Inspection on 03/05/05 for Bishop Herbert House

This inspection was carried out on 3rd May 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Bishop Herbert House 23/11/06

Bishop Herbert House 18/01/06

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 Hilary Richards Announced 3 May 2005 9.00am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bishop Herbert House I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bishop Herbert House Address 34 Globe Place, Norwich, Norfolk, NRR2 2SG Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01603 620710 01603 623654 bhh@btinternet.com Norfolk County Council - Community Care Roy Slater Care Home 14 Category(ies) of Physical disability (14) registration, with number of places Bishop Herbert House I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home can accommodate 14 Service Users who have a Physical Disability. 2. The home provides respite care to four existing service users, named to CSCI, who are aged over 65 years old. 3. The home accomodates four permanent residents, named to CSCI, who are aged over 65 years old. Date of last inspection 15 November 2004 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 ensuite accommodation that is equiped and maintained to a high standard. Bishop Herbert House I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an Announced Inspection that took place over 7 hours; two Inspectors were present in the home throughout. The Inspectors interviewed the Manager and two members of care staff and also spoke in depth to two residents. A number of other residents were spoken to informally during the day. The Manager showed the Inspectors around the home, one resident chose to be present when her room was seen and another resident did not wish his room to be inspected; his views were respected. A number of records maintained in the home were also examined. What the service does well: What has improved since the last inspection? What they could do better: The protracted Staffing Review needs to be completed in order for permanent staff positions to be confirmed and the manager is able to dedicate his time to managerial tasks. The recruitment records within the home must be improved and an accurate duty roster needs to be kept; additional detail is also required in some Service Users Plans. There are two accommodation issues that require addressing in order to fully meet the needs of residents within the home. Bishop Herbert House I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 Page 6 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 I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Bishop Herbert House I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3 and 4 The home’s Statement of Purpose provides clear information to prospective service users in order to make an informed choice regarding their care. Service users needs are assessed and met on a day-to-day basis. EVIDENCE: The home’s Statement of Purpose has recently been updated to reflect the change in management and the altered purpose of the home. The home currently has 12 permanent residents and two additional rooms that are used to offer respite care. The home will not admit any new permanent residents and is intending, over time, to become a dedicated respite care facility. The Service Users Guide has not been updated to reflect these changes. At the time of this Inspection the home was offering respite care to two previously unknown service users; the twelve permanent residents in the home have been in placement for a number of years. The case files for both new service users evidenced a full assessment of their known needs; the assessment for one service user was ongoing within the home to inform his longer term care needs. Bishop Herbert House I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 Page 9 The staff team evidenced their ability to meet the assessed needs of the residents in the home via discussion with service users, discussion with staff, direct observation and recording on case files. Residents are provided with specialist services to meet their physical disabilities and dedicated facilitators assist those residents with communication difficulties on a 1:1 basis. Bishop Herbert House I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 and 9 Service Users are fully consulted regarding the operation of the home and the staff team support their individual goals and aspirations. The Service User Plans and case records for some residents are not sufficiently detailed. EVIDENCE: The case files that were sampled evidenced detailed Service User Plans for the majority of residents; the Service User Plan for one resident required further detail regarding the management of their aggressive behaviour. The records for those residents receiving respite care and/or a period of assessment should record all significant issues to inform future care planning. Residents of the home advised that they are provided with appropriate advice and assistance in order to make decisions regarding their own lives; this was evidenced throughout the Inspection. The Service User Plan for one resident evidenced that the imposed limitations on his mobility had been agreed with him and were in the best interests of all the residents within the home. The home holds regular residents meetings that are well attended; the minutes of such meetings reflect the resident’s contribution to how the home is run on a day-to-day basis. The individuals that were spoken to stated that they felt fully consulted regarding the running of the home. Bishop Herbert House I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 Page 11 Residents are encouraged and supported to take risks as part of an independent lifestyle as evidenced during discussion with both