Inspection on 07/06/05 for 32 South Street

This inspection was carried out on 7th 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

32 South Street 07/08/07

32 South Street 29/08/06

32 South Street 05/12/05

32 South Street 29/11/04

32 South Street 24/05/04

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

CARE HOME ADULTS 18-65 32 South Street Sheringham Norfolk NR26 8LL Lead Inspector Dot Binns Unannounced 7 June 2005 9.30am 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. 32 South Street I55 S27522 32 South Street V232239 070605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 32 South Street Address Sheringham Norfolk NR26 8LL 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) 01263 824040 01263 824040 Prime Life Limited Miss Katherine Angela Pye Care Home 19 Category(ies) of Mental Disorder (19) registration, with number of places 32 South Street I55 S27522 32 South Street V232239 070605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Nineteen (19) Service Users with a mental disorder excluding learning disability or dementia, three of whom are over the age of 65 years, may be accommodated. 2. All new admissions must be between the ages of 18 and 65 years. Date of last inspection 29 November 2004 Brief Description of the Service: 32 South Street accommodates 19 service users with a mental disorder. The accommodation provides 19 single rooms some with en suite facilities on three floors. The top floor consists of a three bedroom flat with its own sitting room and bathroom and a bed sitting room with bathroom. This accommodation is used by those service users who are more independent. The remaining service users live together sharing the communal accommodation. There is a service users kitchen for them to make drinks and a variety of lounges including a smoking lounge and a games room. There is also a very attractive garden.The Home is registered to accommodate those who are under 65 years of age and new admissions will meet this criteria. Because of the previous registration, there are some service users who are older than that and the Home is required to monitor their needs carefully to ensure they are catered for. The Home is in a quiet street in a residential area near to the town centre of Sheringham within reach of the beach and the town’s facilities. 32 South Street I55 S27522 32 South Street V232239 070605 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 lasting three hours. The purpose of the inspection was to see how the Home functioned on a normal day. Discussions were held with the manager, the records were examined and some staff and service users were interviewed. A tour of some of the building was carried out and service users were seen going about their business in the Home. The pharmacy inspector also inspected the home carrying out a full review of the systems for looking after the medication. What the service does well: What has improved since the last inspection? The provision of activities and the involvement of staff in promoting and assisting with activities has substantially improved. This has made for a livelier atmosphere in the Home which is appreciated by both service users and staff and making service users more animated and enthusiastic. 32 South Street I55 S27522 32 South Street V232239 070605 Stage 4.doc Version 1.30 Page 6 The staffing has improved with two staff on duty till 10pm. A new proposed rota will consolidate these duties, allowing greater participation by the staff in the evening activities. Although the food has always been generally liked by the service users, staff were giving greater emphasis to the provision of healthier food on this inspection and ensuing its inclusion on the menu. This is good practice. The visit reports by the head office of the organisation (which are a monthly legal requirement) are improved though they need to be sent to the Commission. 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. 32 South Street I55 S27522 32 South Street V232239 070605 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 32 South Street I55 S27522 32 South Street V232239 070605 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 Prospective service users are appropriately assessed to see whether the Home can meet their needs. EVIDENCE: Samples of care records were chosen at random for inspection. Each contained full assessment information with the Homes own format being completed by the social worker and the service user. Information was also provided from other medical personnel if appropriate. The manager also said that she visits the applicant to assess whether they will fit into the Home. 32 South Street I55 S27522 32 South Street V232239 070605 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 Service users know that their needs and abilities are reflected in their care plans which staff use as a tool to help them. EVIDENCE: Three care records were sampled and found to contain detailed information about each service user. The care plans are based on the assessment information received when the person is admitted to the Home. These were regularly reviewed by the keyworker and good daily notes were written by staff commenting on progress. Service users usually sign their care plan and are aware of their difficulties and what they need to do to achieve them. 32 South Street I55 S27522 32 South Street V232239 070605 Stage 4.doc Version 1.30 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 standard(s) 13,14 and 17 Service users freely use the local community. Service users are engaging in more leisure activities than before and staff are giving more time to social stimulation. This is a big improvement over previous inspections and needs to be consolidated into the practice of the Home. Service users are offered a healthy diet and enjoy their food. EVIDENCE: Service users spoken to said they could come and go as they wished and they did use the facilities like shops in the town. They also went for walks along the beach or in the countryside and have monthly trips to the cinema with a member of staff which was a new development. They also go out more with staff and have trips in the Home’s transport. 