CARE HOME ADULTS 18-65
82 Normandy Street Alton Hampshire GU34 IDH Lead Inspector
Annie Billings Unannounced Inspection 15th December 2005 11:30 82 Normandy Street DS0000011566.V272699.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 82 Normandy Street DS0000011566.V272699.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. 82 Normandy Street DS0000011566.V272699.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service 82 Normandy Street Address Alton Hampshire GU34 IDH 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) 01420 549002 www.together-uk.org Together Working for Wellbeing Elveta MacCready Care Home 6 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (6) of places 82 Normandy Street DS0000011566.V272699.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 14th April 2005 Brief Description of the Service: 82 Normandy Street is a three storey semi-detached building in a residential area of Alton. The town of Alton is nearby, and the property is on a main bus route through the town. The service is managed by Mrs Elveta MacCready. The home provides a comfortable, homely environment for six younger adults with mental health issues. Individual accommodation is arranged over two floors, each with a communal bathroom. Other communal areas include a comfortable sitting room, designated as a smoking area, dining room, kitchen and laundry facilities with a well-maintained garden and small car park at the rear of the premises. The property also has an attic room, which currently is inaccessible to service users, 82 Normandy Street DS0000011566.V272699.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 3.5 hours and was the second inspection of the year April 2005 to March 2006. Many of the core standards were inspected during the previous visit on the 14th April 2005, therefore referral to both reports will give a full overview of the service. A partial tour of the communal areas took place and care and other records were inspected. Additional information was also supplied within a preinspection questionnaire. Discussions were held with four residents and two members of staff, and comment cards were received from all six residents. What the service does well: What has improved since the last inspection?
Since the last inspection the decoration programme has continued, with three bedrooms re-decorated, two with new carpets, and a new sofa provided in the dining room, for residents not wishing to use the smoking lounge. The promotion of independence continues to be actively supported, with several two residents becoming self-catering or others partially self-catering. In response to an issue raised at the last inspection, a standard letter has been developed for signature by consultants, to ensure the home has written instructions in the event of changes in medication. 82 Normandy Street DS0000011566.V272699.R01.S.doc Version 5.0 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. 82 Normandy Street DS0000011566.V272699.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 82 Normandy Street DS0000011566.V272699.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): These standards were not inspected. EVIDENCE: 82 Normandy Street DS0000011566.V272699.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): These standards were not inspected. EVIDENCE: 82 Normandy Street DS0000011566.V272699.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): These standards were not inspected. EVIDENCE: 82 Normandy Street DS0000011566.V272699.R01.S.doc Version 5.0 Page 11 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): These standards were not inspected. EVIDENCE: 82 Normandy Street DS0000011566.V272699.R01.S.doc Version 5.0 Page 12 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): These standards were not inspected. EVIDENCE: 82 Normandy Street DS0000011566.V272699.R01.S.doc Version 5.0 Page 13 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): These standards were not inspected. EVIDENCE: 82 Normandy Street DS0000011566.V272699.R01.S.doc Version 5.0 Page 14 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, 34, 35 Residents are well supported by a competent and skilled workforce, who have been employed following a robust recruitment process to ensure the residents’ safety. EVIDENCE: Comment cards received from residents confirmed that they all like living at the home, that staff treat them well and they feel well cared for. Residents spoken to on the day confirmed this, and said they get on well with the staff, who support them well. The home benefits from a stable core staff team. Staff spoken with confirmed they work well as a team, and feel well supervised and supported in their work. Training records confirmed that five of the six permanent staff have achieved National Vocational Qualification level 2 or above, and that five relief staff used on a regular basis have the necessary skills to meet the needs of residents. Three recruitment files were sampled. These confirmed that appropriate preemployment checks were undertaken, prior to employment, including a criminal records bureau check. The manager advised that an activities volunteer is also undergoing the same checks, prior to working with the residents.
82 Normandy Street DS0000011566.V272699.R01.S.doc Version 5.0 Page 15 Evidence was seen to support that regular training is available to staff, both to support individual’s needs and to develop staff skills and knowledge. Staff members spoken with confirmed this, and also advised that the same training is offered to residents if an interest is shown. An example was given of two of the current residents have undertaken training in food hygiene. Recent training undertaken has included moving and handling updates, control of substances hazardous to health, self-injury, food hygiene and medication refresher. Two staff were identified as needing refresher training in food hygiene, as certificates were dated 2002. The manager agreed to organise this promptly. To further develop staff skills, two members of staff moved temporarily to other services, to gain new experiences and ensure current best practice is shared between services. 82 Normandy Street DS0000011566.V272699.R01.S.doc Version 5.0 Page 16 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): 42 Systems are in place to ensure that residents’ health, safety and welfare are promoted. EVIDENCE: The home is managed very much for the residents, in full consultation with the residents. Meetings of residents meetings support this. Maintenance certificates were sampled and found to be current. Testing of fire safety equipment and staff training are undertaken regularly, with health and safety audits on a monthly basis, to ensure the premises remain safe and hazard free. The premises risk assessment was updated on the 3rd September 2005, and is reviewed annually. Weekly maintenance checks and daily cleaning checklists ensure the home remains clean and hygienic. All the residents confirmed they feel safe in the home and well cared for. Two of the residents have progressed to being fully self-catering, and the other four now partially self-catering, with staff accompanying them to do shopping to 82 Normandy Street DS0000011566.V272699.R01.S.doc Version 5.0 Page 17 ensure their diet remains nutritious. The manager said this was working well so far, and detailed risk assessments and monitoring records were seen. Food stores were sampled and found to be in good order. An award, following a recent environmental health inspection, has again acknowledged the high standard of food hygiene. 82 Normandy Street DS0000011566.V272699.R01.S.doc Version 5.0 Page 18 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 X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
82 Normandy Street Score X X X X Standard No 37 38 39 40 41 42 43 Score X X X X X 3 X DS0000011566.V272699.R01.S.doc Version 5.0 Page 19 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 82 Normandy Street DS0000011566.V272699.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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