Inspection on 11/05/05 for Carrow Hill

This inspection was carried out on 11th 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

Carrow Hill 03/05/07

Carrow Hill 25/05/06

Carrow Hill 07/12/05

Carrow Hill 20/01/05

Carrow Hill 26/11/04

Carrow Hill 15/12/03

Similar services:

Chesham House

Argyll House

Dorset Lodge

Acacia House

Falcon House

Dial House Nursing Home

Cromwell Avenue (9)

Abbey Lodge

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

CARE HOME ADULTS 18-65 CARROW HILL HOSTEL 2-4 Carrow Hill Norwich Norfolk NR1 2AJ Lead Inspector Roger Andrews Announced 11 May 2005 9:30 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. CARROW HILL HOSTEL I55 S27439 Carrow Hill Hostel V217743 110505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Carrow Hill Address 2-4 Carrow Hill, Norwich, Norfolk, NR1 2AJ 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 663845 01603 663845 St Martins Housing Trust Ms Jackie Benmehedi Care Home 22 Category(ies) of MD Mental Disorder registration, with number of places CARROW HILL HOSTEL I55 S27439 Carrow Hill Hostel V217743 110505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20 January 2005 Brief Description of the Service: Carrow Hill is a registered Care home operated by the St Martins Housing Trust, a local charity working with people who have experienced homelessness often through enduring mental health problems or addiction to drugs and/or alcohol or both. The charity also runs another care home and a number of small group living units. Carrow Hill offers residential accommodation to a maximum of 22 persons. It is situated within easy walking distance of the centre of the city. The building is a former detatched period residence situated on a secluded wooded site. All the accommodation (on three floors) is in single rooms with a cluster of two or three sharing bathroom and toilet facilities. The second floor also has shared kitchen facilities which allows it to be used for service users planning to move on to more independent accommodation CARROW HILL HOSTEL I55 S27439 Carrow Hill Hostel V217743 110505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced. There were fifteen residents living at Carrow Hill when the inspection took place. Evidence was gathered from discussions with staff, residents, the manager and from looking at a variety of records. A tour of the home was also undertaken. What the service does well: What has improved since the last inspection? What they could do better: The staff need to have regular private meetings with a senior person or the manager to discuss, for example, how they can develop their skills and how care in the home can be improved. The access into the main lounge needs to be discussed with residents to see if they would prefer to stop people using it as a corridor, (as this disturbs residents who are watching the television). When there are any problems, such as flooding, the manager must tell the Commission so that the Commission can make sure any action taken protects the rights and welfare of residents. CARROW HILL HOSTEL I55 S27439 Carrow Hill Hostel V217743 110505 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. CARROW HILL HOSTEL I55 S27439 Carrow Hill Hostel V217743 110505 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 CARROW HILL HOSTEL I55 S27439 Carrow Hill Hostel V217743 110505 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 Relevant information is available for residents. The needs of residents are properly assessed. EVIDENCE: A Statement of Purpose and a Service User Guide are in place. Copies have been provided to the Commission in line with a requirement in an earlier inspection report. Four resident files were viewed at random. These contained detailed admission assessments. Where possible prospective residents will be invited for preliminary visits and/or an overnight stay, (as set out in the Statement of Purpose), though this may not be possible in some circumstances depending on the urgency of the admission. CARROW HILL HOSTEL I55 S27439 Carrow Hill Hostel V217743 110505 Stage 4.doc Version 1.30 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 standard(s) 6, 7 Care plans are useful tools created through collaboration between residents and staff. Residents have opportunities to gain independent life skills within a risk assessment framework. EVIDENCE: Each resident has a care plan. These are suitably detailed, contain risk assessments and identify goals. A resident reported that they were aware of what was in their care plan and that staff “discuss, (with me), what they are going to write”. Residents also sign their care plans. The resident also reported that their care plan was reviewed regularly. Care plans indicate the involvement of other professionals and agencies. Residents described varying degrees of independence that they are working towards. This was reflected in individual care plans. One resident described a very independent lifestyle which was in preparation for moving on to