Long Stratton Norwich Norfolk NR15 2PG 01508 536059 01508 536103 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.V264160.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 14th October 2005 Brief Description of the Service: 3,Norwich Road is a semi-detached house situated in the busy village of Long Stratton. The registered accommodation is on the ground and first floors and consists of three single bedrooms, a kitchen/diner and a lounge. Large garden to the back and car parking to the front of the premises. 3 Norwich Road DS0000027559.V264160.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection took place over half a day. The home manager Carole Thompson and one member of staff were interviewed. All the service users were out at work or other daytime activities at the beginning of the inspection, but were seen later on their return home .A small sample of records and other documentation were seen, and a brief tour of the premises was undertaken whilst talking to residents. The requirements and recommendations and proposed move to other accommodation were the key items for discussion. This is a small and homely environment with a positive and committed staff team. Six comment cards were received from the users of the service and all expressed satisfaction with the service and care support. What the service does well:
Residents and their relatives are provided with good information about the service. The manager and staff are committed to meeting the needs of the residents. There is a comprehensive service user plan for everyone who lives in the home and service users are directly involved in decision making within the home. Safe and managed risk taking enables residents to maximise their independence. An individualised programme of meaningful employment and personal development activity is promoted. The routine of the home is flexible and relaxed and residents elect how they will spend their leisure time. Meals and mealtimes are flexible and involve service user participation and choice. Staff provide personal support to maximise privacy, dignity and control, and resident’s wellbeing and health is promoted and protected. Residents have a say in what they want and have every opportunity to express their personal views. There is a positive approach to training and learning, and on the day the staff were able to demonstrate a good knowledge and insight into the needs of the family group. 3 Norwich Road DS0000027559.V264160.R01.S.doc Version 5.0 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.
3 Norwich Road DS0000027559.V264160.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 3 Norwich Road DS0000027559.V264160.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,5 Information about the service is accessible and up to date and in easy to read format. All residents have individual contracts, which provide them with the terms and conditions of the home. EVIDENCE: New tenancy and support agreements have been issued to all the residents who have signed and agreed the terms and conditions. Copies were shown to the inspector and are clear and concise. Other information about the service provision is also readily available and up to date. 3 Norwich Road DS0000027559.V264160.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8,10 The residents of this home are enabled to take control of their own lives. Resident’s are helped to make decisions in a safe and supportive way. Resident’s independence and individuality are promoted. EVIDENCE: The inspector was able to talk to the residents on their arrival home from their day services or employment. The residents were keen to show off their home and their individual rooms and did so with confidence and independently. The manager and staff seen on the day were able to demonstrate how they promote residents self esteem and encourage individual thinking and action. It is clear that there are positive and supportive relationships in place and that each person’s privacy dignity and personal expression is treated with respect Information about the residents is maintained on computer and a new password has been installed so that details are kept in a confidential way and in line with the data protection act. 3 Norwich Road DS0000027559.V264160.R01.S.doc Version 5.0 Page 10 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): 13,16,17 Residents live as part of the village community. Residents enjoy varied lifestyles based on their chosen activities and interests. Residents participate and contribute to the planning and preparation of meals. EVIDENCE: The residents enjoy a range of social activities and personal interests through their day services and chosen leisure activities. As previously stated the current house is small and has limited shared space; both residents and staff are actively looking for a larger house which will offer more personal space not only in residents own rooms but communally so that their sports and exercising equipment can be housed separately from their own rooms and the residents can make better use of it. All the residents are mindful of their own well being and attend well woman and well man clinics There was a lively discussion about keeping fit and ‘watching ones weight’ through sensible eating. Residents said that they help with meal preparation and shopping and some of the routine domestic chores. 3 Norwich Road DS0000027559.V264160.R01.S.doc Version 5.0 Page 11 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): 19,20 The residents in this home are supported and cared for which promotes their emotional and social well being and also ensures that their physical healthcare needs are appropriately met. EVIDENCE: This standard was only looked at in part in that from the discussions with staff and residents and from a small sample of records it was demonstrated that individual health care needs are met including promoting preventative care to ensure a healthy lifestyle and sense of well being; including healthy eating and exercise. The manager has reviewed the policies and procedures in place for the administration of medication and they have been re-issued to all the staff with a covering letter setting out their responsibility to ensure that records are accurate and in place. The manager is currently in discussion with the local GPs who attend the home on good practice and use of homely remedies. 