Inspection on 01/11/05 for 7a Taylor Road

This inspection was carried out on 1st November 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

7a Taylor Road 27/09/06

7a Taylor Road 27/01/05

7a Taylor Road 29/09/04

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 7a Taylor Road West Earlham Norwich Norfolk NR5 8LZ Lead Inspector Linda Wells Announced Inspection 1st November 2005 01:30p 7a Taylor Road DS0000027528.V250134.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 7a Taylor Road DS0000027528.V250134.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. 7a Taylor Road DS0000027528.V250134.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 7a Taylor Road Address West Earlham Norwich Norfolk NR5 8LZ 01603 259916 01603 259940 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) Elizabeth Fitzroy Support Miss Carolyn Peacock Care Home 7 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (4), Physical disability (2) of places 7a Taylor Road DS0000027528.V250134.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th May 2005 Brief Description of the Service: 7a Taylor Road is a residential care home providing personal care and accommodation to seven people with a learning disability. It is a detached chalet bungalow that operates as two units within the home and provides mainly ground and some first floor accommodation that is accessed by a passenger lift or the stairs. There are seven, single bedrooms with washbasin and in each unit there is communal use of a lounge, dining area, kitchen, two toilets, a bathroom and in one unit an additional shower room. The home has a small-enclosed garden to the front and rear of the property and there is roadside parking to the front. It is situated on a residential housing estate in Norwich close to local shops and health amenities and the home provides both in-house day care and access to a range of community based activities and day care provision in Norwich. 7a Taylor Road DS0000027528.V250134.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 01st November 2005 over four hours and was carried out as part of a routine inspection plan and as a follow up to an anonymous complaint investigation carried out on the 26th July 2005 when nine requirements were made. Details of this investigation can be provided by CSCI on request. Prior to inspection comment cards were received from three relatives/visitors, a healthcare professional and a G.P. Three commented that they would like to see communication improved and all indicated that they were satisfied with the overall standard of care provided for residents. On the day of inspection seven residents were living at the home, two were in bed and five were seen to be sitting in the two lounges, walking around the home or in their bedrooms, watching television, listening to music, returning from their day centre and having a meal. Conversation was limited for six of the residents and staff members were seen to talk openly with all residents in a warm, inclusive, respectful manner that promoted choice. The inspection took the form of a tour of the building, individual discussion with one resident in bed and five staff members, observation of six residents, group discussion with the manager, operations manager and a student nurse, examination of care plans, records and certificates and compliance with requirements and recommendations from the complaints visit and the last inspection. What the service does well: What has improved since the last inspection? As a result of the complaint investigation and to ensure that the needs of residents are fully met and that they are protected improvements in the group dynamics of residents, management of challenging behaviour, staffing levels, staff training, leisure activities, In-house day care and record keeping were seen. 7a Taylor Road DS0000027528.V250134.R01.S.doc Version 5.0 Page 6 Residents have benefited from a more attractive environment by the redecoration of the kitchen and hall and replacement of carpets in the communal areas of one unit, the replacement of kitchen and domestic cleaning equipment and the use of a volunteer to redesign the rear garden. The home has been given approval to provide a student placement for a student learning disability nurse and both staff and residents are enjoying the additional support from a trainee specialist worker. 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 three requirements and four recommendations were made to further improve the experience of living and working at the home for residents and staff. • • • The medication administration records must be fully completed to ensure residents are protected. A photograph must be held in the staff file of each staff member to support proof of identity. The Quality Assurance system to be carried out in the home must include feedback and the views of residents, visitors/relatives, other professionals and staff to ensure that the opinions of everyone are sought on the standard of care and service provided at the home. It is recommended that the remainder of residents have their arrangements at death recorded in their plan of care to ensure that they are consulted and that the wishes of all residents are known. It is recommended that the redecoration of the remaining walls where the decoration is worn be continued to make all areas of the home attractive for residents. Repeated recommendation. It is recommended that deep cleaning or replacement of the remaining carpets that are stained be continued to make all areas of the home attractive for residents. Repeated recommendation. It is recommended that a copy of the inspection reports completed by CSCI be made available to relatives and visitors to the home. • • • • 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. 7a Taylor Road DS0000027528.V250134.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 7a Taylor Road DS0000027528.V250134.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 and staff 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. She said residents, their family or friends sometimes visited the home, that she often visited residents in their own environment and that residents were admitted on a one-month trial basis. No resident had been recently 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. Also 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. 