Inspection on 18/01/06 for Bishop Herbert House

This inspection was carried out on 18th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bishop Herbert House 23/11/06

Bishop Herbert House 03/05/05

Bishop Herbert House 15/11/04

Bishop Herbert House 16/06/04

Bishop Herbert House 24/02/04

Similar services:

Claremont House

Sun Court Nursing Home

Bramley Avenue (73)

15 Bramble Close

Dolphin Court

Fen Road

Wakes Hall

165 Putnoe Lane

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

CARE HOME ADULTS 18-65 Bishop Herbert House 34 Globe Place Norwich Norfolk NR2 2SG Lead Inspector Mrs Hilary Richards Unannounced Inspection 18 and 25 January 2006 11:00 th th Bishop Herbert House DS0000034848.V279513.R01.S.doc Version 5.1 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 Bishop Herbert House DS0000034848.V279513.R01.S.doc Version 5.1 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. Bishop Herbert House DS0000034848.V279513.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bishop Herbert House Address 34 Globe Place Norwich Norfolk NR2 2SG 01603 620710 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) Norfolk County Council-Community Care Mr Roy Slater Care Home 14 Category(ies) of Physical disability (14) registration, with number of places Bishop Herbert House DS0000034848.V279513.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The manager of the home is responsible for the care offered at Bishop Herbert House. The home can continue to accommodate the four service users aged over 65 years named in the home’s pre-inspection questionnaire dated 18th April 2005. The home can continue to offer respite care to the five service users aged over 65 years named in the home’s Action Plan dated 16th June 2005. The home will not offer respite care to any additional service users over 65 years of age. 3rd May 2005 Date of last inspection Brief Description of the Service: Bishop Herbert House is owned and managed by Norfolk Social Services. It provides accommodation for up to fourteen adults with a physical disability. There are currently twelve permanent places and two respite care places. The providers have informed the Commission that the Home will eventually be providing respite care only. The home is not admitting any new permanent residents. Accommodation is on the ground floor only and there is level access throughout the building. The home has recently undergone major refurbishment work that is now substantially complete. All service users in the home have en suite accommodation that is equipped and maintained to a high standard. Bishop Herbert House DS0000034848.V279513.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Unannounced Inspection that took place over two days and lasted for 4.5 hours. The focus of the Inspection was the key standards not covered in the home’s first Inspection this year and to follow up the requirements made during that Inspection. The Inspector spoke extensively with the manager and a selection of records was examined. The accommodation was not specifically assessed but the majority of the home was viewed during the course of the Inspection; the previously high standard of accommodation was noted to have been maintained. What the service does well: What has improved since the last inspection? 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. Bishop Herbert House DS0000034848.V279513.R01.S.doc Version 5.1 Page 6 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 Bishop Herbert House DS0000034848.V279513.R01.S.doc Version 5.1 Page 7 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 and 2 Prospective Service Users are given appropriate information regarding the home. Service Users’ needs are assessed prior to being admitted to the home. EVIDENCE: The home has satisfactorily addressed the requirement from the previous Inspection relating to the Service User Guide. The Guide has been amended to accurately summarise the Statement of Purpose and includes the contact details for CSCI. The sampled case file for a service user receiving respite care at the home evidenced an initial needs assessment by the social worker and an additional assessment by the home’s staff. The manager advised that all prospective service users are assessed prior to being admitted to the home. Bishop Herbert House DS0000034848.V279513.R01.S.doc Version 5.1 Page 8 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): 6 Residents have detailed and comprehensive Service User Plans that are subject of regular review. EVIDENCE: The home has satisfactorily addressed the requirement from the previous Inspection in relation to behaviour management strategies for specific residents. The case file that was sampled for a permanent resident evidenced a comprehensive and detailed Service User Plan that was subject of regular review. The Plan cross-referenced to individual risk assessments on file, including those relating to behaviour management. The case file for the respite service user that was sampled also evidenced a Service User Plan although this was, appropriately, less detailed than the Plan for the permanent resident. Bishop Herbert House DS0000034848.V279513.R01.S.doc Version 5.1 Page 9 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 assessed as part of this Inspection. EVIDENCE: Bishop Herbert House DS0000034848.V279513.R01.S.doc Version 5.1 Page 10 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): 20 Medication is stored and administered in accordance with the home’s policies and procedures. EVIDENCE: The home has a dedicated Medication Room where all medication administered by staff is held. The room contains a fridge designated solely for medication and an additional secure cabinet for controlled drugs. The Officer in Charge on each shift is responsible for dispensing medication and one of the assistant managers holds responsibility for stock control. The manager advised that the home has a supportive relationship with the local pharmacy and that this pharmacist dispenses all prescriptions for permanent residents. All medication is dispensed from Medi-Wallets where possible, including for respite residents if this can be arranged prior to