32 South Street I55 S27522 32 South Street V232239 070605 Stage 4.doc Version 1.30 Page 11 Staff interviewed also confirmed that there had been an increase in activities over the last three months and this was particularly pleasing to see. The pool table is now used in the evenings and staff are hoping to hold a competition. The Home’s transport is used to take service users on regular outings at the weekends and there is more work being carried out by the keyworkers. Staff described how they were trying to engage and motivate the service users more and had particular action plans for their key residents. For example one staff described assisting one person to have the confidence to walk out more and how they walked round the block together. Service users have been taken to the pub. One service user has a patch of garden to maintain. The Home has also booked a holiday in Yorkshire which the Home is funding. Ten service users hope to go and one service user spoken to was certainly looking forward to that. The inspector was impressed by the energy which was now being devoted to these leisure pursuits and found the responses of staff and residents much more enthusiastic. This is an excellent improvement to the Home. Some structured activities take place for particular service users, for instance one person is being prepared to be rehabilitated and attends a centre during the day in preparation. Another person attends the Jubilee rooms in town and one person has been doing a correspondence course. Not every one can commit to a structured course and their confidence has to be built up first. However with the new emphasis on socialisation, more individual training opportunities may be promoted in the future. Service users were seen having lunch and they said it was very good. Prawn salad was on the menu though one or two had sandwiches. The main meal in the evening was to be pork chops and vegetables. One particular carer spends time in the kitchen preparing the food and she said she was planning to review the menus to ensure variety. She confirmed all the food is homemade and not prepacked. She also caters for three people on special diets (diabetic) and confirmed she had special foodstuffs in for them. The manager also confirmed that they were trying to ensure that there were healthy alternatives on the menu. Service users were also seen in the breakfast room later in the day where they were helping themselves to drinks. 32 South Street I55 S27522 32 South Street V232239 070605 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) 20 The home has made significant improvements to aspects of medicine management in order to ensure the health and welfare of service users is safeguarded. EVIDENCE: The inspection of this Standard was undertaken by specialist pharmacist inspector Mr Mark Andrews. He found overall that since the previous inspection visit of 29th November 2004 the home has made satisfactory improvements to its record-keeping practice. In addition, Ms Pye confirmed that there have been no further erroneous medicine administration incidents and that there was an ongoing program of assessment of staff competence. There were noted, however, to be several further prescribed medicines available for administration for which the home were not keeping current records. In addition, there was evidence that second containers of several medicines surplus to requirement were available with the risk of their confused and erroneous use. 32 South Street I55 S27522 32 South Street V232239 070605 Stage 4.doc Version 1.30 Page 13 The inspector made several recommendations relating to the further development of policy, audit and care planning for the management of diabetes mellitus. A copy of the full pharmacy inspection report has been submitted separately to the provider and is available subject to request. 32 South Street I55 S27522 32 South Street V232239 070605 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) Not inspected on this occasion EVIDENCE: 32 South Street I55 S27522 32 South Street V232239 070605 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) 25,26,27,28 and 30 Service users rooms are personal and promote their independence. The bathrooms and WCs are shabby and need renovating. The communal lounges are varied and comfortable. The laundry facilities are sufficient for the Home and the Home has no offensive odour. It was however in need of cleaning in some parts. 32 South Street I55 S27522 32 South Street V232239 070605 Stage 4.doc Version 1.30 Page 16 EVIDENCE: A few of the service users rooms were visited and in general were personal to the service users with evidence of their possessions, ideas about tidiness and interests. Each room has a lock and a knocker on the door to promote their privacy, and lighting and electrical sockets were adequate. The bedding in some rooms needs to be replaced. Two rooms were found with lumpy or flat pillows and one had a very thin quilt though the manager said that in that case the service user preferred it cool. However the manager should check the bedding to see what needs to be renewed. The rooms also needed to be cleaned. It is understood that the cleaner was off sick but no substitution of staff had been arranged. The Home has a condition on the registration to accommodate three service users who are over 65 years of age. One of these is accommodated on the ground floor to assist with mobility. The others are able to use the stairs though the manager reported that she will continue to monitor their abilities. The bathrooms and toilets of the Home were inspected. There is a bathroom and a shower room on the ground floor and another on the first floor with a bath and a shower over the bath. The top floor has its own bathroom but no shower because of height restrictions. In general the bathrooms and WCs were rather shabby. One bath in particular needed renovation and the standard of cleanliness was very poor. All had locks and the hot water was checked and found to be of an appropriate temperature. The Home has two interconnecting lounges which are bright and attractive though smoke does filter through from one to the other. There is also a games room with pool table and darts board as well as a keyboard. This room is reported to be more often used at night. There is also a small lounge on the first floor where smoking is also allowed. Service users also have a dining room and a small breakfast room where they can make their own drinks. Four service users live on the top floor in a semi independent flat and they have their own lounge and kitchen. Overall there is a good supply of different rooms which the service users can enjoy. However the issue of non smoking facilities should be kept on the agenda to ensure all service