staff and residents. A number of individual residents made specific comment regarding how the location and operation of the home actively promotes their independence. Bishop Herbert House I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14, 15, 16 and 17 The home actively promotes an independent lifestyle for all residents, based on their individual needs and interests. The operation and management of the home promotes positive relationships with the local community and the families of those using the service. EVIDENCE: As stated previously, residents clearly articulated that their social and leisure needs are supported by and encouraged by the staff team in the home. The routine of the home encourages freedom of choice, as evidenced by the welcoming attitude to families and friends and the individual choices made regarding participation, or not, in mealtimes and other social activities. Resident’s rooms are not entered without their permission and the manager of the home specifically asked each person whether their accommodation could be seen as part of the Inspection. Staff were observed to knock before entering any room and the resident’s mail is delivered, unopened to their room – see “Premises” for additional comment. Bishop Herbert House I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 Page 13 Residents made numerous positive comments regarding the meals provided within the home; individuals can exercise personal choice as to when they have their main meal and where they chose to eat. The catering staff will provide alternative meals on request should residents prefer an alternative choice to the meal on the menu. The home provides a range of snacks and drinks for residents that are freely available throughout the day and evening. Bishop Herbert House I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 20 Staff provide personal support and sensitive care that maximises resident’s privacy, dignity and independence. Residents who self administer medication are not subject of a risk assessment. EVIDENCE: The Service User Plans detail resident’s preferences regarding their daily routine and their individual preferences although the language used in some plans was ambiguous. Service User Plans evidence that the home offers flexible care that meets the specific needs of individuals. Individual residents confirmed that personal care is sensitively provided and service users can usually work with staff of their choice – see “Staffing” for further comment. The home is fully equipped with appropriate technical aids and equipment to meet the needs of the residents as evidenced by discussion with staff and residents and by observation throughout the Inspection. The Inspection did not fully assess the home’s ability to meet the outcome for Standard 20 although this standard was partially assessed. The case records for one resident evidenced a conflict regarding her ability to hold and administer her own medication. This conflict had not been resolved and there was no evidence on file to indicate whether her self-medication was subject of a risk assessment. Bishop Herbert House I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standards 22 and 23 were not assessed as part of this Inspection. EVIDENCE: Bishop Herbert House I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 29 and 30 The home provides a well equipped and maintained environment that has recently been refurbished to a high standard. Further adaptations are required to fully meet the needs of all residents and promote their independence. EVIDENCE: Bishop Herbert House has been subject of an extensive refurbishment programme that is now substantially complete. All residents have en suite facilities and individual rooms have been redecorated and furnished according to the wishes and needs of each resident. All the residents that were spoken to were very pleased with the improvements to their accommodation. The home has a number of separate dining rooms and lounges that provide a variety of communal spaces for use by residents. The refurbishment has included the provision of an enclosed courtyard and pond which provides an additional pleasant space for use by residents and their visitors. The home has appropriate facilities for managing laundry, soiled linen is laundered by an external laundry service and resident’s clothes are laundered on the premises. The home was noted to be clean and free from any offensive odour during the course of the Inspection. Bishop Herbert House I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 Page 17 The bedroom doors for those residents who use wheelchairs are too heavy to be opened by hand by someone in a wheelchair; residents have resorted to propping these doors open to allow freedom of access without having to ask for staff assistance. A number of bedroom doors have been fitted with electronic keypads that automatically open the door and then close on a timer but these are not standard for each bedroom. The second fire escape for the home exits onto a corrugated concrete platform with steps that lead to the ground level. The residents of the home who use wheelchairs would be unable to proceed further than the concrete platform without assistance; this is inappropriate. Bishop Herbert House I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34 and 36 The home does not have a robust system in place for the recruitment and supervision of staff. The home was adequately staffed on the day of the Inspection but a judgement could not be made regarding staffing levels in general due to inadequate records. EVIDENCE: On the day of the Inspection there were sufficient staff on duty to meet the needs of the residents in the home, including 1:1 facilitators for individuals where necessary. The