Inspection on 10/11/05 for 31 Wensum Way

This inspection was carried out on 10th November 2005.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

31 Wensum Way 28/11/08

31 Wensum Way 13/11/07

31 Wensum Way 06/06/06

31 Wensum Way 03/06/05

31 Wensum Way 19/01/05

31 Wensum Way 08/07/04

31 Wensum Way 18/03/04

31 Wensum Way 18/12/03

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 31 Wensum Way Fakenham Norfolk NR21 8NZ Lead Inspector Linda Wells Announced Inspection 10th November 2005 01:45 31 Wensum Way DS0000027503.V254887.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 31 Wensum Way DS0000027503.V254887.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. 31 Wensum Way DS0000027503.V254887.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 31 Wensum Way Address Fakenham Norfolk NR21 8NZ 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) 01328 863440 NO FAX # Elizabeth Fitzroy Support Mr Graham Stephen Foster Snell Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 31 Wensum Way DS0000027503.V254887.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd June 2005 Brief Description of the Service: 31, Wensum Way is a modern semi-detached house providing accommodation and care for up to eight people with a learning disability. The home has accommodation on both floors and access to the first floor is by a flight of stairs or the chair lift. The home is run as two units each providing living accommodation for four people. The bedrooms are all single rooms that contain a wash basin and the ground floor of the home has been designed and adapted to deliver a service to people with special mobility needs. On each floor there is a commual kitchen/dining room, a lounge, adapted bathroom and toilet and on the ground floor there is an additional shower room. The lounge on the ground floor has been made into a sensory/games room and there is a small room on the first floor for the use of those residents that smoke. There is a large well kept garden to the rear of the property that offers access to all residents and a pleasant area to sit and parking to the front of the building. The home is sited in a residential housing estate approximately half a mile from the centre of Fakenham which offers local health amenities, leisure activities and shops. 31 Wensum Way DS0000027503.V254887.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection undertaken on the 10th November 2005 over four and one half hours and was a follow up to a previous investigation by the Adult Protection Unit and part of a routine inspection plan. Prior to inspection comment cards were received from six residents who all said that they liked living at the home and felt safe, one said that he “lives in a happy home and feels there is lots going on”, six relatives/visitors who all said that they were made welcome in the home, one said “there is a very warm and happy atmosphere, even when I call unexpectedly” and two healthcare professionals who said that they were satisfied with the overall care provided to residents and that staff were “always friendly and helpful”. On the day of inspection eight residents were living at the home and were seen to return from local day and garden centres, to be sitting in the lounge/dining rooms, watching television and eating a meal and moving around the home. The inspection took the form of a tour of the premises, individual discussion with five residents, three staff members, the assistant manager and the manager, observation of residents and staff in the home, examination of care plans, records, certificates and the compliance of requirements and recommendations from the last inspection. What the service does well: What has improved since the last inspection? Residents have benefited from the home being made more attractive and safe by the retiling of a bathroom, the replacement of some door locks and the outside of the home being re-pointed where necessary. 31 Wensum Way DS0000027503.V254887.R01.S.doc Version 5.0 Page 6 As a result of the complaint investigation and to ensure that the needs of residents are fully met and that they are protected, additional staff training in the protection of vulnerable adults had taken place and improvements to record keeping were seen. What they could do better: The requirements and recommendations from the last inspection and complaints investigation have been complied with but there is still more to do to completely ensure that residents are fully protected, consulted and the environment well maintained in all areas. The following four requirements and four recommendations were made to further improve the experience of living and working at the home for residents and staff. • • • The arrangements at death must be recorded for each resident in their plan of care to show that they are consulted and to ensure that their wishes are known. The carpets in the hallways must be deep cleaned or replaced to ensure that residents live in a home that is maintained to a good standard. An effective Quality Assurance system must be in place and carried out in the home and take into account the feedback and opinions of residents, staff, relatives, visitors and other professionals and show they are consulted. (In the process of being produced) Copies of all staff recruitment checks and proof of identity must be held in staff files to show that residents are protected. It is recommended that the information held in the plans of care be continued to be improved to a good standard to ensure the needs of residents are met and staff members fully informed. It is recommended that the increase in the numbers of staff undertaking NVQ2 be continued to enable the target of 50 to be met. It is recommended that a list of the training undertaken by staff members be held in their staff file to show the training and updated training that staff members have completed to meet the needs of all residents. It is recommended that a copy of the inspection reports completed by CSCI be made available to anyone who wished to read them. • • • • • 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. 31 Wensum Way DS0000027503.V254887.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 31 Wensum Way DS0000027503.V254887.