Inspection on 03/06/05 for 31 Wensum Way

This inspection was carried out on 3rd June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 9 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 10/11/05

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:

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Paradise Lodge

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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 31 Wensum Way Fakenham Norfolk NR21 8NZ Lead Inspector Linda Wells Unannounced 03 June 2005 14:30 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 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 Stationary 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 I55 s27503 Wensum Way v230281 (un) 030605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 31 Wensum Way Address 31 Wensum Way Fakenham Norfolk NR21 8NZ 01328 863440 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Elizabeth Fitzroy Support Mr Graham Snell Care Home 8 Category(ies) of Learning Disabilities (8) registration, with number of places 31 Wensum Way I55 s27503 Wensum Way v230281 (un) 030605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19 January 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 I55 s27503 Wensum Way v230281 (un) 030605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection undertaken on the 3rd June 2005 over four and one half hours as part of a routine inspection plan. The Adult Protection Unit is undertaking an investigating into an allegation of abuse. On the day of inspection seven residents were living at the home, one resident was out for the day and one resident was absent from the home on leave. Residents were seen to be sitting in the two lounges, moving around the home, watching television, returning from their community day care, having a hot meal and talking to staff in the kitchen/dining rooms. Staff members were seen to talk openly with all residents in a warm, respectful manner that promoted choice. The inspection took the form of a tour of the building, individual discussion with three residents, four staff members and the assistant manager, observation of three residents and the staff on duty, examination of plans of care, 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? Since the last inspection the bedroom of one resident has been redecorated to reflect the changing interests of the resident, enough money has been raised by staff at the home and donations of money from relatives to purchase a green house for the garden and two residents have been on holiday with staff. 31 Wensum Way I55 s27503 Wensum Way v230281 (un) 030605 Stage 4.doc Version 1.30 Page 6 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. 31 Wensum Way I55 s27503 Wensum Way v230281 (un) 030605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection 31 Wensum Way I55 s27503 Wensum Way v230281 (un) 030605 Stage 4.doc Version 1.30 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 standard(s) 2, 4, 5 Residents and staff are able to make a decision on whether the home will meet the needs of anyone wishing to live there. The written information held is incomplete and does not give residents access to information they need. EVIDENCE: To ensure that the needs of the residents are identified as being able to be met by the home an assessment is completed prior to admission to the home and includes the views of the resident, their family and other professionals. Prior to admission, residents visit the home and sometimes stay at the home overnight or for the weekend to enable the prospective resident, existing residents and staff to make a decision on whether the home will meet the health and social care needs of a prospective resident. A copy of the Statement of Purpose and Terms and Conditions contract is not kept in the individual plan of care resulting in residents not having access to the information they need about the home. All information must be signed, dated and copies kept in the plan of care. 31 Wensum Way I55 s27503 Wensum Way v230281 (un) 030605 Stage 4.doc Version 1.30 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 standard(s) 6, 7, 9, 10 The information currently held on each resident did not fully demonstrate that the health and social care needs of residents were met and that they were consulted and supported to take risks. This needs to improve. EVIDENCE: Residents were well looked after, however, not all individual plans of care were well organised, up to date, reviewed and complete. Examination of four care plans revealed that they contained personal health and social care information, involvement with other professionals, communication needs, guidance on immediate actions and key worker reports that were not all easy to read or up to date. They contained past information on challenging behaviour reports, life choices, preferences, interests, worst day prompts and routines but they must be regularly reviewed to ensure that they are up to date, all contain 1st person accounts of life choices and to demonstrate the involvement, consultation and agreement of each resident on their plan of care. One plan of care seen had been compiled by the assistant manager and was produced using a person centred approach and should be commended for it’s content and presentation. She said that all staff would be offered training in person centred care planning in the near future. 