7a Taylor Road DS0000027528.V250134.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): Residents are consulted and the information held in the individual plans of care ensures that the personal and health care needs of residents are identified and met. EVIDENCE: Residents were seen to be well looked after. Examination of four care plans revealed that they were improved. They contained personal health and social care information, daily report, exceptional report, food chart, nutrition, support plan, routine, needs assessment, professional guidelines, involvement with other professionals, medical appointments, weight records, key worker meetings, personalised support and risk assessments, reviews, personal, social and leisure activities and a photograph of the resident. Records demonstrated that residents were consulted on their daily activities, given choice, supported to take risks, were protected and that their confidentiality was maintained by the individual and safe storage of their information. 7a Taylor Road DS0000027528.V250134.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 14, 15, 16, 17 Meals and social activities, which have improved, are both planned and provide daily variation and interest for the people living in the home. EVIDENCE: Residents have access to improved daily In-house and community leisure activities and records were seen to demonstrate that residents attend a local day centre, take part in-house activities such as craft, music, cookery and enjoy outings such as horse riding, shopping, going for walks, attend community events such as the theatre and are taken on holiday by staff members. The staff gave examples of how they work with residents to support them in their personal development, behavioural management and in maintaining friendships and relationships by working with other professionals. They encourage each resident to be independent and to make choices whilst ensuring that the rights of each resident were promoted and protected. 7a Taylor Road DS0000027528.V250134.R01.S.doc Version 5.0 Page 11 Staff said that the menus were agreed with residents, twice a week, before the shopping was carried out and records showed that the meals were varied and balanced and food hygiene certificates held by staff members. 7a Taylor Road DS0000027528.V250134.R01.S.doc Version 5.0 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 the following standard(s): 18, 20, 21 Personal support is given to residents in the way they prefer, their needs are met but they are not fully protected by the homes medication procedures. EVIDENCE: Residents were assisted with decision-making and the five staff spoken to said that they assisted the six residents with limited communication skills by understanding their response to questions and preferred manner of communication, using simple sign language, pictures and observation. The plans of care did not all contain the arrangements at death for each resident and a requirement was made that this information be held for each resident to demonstrate that they were consulted and their wishes known. The manager said that she was gradually working with each resident and staff members to agree and arrange a funeral plan for each resident. The four individual person centred plans examined contained past information on challenging behaviour reports, personalised risk assessments and the management of challenging behaviour, aftercare, personal 1st person accounts of lifestyle plan, choices, preferences, interests, worst day prompts, routines, communication needs, health care instructions and reviews which demonstrated the involvement, consultation and agreement of each resident, staff and other professionals on their plan of care. 7a Taylor Road DS0000027528.V250134.R01.S.doc Version 5.0 Page 13 Records demonstrated that staff had undertaken training in medication administration, medication was stored correctly, policies and procedures were held but had not been fully complied with on three occasions when medication administered had not been signed for or a code used. A requirement was made that all medication administration records be completed to protect residents. 7a Taylor Road DS0000027528.V250134.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 about the service they provide but one anonymous complaint containing ten areas of concern was received by CSCI. It was alleged that the behaviour of two residents was abusive and often verbally and physically aggressive towards one resident and at times staff members. This complaint was upheld in five elements, partially upheld in one element, unresolved due to lack of evidence in two elements and not upheld in two elements, and resulted in nine requirements being made. Records seen demonstrated that the manager and staff took appropriate action upon notification of the complaint, sought advice from healthcare professionals, moved the resident at risk of being abused to another unit, undertook additional staff training in the management of challenging behaviour and the protection of vulnerable adults and improved the records held to help staff recognise, prevent and deal with any potential abuse. 7a Taylor Road DS0000027528.V250134.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, 28, 29, 30 The standard of the environment within this home is mainly good providing residents with an attractive, safe and homely place to live, however some areas require attention. EVIDENCE: The home is purpose built and a tour of the building revealed that the home had a bright, homely environment and that residents benefit from an environment that was clean, odour free, well decorated in most areas and furnished and maintained to a good standard. The walls in some rooms are showing signs of wear and required redecoration and some of the carpets in the hallways and dining areas are in need of cleaning or replacing. The home is in the process of doing this work and has completed the redecoration and re-carpeting of one unit. Two recommendations were repeated that this work is completed in the second unit of the home to ensure that all areas of the home are maintained to a good standard. The home has sufficient and suitable adapted toilet, bathing and washing facilities and equipment and residents had personalised their bedrooms. All infection control measures were in place and the laundry room contained a 7a Taylor Road DS0000027528.V250134.R01.S.doc Version 5.0 Page 16 service washing machine, tumble dryer and sluicing facilities to aid in the protection of the health and safety of all residents and staff. 