users are happy with the arrangements. The Home’s laundry has an industrial washer and tumble drier which is adequate for the size of the Home. 32 South Street I55 S27522 32 South Street V232239 070605 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) 32,33,35 The staff on duty are competent and have the qualities needed to support the service users. NVQ training once completed will enhance their competence. The number of staff on duty is satisfactory. Training is offered to staff which helps them to more effectively meet the needs of the service users. EVIDENCE: One staff seen at the inspection confirmed that she was studying for the NVQ2 and one staff was waiting to go on it. The manager provided the training programme which showed that four staff are currently studying for their NVQ2. If completed, the Home will be close to meeting the standard of having 50 trained staff. Staff convinced the inspector with their knowledge of the service users and their motivation to help to make their lives more interesting and comfortable. One staff was very experienced and her training file showed attendance at many courses over the years. 32 South Street I55 S27522 32 South Street V232239 070605 Stage 4.doc Version 1.30 Page 18 The rota for the week of the inspection showed that three staff were on duty until 8pm with the manager on during the day. After 8pm two staff were on duty till 10pm when the sleeping in staff went on stand by duty. Twelve hour shifts continue to be the norm though the manager is hoping to slightly reduce the number of staff doing such a long shift. (Proposed new rota seen – still to be approved by the organisation.) The rota also showed that 15 cleaning hours were provided though on the day of the inspection, the cleaner was off sick and no replacement staff had been put in place. No separate catering hours are provided but there are enough care staff hours to incorporate the cooking. Overall the staff hours on the rota for the week of the inspection were satisfactory. Staff files were scrutinised to see what training staff had received. There was evidence of induction training and one staff interviewed confirmed that she had received such training which included looking at attitudes towards service users and how they should be treated. The file of an experienced member of staff showed training on first aid, food hygiene, mental health and other courses. This shows good support to staff. 32 South Street I55 S27522 32 South Street V232239 070605 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) 37,41 and 42 Service users benefit from an experienced manager. Record keeping is properly maintained and safeguards the service users interests. The health and safety of service users and staff is protected except for fire prevention measures which need tightening up. EVIDENCE: The manager has a care qualification and is currently studying for her NVQ4 in management. She has been in post for at least two years. She is supported by this national organisation’s policies and management structure. 32 South Street I55 S27522 32 South Street V232239 070605 Stage 4.doc Version 1.30 Page 20 All the records required for this inspection were available and completed satisfactorily except where specially mentioned. This demonstrates an efficiency in the Home which protects the service users. A regulation 26 visit (a report by the provider on the Home) was seen and was an improvement on the previous reports for which a requirement had been made at the last inspection. It had not been forwarded to the Commission however and this needs to be done in future. Some of the health and safety systems in the Home were inspected. The Home has a policy on safe working practices and on health and safety policies. Tests on the lift equipment and on the thermo valves controlling the temperature of bath water were seen to be tested regularly and the testing of electrical equipment was also carried out. An accident book was correctly recorded. Staff were given training in health and safety matters. The fire system had been checked recently as had the emergency lighting in the Home. However the testing of the fire alarms was not carried out consistently enough neither was it possible to tell when the last fire drill was carried out though the manager said there had been one in the autumn. These should be carried out twice a year. These fire precautions need to be more consistently carried out to keep the service users safe. 32 South Street I55 S27522 32 South Street V232239 070605 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score x 3 3 2 3 x 2 Standard No 11 12 13 14 15 16 17 x x 3 3 x x 3 Standard No 31 32 33 34 35 36 Score x 3 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 32 South Street Score x x 2 x Standard No 37 38 39 40 41 42 43 Score 3 x x x 3 2 x I55 S27522 32 South Street V232239 070605 Stage 4.doc Version 1.30 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 27 Regulation 23(2)(d) Requirement The registered person must ensure that all parts of the building are kept clean and reasonably decorated. In this instance, the bathrooms require renovation and floors in the home need to be more frequently cleaned. The registered person must make adequate arrangements for reviewing fire precautions and testing fire equipment at suitable intervals, and to ensure by means of fire drills and practices that the staff and service users are aware of the procedure to be followed in case of fire. The registered person must ensure medicines no longer in use are promptly disposed of to reduce the risks of their erroneous administration. In addition, records of medicines actively prescribed must be kept up to date and include details of all active prescriptions. Timescale for action 30th September 2005 2. 42 23(4)and( e) 16th July 2005 3. 20 13.2,17.1 (a) schedule 3 24th June 2005 32 South Street I55 S27522 32 South Street V232239 070605 Stage 4.doc Version 1.30 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 26 Good Practice Recommendations It is recommended that the pillows and bedding in the Home are reviewed to ensure they are fit for purpose. 32 South Street I55 S27522 32 South Street V232239 070605 Stage 4.doc Version 1.30 Page 24 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 32 South Street I55 S27522 32 South Street V232239 070605 Stage 4.doc Version 1.30 Page 25 - 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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