31 Wensum Way I55 s27503 Wensum Way v230281 (un) 030605 Stage 4.doc Version 1.30 Page 10 Residents were not fully protected and confidentiality maintained because risk assessments, information and instructions on the health and social care needs of each resident were held in a memo file and risk assessment file with the information of other residents. All resident information must be held in the individual plan of care and must be signed and dated. Residents were assisted with decision-making and the five staff spoken to said that they assisted the three residents with limited communication skills by understanding their response to questions, using simple sign language, pictures and observation and recording the compliance or objection of a routine or choice to indicate agreement or disagreement. One resident was observed communicating with staff in this way to identify her needs, choices and to make a joke. 31 Wensum Way I55 s27503 Wensum Way v230281 (un) 030605 Stage 4.doc Version 1.30 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 standard(s) 12, 13, 14, 17 Social activities and meals are well planned, creative and provide daily variation and interest for those living at the home. EVIDENCE: Residents are stimulated by the program of activities and records were seen to demonstrate that residents attend a local day care centre, take part in leisure activities and outings such as going to the pub, shopping, for walks, attend local community events such as the theatre and are taken on holiday by staff. The five staff spoken to said that residents were supported to take part in appropriate activities by staff accompanying residents to health care appointments and by arranging leisure pursuits that were determined by the interests and personal development plan of each resident. The three residents spoken to gave examples of the outings they had been on and one resident spoke of the Adult Education course on “writing” that he was attending. The main meal and menus were seen and were balanced and varied. Records showed that residents were given a choice and an alternative offered. 31 Wensum Way I55 s27503 Wensum Way v230281 (un) 030605 Stage 4.doc Version 1.30 Page 12 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 standard(s) 18, 19 and 20 Personal support is given to residents in the way they prefer and their needs are met, however, they are not fully protected by the homes medication procedure, which is not diligently followed by staff, allowing for errors to occur. EVIDENCE: As previously highlighted, the information held in the plans of care was incomplete and not up to date but there was some relevant information in each of the care plan, daily recording book, memo file and risk assessment file that when read altogether informed staff and ensured that residents were supported in the manner they prefer whilst meeting their needs. Residents receive personal, physical and emotional support, however, it was observed that one resident was in need of reassessment by his CPN to ensure that his deteriorating mental health was assessed and appropriate action taken and a recommendation was made. The five staff spoken to said that residents were encouraged to be as independent as possible and that up to date information on the needs and preferences of each resident was verbally given to staff at each handover. As part of an ongoing process, staff talked to and observed residents when assisting them and recorded in the individual residents daily record book and the memo file those actions or routines that did or did not work or could be improved upon. A requirement has been made to improve the recording and storage of information in standard six. 31 Wensum Way I55 s27503 Wensum Way v230281 (un) 030605 Stage 4.doc Version 1.30 Page 13 Residents were not fully protected and although the staff on duty had undertaken medication training and records demonstrated that no resident was self-medicating, the medication policies and procedures held had not been fully followed resulting in two instances of poor practice. The records demonstrated that on two occasions staff had not recorded whether a resident had taken their medication and a requirement was made that all administration or refusal of medication must be recorded. 31 Wensum Way I55 s27503 Wensum Way v230281 (un) 030605 Stage 4.doc Version 1.30 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 standard(s) 22 and 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 three residents spoken to said that if they were unhappy they would tell their key worker, the staff member on duty or the assistant manager 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 staff have undertaken training in Adult Abuse to help them recognise, prevent and deal with any potential abuse. The home has received one complaint allegation that was passed to the Adult Protection Unit and is being investigated. Records seen demonstrated that immediate and appropriate action was taken by the manager to protect those living in the home. 31 Wensum Way I55 s27503 Wensum Way v230281 (un) 030605 Stage 4.doc Version 1.30 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 standard(s) 24, 25, 27, 28, 30 The standard of the environment within this home is mainly good providing residents with an attractive and homely place to live, although isolated areras are in need of cleaning or refurbishment. EVIDENCE: The home is purpose built and a tour of the building revealed that the home 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 made. 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. The health and safety of the residents using the upstairs smoking room was not fully protected by the very large amount of flies in the small room and a 31 Wensum Way I55 s27503 Wensum Way v230281 (un) 030605 Stage 4.doc Version 1.30 Page 16 recommendation was made that the room be thoroughly cleaned and action taken to prevent reoccurrence. 