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, 3, 5 The written information available about the home is complete and enables residents to make a decision on whether the home will meet the needs of anyone wishing to live there. EVIDENCE: The homes Statement of Purpose, Service User Guide and Terms and Conditions contract were seen and found to contain relevant information. The manager said that prior to admission as much information as possible was collected from a prospective resident, their family and other professionals. He said residents, their family or friends sometimes visited the home, that he often visited residents in their own environment and that residents were admitted on a one-month trial basis. No resident had been admitted to the home and the records held showed that an assessment was completed prior to admission to the home to ensure that the needs of residents were identified as being able to be met by the home, that the views of residents, their family members and other professionals were sought and that residents and their relatives, friends or advocates visited the home prior to admission. 31 Wensum Way DS0000027503.V254887.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): 6, 8, 9, 10 Residents are consulted and improvements have been made to the information held in the individual plans of care but further work is needed in some to ensure that the needs of residents are fully identified and clearly recorded. EVIDENCE: Residents said that they were well cared for by the staff members who could be trusted to keep their confidences. Four individual plans of care and support plans were examined and found to have improved and to contain relevant health, personal and social care information, a photograph, daily records, risk assessments, past history, involvement with health care professionals, preferences, routine, assessment of needs, activities and medical reports. The assistant manager said that key workers were now carrying out regular key worker meetings with residents that formed the basis of the reviewed information held. This was seen in the plan of care but a recommendation was made that the information held in the plans of care be continued to be improved to a good standard to ensure the needs of residents are met and staff members fully informed. Residents said that they were encouraged to be independent, make their own choices and that staff members supported them in taking risks within their 31 Wensum Way DS0000027503.V254887.R01.S.doc Version 5.0 Page 10 daily lives by maximising their potential around confidence, goals, self-care and promoting life skills. One said “I like to help with the washing up” and two said that they enjoyed their holiday with staff. 31 Wensum Way DS0000027503.V254887.R01.S.doc Version 5.0 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): 11, 15, 16, 17 Social activities and meals are both planned around resident choice and provide variation and interest for the people living in the home. EVIDENCE: Residents said that they enjoyed their daily activities and records and photographs were seen to demonstrate that residents attend a local day or garden centre, had enjoyed a “Halloween Party”, took part in leisure activities and outings such as shopping, for a meal and bowling, attend community events such as the Gateway Club, to watch football and the theatre and are taken on holiday by staff members. The staff members spoken to gave examples of how they work with residents to support them in their personal development and behavioural management by working with other professionals, encouraging each resident to be independent and to make choices whilst ensuring that the rights of each resident were promoted and protected. Residents said that they enjoyed the meals cooked by staff members, that they were given enough to eat and a choice and one said that he “liked to help 31 Wensum Way DS0000027503.V254887.R01.S.doc Version 5.0 Page 12 prepare the vegetables”. Records showed that menus were agreed with residents twice a week prior to the shopping being completed, that the meals were varied and balanced and food hygiene certificates held by staff members. 31 Wensum Way DS0000027503.V254887.R01.S.doc Version 5.0 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, 21 Personal support is given to residents in the way they prefer, their needs are met and they are protected by the homes medication policies and procedures. EVIDENCE: Residents were assisted with decision-making and the staff spoken to said that they assisted residents with limited communication skills by understanding their response to questions and preferred manner of communication, using simple sign language, pictures, observation and as recorded. Residents said that they received personal and emotional support from staff members who were always willing to listen to them and demonstrated that they knew who to tell if “they were unhappy”. One member of staff was observed correctly withdrawing medication from the locked medication cupboard and records demonstrated that staff had undertaken training in medication administration, that accurate records were held, medication was stored correctly and policies and procedures were held. Records held on residents showed that residents had not been consulted on their arrangements at death and a requirement was made that the wishes of each resident be recorded to demonstrate consultation and agreement of each resident. 31 Wensum Way DS0000027503.V254887.R01.S.doc Version 5.0 Page 14 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 home has an active procedure on the protection of vulnerable adults that protects residents and supports the investigation of any cause for concern. EVIDENCE: The home has not received any complaints the service they provide since the last inspection in June 2005. The Adult Protection Unit completed their investigation into an allegation of a physical assault, on a resident living in the home, by one member of staff. No criminal charges were brought and the member of staff, who is no longer working at the home, was referred to the POVA list. Residents spoken to said that if they were unhappy they would tell staff members and all agreed that they would be listened to and the appropriate action taken to resolve the problem to the satisfaction of all concerned. Residents are protected from abuse, neglect and self-harm by the objectives, policies and procedures of the home and the assistant manager said that all staff are in the process of repeating training in the prevention of Adult Abuse to help them recognise, prevent and deal with any potential abuse. 31 Wensum Way DS0000027503.V254887.R01.S.doc Version 5.0 Page 15 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, 26, 29, 30 The standard of the environment within this home is mainly good providing residents with an attractive, safe and homely place to live. EVIDENCE: The home is purpose built and a tour of the building revealed that residents benefit from a home that has a bright, homely environment that was clean, odour free, well decorated in most areas and furnished and maintained to a good standard. The carpets in the hallways and some bedrooms were in need of cleaning or replacing and a requirement was repeated. The manager said that he was in the process of arranging for the carpets in the hallways to be replaced. The home has specialist equipment, sufficient and suitable adapted toilet, bathing and washing facilities and residents had personalised their bedrooms. All infection control measures were in place and the laundry room contained a service washing machine, tumble dryer and sluicing facilities to aid in the protection of the health and safety of all residents and staff. 