a more independent setting. This coincided with the current philosophy of the home, (as described by the manager), which was to encourage people to move on in preference to an environment where there was little change. It was felt by several staff that this was a recent improvement in the way Carrow Hill operates. CARROW HILL HOSTEL I55 S27439 Carrow Hill Hostel V217743 110505 Stage 4.doc Version 1.30 Page 10 Risk taking and risk assessments relating to harm minimisation are in place. This includes self-harm, harm from others and the environment. Residents and staff discuss and agree, for example, money management and alcohol use as part of a harm minimisation process. Such agreements will usually take place as part of the admission process and are recorded in care plans. Residents’ meetings are held. Following a recent meeting residents have asked for a fortnightly meeting. Information is securely stored, though residents reported that they can ask to see their care plan when they wish. CARROW HILL HOSTEL I55 S27439 Carrow Hill Hostel V217743 110505 Stage 4.doc Version 1.30 Page 11 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) 13, 14, 16 & 17 Residents have a flexible routine and any restrictions are agreed with staff as part of an individual programme of care. The food is good in terms of variety and quality. Residents are encouraged to take on independent living skills such as cooking and shopping. EVIDENCE: The home is situated in a quiet location, though is within easy walking distance of the city centre and a local parade of shops. Staff assist residents from time to time, e.g. with shopping trips and in sorting out benefits. Residents can participate in various pastimes and activities. One resident has been renovating an area of the garden, (which is a particular interest of his). Other activities include bowling, bingo, visits to a karaoke pub and d.v.d.’s and videos. One resident reported that she attends a work scheme and works in a charity shop during the week. CARROW HILL HOSTEL I55 S27439 Carrow Hill Hostel V217743 110505 Stage 4.doc Version 1.30 Page 12 Residents are given a key to their own bedrooms and also have a key to the front door. There are no hard and fast routines. Getting up and going to bed times are flexible. Residents can bath and/or shower as frequently as they wish. One resident reported that they had “ a shower every morning”. “House rules” regarding drinking and unacceptable behaviours are made clear to residents. Residents do their own laundry and a laundry room with washing machine and tumble dryer is provided. The food provided at Carrow Hill was commented upon favourably. The menu rotates on a four weekly basis and offers a reasonable variety of choice. Some residents participate in cooking sessions on a weekly basis. One resident reported that she creates her own menu for the week and cooks all her meals Monday to Friday. This resident receives a weekly food budget and purchases her own supplies from local shops and the nearby supermarket. There is a kitchen on the first floor for the use of residents. CARROW HILL HOSTEL I55 S27439 Carrow Hill Hostel V217743 110505 Stage 4.doc Version 1.30 Page 13 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 & 20 Personal support is discussed and agreed with residents and geared to their needs. Medication is properly stored and records are up to date. EVIDENCE: Residents are generally very able and require little or no help with personal tasks such as washing, dressing and mobility. Each resident has a designated link worker and the main emphasis is on staff encouraging and supporting residents in achieving identified lifestyle goals. Specialist support and counselling from other services, (e.g. alcohol support services), are accessed and used on a regular basis. All staff undertake the Boots training in storing and handling medication. Medication is stored in a secure cabinet. No controlled drugs were being kept when the inspection was carried out. One resident reported that she manages her own medication, but on a daily rather than weekly basis. The daily administration sheets were observed and were up to date. CARROW HILL HOSTEL I55 S27439 Carrow Hill Hostel V217743 110505 Stage 4.doc Version 1.30 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 standard(s) EVIDENCE: These standards were not inspected on this occasion. CARROW HILL HOSTEL I55 S27439 Carrow Hill Hostel V217743 110505 Stage 4.doc Version 1.30 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 standard(s) 24, 26 & 30 The home’s location allows residents to make good use of community facilities. Staff respect the privacy of residents’ bedrooms. EVIDENCE: The building is a large period house. Decoration and repair tends to be an ongoing project, though the interior of the house does have some character. The home is situated close to the city and local facilities such as shops. There is a garden that residents can help maintain if they wish. Residents have their own rooms and have locks