7a Taylor Road DS0000027528.V250134.R01.S.doc Version 5.0 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 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, the procedure for the recruitment and training of staff were robust and provide adequate safeguards to protect people living at the home. EVIDENCE: Residents were seen to be well supported and the staff spoken to said that there were enough staff on duty to meet the needs of each resident and that staff morale had improved since the introduction of an additional member of staff to provide 1.1 care for a resident with high dependency. The five staff members spoken to said that they were supported by the manager, deputy manager, handover, staff meetings and increased 1.1 supervision and demonstrated that they were aware of their role and responsibilities. Records showed that residents were fully protected because all staff recruitment checks had been carried out and CRB checks, references, personal details and proof of identity of each staff member were held in each staff file. However there was not a photograph of staff members and a requirement was made that one be held in the file of each staff member to support proof of identity. 7a Taylor Road DS0000027528.V250134.R01.S.doc Version 5.0 Page 18 Records demonstrated that staff members had a mix of experience and skills, four staff had completed and four were in the process of completing NVQ2 training. Certificates showed that induction, foundation and updated training programs were undertaken by all staff. Additional staff training in the management of challenging behaviour and the prevention and protection of abuse of vulnerable adults had recently taken place to ensure that residents were fully protected and to enable staff to gain the knowledge necessary for the range of needs of residents living at the home. 7a Taylor Road DS0000027528.V250134.R01.S.doc Version 5.0 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 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, 39, 40, 41, 42, 43 The manager is supported by the senior staff member, in providing leadership, guidance and direction to staff to ensure that residents receive a good standard of care and support. EVIDENCE: Residents and staff members said that the home was well run; the manager approachable and records demonstrated that residents are protected by the management and administration procedures carried out in the home. The manager is a qualified nurse, who has past experience of working with those with a learning disability and complex needs, has been in post for five years and has completed training in management, health and social care and the NVQ4 Registered Manager award. Policies and procedures have been produced and were seen on all aspects of the home and service provided. The records held were found to promote and protect the rights and best interests of each service user. 7a Taylor Road DS0000027528.V250134.R01.S.doc Version 5.0 Page 20 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. A Quality Assurance system is in the process of being produced that the manager said 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. The handover, staff meeting minutes and communication records seen demonstrated that staff members worked as a team and were supported and regularly supervised by the manager or deputy manager to ensure that their knowledge of the needs of each resident, their work practice, commitment and training needs were identified, clarified and reviewed. 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. 7a Taylor Road DS0000027528.V250134.R01.S.doc Version 5.0 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 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 3 X 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 3 x 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 X 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 7a Taylor Road Score 3 X 2 2 Standard No 37 38 39 40 41 42 43 Score 3 x 2 3 3 3 3 DS0000027528.V250134.R01.S.doc Version 5.0 Page 22 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13.2 Requirement The registered person must ensure that medication administration records are completed. The registered person must ensure that each staff file contains a photograph of the staff member. The registered person must ensure that an effective Quality Assurance system is in place. Timescale for action 01/12/05 2. YA34 19.1.a.b schedule 2 24.1-3 31/12/05 3. YA39 31/03/06 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 YA21 Good Practice Recommendations It is recommended that the remainder of residents have their arrangements at death recorded in their plan of care to ensure that they are consulted and that the wishes of all residents are known. It is recommended that the redecoration of the remaining walls where the decoration is worn be continued to make all areas of the home attractive for residents. Repeated recommendation. DS0000027528.V250134.R01.S.doc Version 5.0 Page 23 2. YA24 7a Taylor Road 3. YA24 4. YA39 It is recommended that deep cleaning or replacement of the remaining carpets that are stained be continued to make all areas of the home attractive for residents. Repeated recommendation. It is recommended that a copy of the inspection reports completed by CSCI be made available to anyone who wished to read them. 7a Taylor Road DS0000027528.V250134.R01.S.doc Version 5.0 Page 24 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 7a Taylor Road DS0000027528.V250134.R01.S.doc Version 5.0 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. 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!