31 Wensum Way I55 s27503 Wensum Way v230281 (un) 030605 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 36, Staff are competent and the procedure for the recruitment and supervision of staff provides safeguards to offer protection for the people living at the home. More of the staff group need to undertake NVQ training to ensure they are skilled to undertake the caring task. EVIDENCE: The four staff members spoken to felt supported by the assistant manager and the manager, 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 and had completed or were waiting to commence NVQ 2 or 3 but a requirement has been made that additional numbers of staff undertake NVQ2 training to meet the target of 50 . The staff spoken to felt that generally there were enough staff on duty but at the times when a resident was experiencing low mood or deteriorating mental 31 Wensum Way I55 s27503 Wensum Way v230281 (un) 030605 Stage 4.doc Version 1.30 Page 18 health that two staff members were needed to care for those residents that live upstairs. A requirement has been made that risk assessments are carried out on the staffing levels required by each resident and that adequate staffing levels are provided at all times. Records showed that residents were protected and that all staff recruitment checks were carried out and CRB, proof of identity, references and personal details were held on each member of staff. The staff files did not all contain a photograph of each member of staff because the individual staff photographs were kept in a draw in the main downstairs hall. They were used daily by a resident to display a picture of the members of staff on duty each day, on a board on the wall, but in light of the tendency of the resident to carry them around with her and to permanently dispose of them a recommendation was made that a photograph of each member of staff be held in the staff file. 31 Wensum Way I55 s27503 Wensum Way v230281 (un) 030605 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 41, 42 The home is well run and the manager provides 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. The servicing and testing of all equipment in the home had been carried out and relevant and timely certificates were held on all items. A requirement was made that a current insurance certificate be held and displayed in the home. The manager was not present at the inspection and the experience and qualifications of the manager will be examined at the next inspection. 31 Wensum Way I55 s27503 Wensum Way v230281 (un) 030605 Stage 4.doc Version 1.30 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 x 3 x 3 2 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 2 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x 3 3 x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x x 3 Standard No 31 32 33 34 35 36 Score 3 2 2 2 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 31 Wensum Way Score 3 2 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x 3 3 2 I55 s27503 Wensum Way v230281 (un) 030605 Stage 4.doc Version 1.30 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 YA5 Regulation 5.1 2 Requirement The Registered person must ensure that a copy of the Terms and Conditions contract signed by each resident is held in their plan of care. The registered person must ensure that information held on each resident is kept in their plan of care and is up to date. The registered person must ensure that the plan of care for each resident is reviewed with the resident and records kept. The registered person must ensure that risk assessments are stored in the individual plan of care of each resident. The registered person must protect the confidentiality of information held on each resident and store in individual plans of care. The registered person must ensure that the records for administering medication are complete. The registered person must ensure that increased numbers of staff undertake NVQ2 to meet the 50 target. The registered person must Timescale for action 31st August 2005 2. YA6 17.1-3 1st August 2005 31st July 2005 and ongoing 1st July 2005 1st July 2005 3. YA6 15.2.b c 4. YA9 17.1.a schedule 3.3.q 17.1.b 5. YA10 6. YA20 13.2 1st July 2005 and ongoing 31st December 2005 31st July Page 22 7. YA32 18.1.c 8. YA33 18.1.a 31 Wensum Way I55 s27503 Wensum Way v230281 (un) 030605 Stage 4.doc Version 1.30 9. YA43 25.2.e ensure that risk assessments are completed on the staffing levels required upstairs and provide adequate staffing levels at all times The registered person must ensure that a current insurance certificate is held and displayed. 2005 and ongoing 31st July 2005 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. Refer to Standard YA19 YA24 YA24 YA34 Good Practice Recommendations It is recommended that the mental healthcare needs of a resident living in the home are reassessed by a Community Psychiatric Nurse to ensure well being. It is recommeded that the carpets in the hallways and bedrooms that are soiled are deep cleaned or replaced. It is recommended that the upstairs smoke room is thoroughly cleaned and action taken to prevent the occurance of flies. It is recommened that a photograph of each staff member is held in their plan of care. 31 Wensum Way I55 s27503 Wensum Way v230281 (un) 030605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection 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 I55 s27503 Wensum Way v230281 (un) 030605 Stage 4.doc Version 1.30 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. 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