admission. The manager advised that some residents self-medicate, they have been assessed as able to do so and have lockable storage in their rooms. The medication records and dispensing procedures within the home appear robust. Bishop Herbert House DS0000034848.V279513.R01.S.doc Version 5.1 Page 11 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 and 23 Service User’s are listened to and are protected from abuse, neglect and selfharm. EVIDENCE: The home has a robust Complaints Procedure in place that is contained within the Service User Guide to the home. The manager also holds Regular Residents Meetings and is available to service users and staff on a daily basis. Comments made by residents during the previous Inspection of the home this year evidenced their confidence that the manager would resolve any issue to their satisfaction. The Complaint Record evidenced that the last complaint made was by a neighbour in August 2005 regarding the music being played by a resident of the home; the complaint was resolved satisfactorily. The home has robust procedures in place with regard to adult protection and whistle-blowing; these are Norfolk County Council’s generic policies. In addition the home has a specific policy relating to the privacy. dignity and selfdetermination of residents at the home; the content and ethos of this document is to be commended. The manager advised that he has attended specific Adult Protection training and this knowledge is cascaded to his staff team via individual supervision and Team Meetings. Bishop Herbert House DS0000034848.V279513.R01.S.doc Version 5.1 Page 12 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): Service User’s live in a homely, comfortable and safe environment. EVIDENCE: The home has satisfactorily addressed two of the three requirements made in relation to accommodation following the previous Inspection. Residents in the home no longer wedge their fire doors open to assist access; all bedroom doors now have appropriate DoorGuards that are linked to the home’s fire alarm system therefore residents can safely chose whether or not to have their doors open or closed. The third requirement relating to the poor design of one of the home’s fire exits has yet to be addressed although Norfolk County Council have agreed the expenditure and the work is currently out to tender. Bishop Herbert House DS0000034848.V279513.R01.S.doc Version 5.1 Page 13 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): 33, 34, 35 and 36 Service Users are supported by sufficient competent, trained staff who receive appropriate supervision from the management team within the home. The home’s recruitment practice is not fully satisfactory. EVIDENCE: The home has satisfactorily addressed two of the three requirements relating to Staffing from the previous Inspection and partially addressed the remaining outstanding requirement relating to recruitment. Records within the home evidence that the home is adequately staffed at all times and that specific residents receive one to one staff support as identified in their Needs Assessment and Service User Plan. The three staff files that were sampled evidenced that individuals receive regular supervision, at a minimum of six times per year. Files also evidenced Annual Appraisals and records of staff training. All staff have undertaken relevant training to their role and records evidence that refresher courses are undertaken when required. The overall training record for the home evidenced that over 50 of the staff team hold NVQ Level 2 or 3 in Care or an equivalent academic qualification. The staff recruitment files have been notably improved since the previous Inspection and all documents are now filed in appropriate sections and easily Bishop Herbert House DS0000034848.V279513.R01.S.doc Version 5.1 Page 14 retrieved. The three sampled files evidenced all the requirements of Schedule 2 of the Care Homes Regulations 2001 with the exception of proof of identity. Bishop Herbert House DS0000034848.V279513.R01.S.doc Version 5.1 Page 15 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 The health, safety and welfare of service users are promoted and protected. EVIDENCE: Staff training records evidence that all staff receive relevant training in safe working practices and that refresher training is provided when required. Health and Safety Records evidence that all equipment within the home is serviced as required and the weekly inspection record evidenced that problems are quickly identified and reported. The home holds appropriate COSHH assessments and product information and regular water testing is undertaken in relation to the control of Legionella. The staff team receive regular training from both Norfolk Fire Service and inhouse training. The records of Fire Drills evidenced that the last drill took place in March 2005. Bishop Herbert House DS0000034848.V279513.R01.S.doc Version 5.1 Page 16 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 3 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 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X X X X X X 3 X Bishop Herbert House DS0000034848.V279513.R01.S.doc Version 5.1 Page 17 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 YA24 Regulation 23 Requirement Timescale for action 01/04/06 2. YA34 19 The Registered Provider must ensure that the fire exits from the home can be used by residents without assistance if able to do so. (Previous timescale of 01/12/05 not met) The Registered Provider must 01/04/06 ensure that the information listed in Schedule 2 is kept for all members of staff in the home. (Previous timescales of 31.12.04 and 01/08/05 not met) 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 YA42 Good Practice Recommendations It is recommended that the home seek advice from Norfolk Fire Service regarding the appropriate time interval between fire drills. Bishop Herbert House DS0000034848.V279513.R01.S.doc Version 5.1 Page 18 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 Bishop Herbert House DS0000034848.V279513.R01.S.doc Version 5.1 Page 19 - 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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