Inspection on 20/08/07 for 43 Freeman Street

This inspection was carried out on 20th August 2007.

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

Other inspections for this house

43 Freeman Street 25/04/06

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 43 Freeman Street Wells-next-the-Sea Norfolk NR23 1BQ Lead Inspector Debra Allen Unannounced Inspection 20th August 2007 09:30 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 43 Freeman Street Address Wells-next-the-Sea Norfolk NR23 1BQ 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 710140 bj.marshall@virgin.net Miss Bridget Jane Marshall Not applicable Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th April 2006 Brief Description of the Service: 43 Freeman Street is a small domestic type environment offering support to three adults with learning difficulties. The residents share the house with the provider, Miss Bridget Marshall. The house is situated close to the centre of the seaside town of Wells-NextThe-Sea on the Norfolk coast. 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care Services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out, by using information from previous inspections, information from the providers, the residents and their relatives, as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and the current judgements for each outcome group. This inspection was carried out over a period of three and a half hours, during which time discussions were held with the manager and all three service users, a number of records were inspected and a tour of the premises was undertaken. All three service users returned questionnaires, which contained very positive comments, about the home they live in and the service they receive. The comments included: What’s good about living at your home? “It’s close to the sea and the shops and we can get the bus easily if we want to go into town.” “Lots to do and freedom.” “I like living here and the company.” What’s not so good? “Can be very busy in the summer with holiday makers.” “If we get floods.” Following a discussion with the three service users, an ‘Easy Read Summary’ has not been produced for this report as they all said they preferred this format. Three requirements and one recommendation have been made as a result of this inspection. 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 Page 7 There is still a lack of regular and ongoing information relating to the day-today lifestyles of each service user, including work, leisure, family contacts and general mood and wellbeing. The biggest issue for Miss Marshall remains paperwork and record keeping, a more in-depth quality assurance process and commencing a management qualification programme. Miss Marshall did however confirm, during discussions that these are areas which are currently being addressed and improvements have been noted since the last inspection. Further improvements are also envisaged as a result of the recent recruitment of a staff member and potential further recruitment. 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. The summary of this inspection report can be made available in other formats on request. 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 Page 8 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 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. Service users’ individual needs and aspirations are assessed on an ongoing basis to help ensure the service continues to meet their requirements. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As with the previous inspection, there have been no new admissions for some years. The three residents are settled and there are no foreseeable plans for any future admissions. 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9 & 10 Quality in this outcome area is good. Each of the service users know that they are able to make decisions about their lives and that their assessed and changing needs and personal goals are shown in their personal plans, although ‘daily event’ record keeping still needs to be improved. Service users are consulted and are able to join in with all aspects of life in the home. They are also supported to live an independent lifestyle and take risks as part of this. The service users are confident that information about them is looked after and handled appropriately. This judgement has been made using available evidence including a visit to this service. 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 Page 11 EVIDENCE: Care plans were examined for all three service users and found to contain detailed information about each individual and how they are supported. These have been reviewed since the last inspection and now focus more on the more positive attributes of each service user. Each person confirmed that they had been actively involved in the compilation of their care plan. There is still a lack of regular and ongoing information relating to the day-today lifestyles of each service user, including work, leisure, family contacts and general mood and wellbeing. A repeated requirement has therefore been made for this to happen, together with a recommendation that each service user is actively involved in creating their own ‘This is Me’ styled person centred plans. Risk assessments continue to be in place, which cover aspects such as being home alone, cycling, money handling and fishing. Discussions with the service users and Miss Marshall confirmed that each person has a significant say in all aspects of the home and two people in particular said they talked all the time to each other and Miss Marshall about life in general. The service users’ records were seen to be confidential and secure at this inspection and the three people living at 43 Freeman Street confirmed that they trusted Miss Marshall to look after them. 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. Service users are able to pursue their own hobbies and interests and each person has a work/day placement during the week. Service users are able to have regular contact with friends and family, as they wish. All three service users enjoy their meals and are involved in food shopping and deciding what they want to eat. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All three service users were spoken to on their own and together as a group. These discussions provided confirmation that each person has their own hobbies and interests such as fishing, keep fit/treadmill, piano keyboard, cars, cycling, watching television soaps and helping with the local lifeboat. 