31 Wensum Way DS0000027503.V254887.R01.S.doc Version 5.0 Page 16 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, 35, 36 Staff members are competent, supervised and the procedure for the recruitment of staff provides safeguards to offer protection for residents but records were not all complete. EVIDENCE: The four staff members spoken to felt supported by the assistant manager and the manager, by handovers, staff meetings and supervision and were aware of their role and responsibilities. The assistant manager said that she worked closely with the manager and was supported by him through supervision and shared responsibilities. Staff had undertaken basic training such as induction and foundation, food hygiene, emergency aid, medication, moving and handling and some staff had completed training in challenging behaviour. The numbers of staff that had completed or commenced NVQ 2 had increased. However, two recommendations were made that the increase in the numbers of staff undertaking NVQ2 be continued to enable the target of 50 to be met and that a list of the training undertaken by staff members be held in their staff file to demonstrate that staff had completed training to meet the needs of all residents. The staff spoken to felt that generally there were enough staff on duty if all shifts were fully covered and the manager agreed with the comments received 31 Wensum Way DS0000027503.V254887.R01.S.doc Version 5.0 Page 17 by three relatives/visitors in their comment cards that there were occasions when shifts were not fully staffed. He said that every effort was made to ensure that the full complement of staff were on duty and that he had now successfully recruited additional staff members. The manager said that residents were protected and that all staff recruitment checks were carried out and held at the main office. A CRB, photograph and personal details were seen for all staff members but staff files did not all contain copies of proof of identity, references, application form and a contract for each member of staff therefore a requirement was made that copies of all staff recruitment checks and proof of identity be held in staff files to demonstrate that residents are fully protected. 31 Wensum Way DS0000027503.V254887.R01.S.doc Version 5.0 Page 18 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, 38, 39, 40, 43 The home is well run and the assistant manager supports the manager in providing leadership, guidance and direction to ensure that the residents receive a good standard of care. EVIDENCE: Residents are protected by the management and administration procedures carried out in the home. Policies and procedures have been produced on all aspects of the home and service provided and the records held promote and protect the rights and best interests of each service user. Those who returned their comment cards commented that they did not have access to inspection reports produced by CSCI and the manager said that they were not made available to relatives, visitors, other professionals and staff. Therefore a recommendation was made that copies be available to anyone who wished to read them. The Regional manager said that arrangements were being made for the relative/representative of each resident to receive a copy and that any request to view a report would be met. 31 Wensum Way DS0000027503.V254887.R01.S.doc Version 5.0 Page 19 A Quality Assurance system is in the process of being produced and the Regional Manager said this would be carried out monthly with residents. A requirement was made that the Quality Assurance system include the feedback and views of residents, relatives, visitors, other professionals and staff members on the standard of care, service, facilities and lifestyle provided for residents and that an action plan of improvements be produced from the information gathered. To ensure that the health and safety of residents is protected, the servicing and testing of all equipment had been carried out. Relevant and timely certificates were held and records were stored securely. The manager successfully monitored identified financial budgets for the home and there was no reason to doubt that the financial security of Elizabeth Fitzroy Support was not sound. 31 Wensum Way DS0000027503.V254887.R01.S.doc Version 5.0 Page 20 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 3 X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X 3 X X 3 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 31 Wensum Way Score 3 3 3 2 Standard No 37 38 39 40 41 42 43 Score X X 2 3 X X 3 DS0000027503.V254887.R01.S.doc Version 5.0 Page 21 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 YA21 Regulation 12.2 Requirement The registered person must ensure that the arrangements at death are recorded for each resident in their plan of care. The registered person must ensure that the carpets in the hallways are deep cleaned or replaced. The registered person must ensure that copies of all staff recruitment checks and proof of identity are held in all staff files. The registered person must ensure that an effective Quality Assurance system is in place and carried out in the home. Timescale for action 01/02/06 2. YA24 23.2.b 31/03/06 3. YA34 19.1.a.b. schedule 2 24.1.a.b, 2.3 31/01/06 4. YA39 31/12/05 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 YA6 Good Practice Recommendations It is recommended that the information held in the plans of care be continued to be improved to a good standard to ensure the needs of residents are met and staff members DS0000027503.V254887.R01.S.doc Version 5.0 Page 22 31 Wensum Way 2. 3. YA35 YA35 4. YA39 fully informed. It is recommended that the increase in the numbers of staff undertaking NVQ2 be continued to enable the target of 50 to be met. It is recommended that a list of the training undertaken by staff members be held in their staff file to show the training and updated training that staff members have completed to meet the needs of all residents. It is recommended that a copy of the inspection reports completed by CSCI be made available to anyone who wished to read them. 31 Wensum Way DS0000027503.V254887.R01.S.doc Version 5.0 Page 23 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 31 Wensum Way DS0000027503.V254887.R01.S.doc Version 5.0 Page 24 - 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!