3 Norwich Road DS0000027559.V264160.R01.S.doc Version 5.0 Page 12 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 Procedures are in place to promote and protect the views of residents. The homes own policies, procedures and training also protect residents EVIDENCE: The staff group have attended training on protecting vulnerable adults. A draft complaints log has also been established in both words and pictures. Residents views are being sought on the format and style and whether they find it easy to use. It will be brought into formal use once agreement has been reached. Changes in the way residents personal allowances are managed have been made and staff now have a format to sign at each shift to ensure all monies and expenditure are recorded and reconciled. 3 Norwich Road DS0000027559.V264160.R01.S.doc Version 5.0 Page 13 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 Residents live in a comfortable and clean environment but with limited personal and communal space. EVIDENCE: This standard was only inspected in part. The CSCI are aware that the Charity Prospects and the manager of the home are actively looking to move from their current accommodation to a better property. The house is small, situated on a busy main road and access can be difficult because of the heavy use by traffic. The property also has limited communal space. Some of the communal space is taken up by large pieces of domestic equipment, which only adds to the sense of overcrowding. Whilst the accommodation is appropriately maintained, the property overall and external grounds are in need of general improvement and refurbishment and redecoration Resident’s rooms are small and have to accommodate most of their personal things including big items like exercise equipment. The plan to acquire a better property in a more suitable location near to their employment and day services and that will provide residents with added space and improved facilities is commended by the Commission. (See recommendation)
3 Norwich Road DS0000027559.V264160.R01.S.doc Version 5.0 Page 14 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): 32,33,34 The staff group work efficiently and effectively to meet and promote the needs and wishes of the residents at all times. EVIDENCE: The manager and one member of staff were on duty on the day of the inspection. The inspector was also able to chat briefly to the volunteer driver. The staff group have all completed their POVA training and both first aid and fire training which is planned for 19.March 2006. Resident’s spoke positively and warmly about the staff, describing them as ‘good people’ and ‘nice to live with’. The inspector was also aware of how very comfortable and relaxed staff and residents were with each other. One of the residents has been playing an active part in the acquisition of a new property; by seeking support and help from the Charity Prospects and from the board members. They travelled to the head office and participated in the formal presentation made by the manager. Residents are also taking part in the viewing process and their views will be central to any decision-making and choice. The manager is completing her NVQ4 and two staff have NVQ3 qualifications. There is a strong commitment to training and a new induction training process is being brought into use.
3 Norwich Road DS0000027559.V264160.R01.S.doc Version 5.0 Page 15 Staff records are also undergoing a major review and being updated in line with schedule 2-4 of the care home regulations. It was agreed that this piece of work will be inspected at the next visit. (See requirements) 3 Norwich Road DS0000027559.V264160.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 38,39,42 Resident’s views are sought on the development of the home and the service. The health and safety of the residents and staff is protected. EVIDENCE: The inspector was made aware of resident’s involvement in the running and development of their own home. They also have independent advocates they can access if needed. Residents are actively supported to be involved in the management and development of the home in every way and to have a view about their care and interests. Prospects have their own QA system in place and the manager plans to use the basics to develop a personal QA process for the home which will deliver a more personal review of progress and change in the home and service. It is acknowledged that this piece of work is in progress and will be looked at again at the inspection. (See requirement). The home has recently been inspected by the fire officer and the minor recommendations made have been implemented. The manager acknowledged
3 Norwich Road DS0000027559.V264160.R01.S.doc Version 5.0 Page 17 that a review of both generic and individual risk assessments has been completed and will be implemented as soon as possible. A review of maintenance records and service maintenance records and water temperature record are all now being maintained and logged. 3 Norwich Road DS0000027559.V264160.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x x x 3 Standard No 22 23 Score 3 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x 3 x 3 Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 3 14 x 15 x 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 3 2 x x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
3 Norwich Road Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x 3 2 x x 3 x DS0000027559.V264160.R01.S.doc Version 5.0 Page 19 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA34 Regulation 19 Requirement Timescale for action 31/05/06 2 YA39 10 The registered providers must continue and complete the review and update of all staff records in line with schedule 2-4 of the care Home regulations and NMS for younger adults. The registered providers must 31/05/06 continue and complete and effective quality assurance process to ensure residents and users of the service views are sought. 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 YA24 Good Practice Recommendations It is recommended that the registered providers and management continue to seek appropriate accommodation which will improve the personal and communal space and overall facilities for residents . 3 Norwich Road DS0000027559.V264160.R01.S.doc Version 5.0 Page 20 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. Extracts may not be used or reproduced without the express permission of CSCI 3 Norwich Road DS0000027559.V264160.R01.S.doc Version 5.0 Page 21 - 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!