Inspectors were advised of the shift pattern for the home but the rosters available within the home did not evidence the rosters as described. Staff and residents advised that there were always sufficient staff on duty although some concern was expressed regarding the level of agency staff that are used. This issue could not be investigated in depth as the rosters do not clearly evidence when agency staff have been used. Bishop Herbert House I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 Page 19 The personnel records for three members of staff were inspected; the files evidenced that the requirements of Schedule 2 have not been met in every case. The files also evidenced that not all staff are receiving individual supervision 6 times per year as required – see “Management” for additional comment. The members of staff that were spoken stated that they felt fully supported by the management team in the home and informal supervision is always available if required. Bishop Herbert House I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38 and 39 The home is well managed by a competent and enthusiastic manager who ensures that the welfare of residents underpins all care practice within the establishment. EVIDENCE: The acting manager successfully completed the Fit Person Process with CSCI on 21 March 2005 and is now the Registered Manager for the home. The feedback from staff and residents regarding the management of the home was overwhelmingly positive; numerous comments were made regarding the manager’s open and positive manner and his inclusive style of management. The manager has strategies in place via resident/staff meetings and regular newsletters to ensure that all stakeholders can voice their opinion regarding the service. Bishop Herbert House I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 Page 21 The staff team at the home are currently experiencing a period of uncertainty due to an ongoing Staffing Review; this has been in process for a protracted period of time. A consequence of this review is that some vacant positions have not been permanently filled and a number of staff are in “acting” positions. The manager of the home has subsequently covered some shifts on the roster to provide continuity of care to residents and is also covering for a member of the management team who is on sick leave. The manager is to be commended for placing the needs of residents foremost but this is impacting on his ability to fully meet some managerial tasks e.g. staff supervision. The home has in place a quality monitoring system for seeking the views of residents, as evidenced during the Inspection. The feedback from this survey should contribute to the home’s annual development plan. Bishop Herbert House I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 Page 22 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 2 3 3 3 x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 4 4 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 4 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 4 4 4 3 4 Standard No 31 32 33 34 35 36 Score x x 2 1 x 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bishop Herbert House Score 3 x 2 x Standard No 37 38 39 40 41 42 43 Score 3 4 3 x x x x I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 Page 23 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 1 Regulation 5 Requirement The Registered Provider must update the Service Users Guide to accurately summarise the Statement of Purpose and include the contact details for the Commision. The Registered Provider must ensure that Service User Plans detail how aggressive and challenging behaviour is managed. The Registered Provider must ensure that Fire Doors within the home are not wedged open. The Registered Provider must ensure that residents are able to access their bedrooms without staff assistance if able to do so. Residents should be able to have their bedroom doors open if they so chose. The Registered Provider must ensure that the fire exits from the home can be used by residents without assistance if able to do so. The Registered Provider must ensure that an accurate copy of the duty roster worked is kept in the home. The Registered Provider must I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Timescale for action 01.08.05 2. 6 15 01.07.05 3. 4. 24 24 23 23 Immediate Effect 01.12.05 5. 24 23 01.12.05 6. 33 17 Immediate Effect 01.08.05 Page 24 7. 34 19 Bishop Herbert House Version 1.30 8. 36 18 ensure that the information listed in Schedule 2 is kept for all members of staff in the home. (Previous timescale of 31.12.04 not met) The Registered Provider must 01.08.05 ensure that staff receive individual supervision six times per year. 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. 2. 3. 4. 5. Refer to Standard 1 6 18 20 39 Good Practice Recommendations It is recommended that the service users views of the home are incorporated in the Statement of Purpose. It is recommended that the case records for new service users or those being assessed detail all significant issues that arise during their stay in the home. It is recommended that the language that is used in Service User Plans is clear and unambiguous. It is recommended that residents who self administer medication should be subject of a risk assessment. It is recommended that the results of the residents survey inform the annual development plan for the home. Bishop Herbert House I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection 3rd Floor Cavell House St Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bishop Herbert House I55 S34848 Bishop Herbert House V217223 030505 Stage 4.doc Version 1.30 Page 26 - 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. 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