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 Page 13 The service users also described other activities they do such as picnics, shopping, going to the cinema, swimming, bowling, gardening, helping in and around the house and looking after the household pets. All three people said they always had lots to do and they enjoyed living at Freeman Street. Each person also said that they enjoyed their food and explained how they were involved in choosing what to have and how they helped to do the food shopping. 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. Each of the service users receive personal care and support in the way they choose and their physical and emotional healthcare needs continue to be met. Medication is handled appropriately and this, together with the medication records are now stored securely. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All three people are capable of carrying out most of their own personal care needs and generally only require encouragement and prompting from Miss Marshall. Each person is registered with the local doctor and dentist. Other healthcare professionals were noted to be an optician, psychiatrist and osteopath. The care plans are fully updated and printed out every three months but are updated on the computer system on a regular basis – as and when any appointments occur or issues arise. Medication and records were noted to be stored securely now, in accordance with the requirements from the previous inspection. 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. The service users feel safe and know who to talk to if they have any problems or concerns. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no complaints since the last inspection. All three service users are very settled at 43 Freeman street and each person confirmed that they were happy and felt safe there. They also said that they knew they could talk to Miss Marshall or staff at their work places. As at the previous inspection, Miss Marshall confirmed that she is aware of the need to report any concerns and has continued to be proactive in notifying the Commission and social workers when any issues have arisen. Miss Marshall has familiarised herself with adult protection and confirmed, during the inspection, that she is seeking appropriate training for herself for POVA (Protection of Vulnerable Adults). 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27 & 30 Quality in this outcome area is good. Service users live in a homely, comfortable and safe environment, which is clean and hygienic and their bedrooms suit their needs and lifestyles and promote their independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each of the service users gave their individual time to assist with a tour of the premises, which was found to be very homely and well presented. A lot of work has been done in the home in order to further improve it since the last inspection and everybody told of their involvement and how they enjoyed helping with these works. Each person’s bedroom was seen to be very individual and personalised and each person said they were very happy with their rooms. Overall, the home was found to be clean, hygienic and free from hazards. 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. Service users are well supported by Miss Marshall and a competent part time member of staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection, Miss Marshall has recruited a part time member of staff who also does some sleep-in duties. It was also confirmed, during discussions, that Miss Marshall is actively seeking a second part time person to join her team. The current member of staff had been police checked prior to starting work at 43 Freeman Street and a copy of their clear, enhanced Criminal Records Disclosure was duly noted during the inspection. As at the previous inspection, it was apparent that the service users continue to be well supported in a family environment where they are respected as adults and take part in daily decision making within their home. 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate. Further training needs to be undertaken by Miss Marshall and a management qualification obtained. The quality assurance process and general record keeping needs to be developed further. This judgement has been made using available evidence including a visit to this service. EVIDENCE: It was evident from observations during the inspection that the home is generally very well run and the atmosphere felt happy, comfortable and relaxed. The biggest issue for Miss Marshall remains paperwork and record keeping, a more in-depth quality assurance process and commencing a management qualification programme. 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 Page 19 Miss Marshall did however confirm, during discussions that these are areas which are currently being addressed and improvements have been noted since the last inspection. Further improvements are also envisaged as a result of the recent recruitment of a staff member and potential further recruitment. 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 3 X 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 Page 21 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 YA6 Regulation 16 Requirement A written record is required, which demonstrates the involvement of residents in activities, contact with friends and family, healthcare appointments and general well being needs to be kept and updated on a reasonably regular basis. Repeated Requirement. Timescale for action 30/11/07 2. YA39 24 A process is required for 30/11/07 maintaining and improving the quality of care such as identifying relevant training and ensuring quality of life indicators such as choice and independence are continuously promoted. Repeated Requirement. Miss Marshall must commence a relevant programme in order to obtain an appropriate management qualification. 31/01/08 3. YA37 9 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 Page 22 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 each service user is actively involved in creating their own ‘This is Me’ styled person centred plans. 43 Freeman Street DS0000065466.V349516.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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