on their doors. There is a choice of lounge areas and a large dining room which has tea and coffee making facilities available at all times for residents. Several residents allowed access to their bedrooms. These are personalised and residents can have their own televisions, music equipment and furniture if they wish. Residents reported that staff knock on bedroom doors. The main lounge has two entrances/exits and tends to be used as a corridor by residents and staff which interferes with those residents trying to watch the television. See recommendation. CARROW HILL HOSTEL I55 S27439 Carrow Hill Hostel V217743 110505 Stage 4.doc Version 1.30 Page 16 The home was free from unpleasant odours. Laundry facilities are appropriately sited. CARROW HILL HOSTEL I55 S27439 Carrow Hill Hostel V217743 110505 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34, 35 & 36 A proper recruitment process is being followed. Excellent training opportunities are being provided for staff. Formal supervision on a regular basis needs to be implemented EVIDENCE: A sample of staff files was viewed. They contained the required information such as written references and Criminal Records Bureau checks. A training profile for all staff is in place. This includes first aid, food hygiene, substance misuse, mental health and equal opportunities. These examples are not exhaustive. New staff undertake a three day induction course which is run by an external agency. This is followed up by foundation training by the same company. NVQ training is available, though equivalent courses are also available. Some staff have opted for the Diploma in Health and Social Care and Community Mental Health Training which is more geared to the needs of the residents at Carrow Hill. One member of staff who has been working at the home for the last year reported that he had attended a different training course each month since he started work. CARROW HILL HOSTEL I55 S27439 Carrow Hill Hostel V217743 110505 Stage 4.doc Version 1.30 Page 18 From discussion with the manager and staff formal supervision is not taking place at regular intervals. Formal supervision of staff should occur every two months, be in private and be documented. The manager should also receive formal supervision from her line manager. However, a good deal of day to day informal supervision is taking place. See requirement. CARROW HILL HOSTEL I55 S27439 Carrow Hill Hostel V217743 110505 Stage 4.doc Version 1.30 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 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) 39 & 42 A reasonable quality assurance process is in place. The health and safety of residents is protected by the keeping of proper records such as fire records and checks. EVIDENCE: A quality assurance statement is in place. This includes monthly visits in line with regulation 26 of the Care Homes Regulations 2001. Periodic health and safety audits are carried out. A business plan is in place and residents have opportunities to express their views. The regular supervision of staff needs to be put in place to augment the quality assurance process, (see comments in previous section). Fire records were checked and were in order. Fire drills are held. The Fire Officer visited on 23rd April 2005. Records of residents’ monies are kept. No obvious health and safety hazards were noted during the inspection. Incidents affecting the well being of residents, (such as the flooding incident earlier this CARROW HILL HOSTEL I55 S27439 Carrow Hill Hostel V217743 110505 Stage 4.doc Version 1.30 Page 20 year), must be notified to the Commission at the earliest opportunity. See requirement. CARROW HILL HOSTEL I55 S27439 Carrow Hill Hostel V217743 110505 Stage 4.doc Version 1.30 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 3 x x x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 x x x 3 Standard No 11 12 13 14 15 16 17 x x 3 3 x 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 CARROW HILL HOSTEL Score x x x x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x I55 S27439 Carrow Hill Hostel V217743 110505 Stage 4.doc Version 1.30 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 36 Regulation 18 Requirement Timescale for action 1st August 2005 2. 42 37 All staff must receive regular formal supervision in line with the guidance in the National Minimum Standards. This includes the manager of the home. The Commission must be notified Immediate of events affecting the health and and well being of residents in ongoing line with regulation 37 of the Care Home Regulations 2001 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 28 Good Practice Recommendations The manager should consult with residents to see if they wish to make changes about how the main lounge is accessed as it tends to be used as a corridor CARROW HILL HOSTEL I55 S27439 Carrow Hill Hostel V217743 110505 Stage 4.doc Version 1.30 Page 23 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 CARROW HILL HOSTEL I55 S27439 Carrow Hill Hostel V217743 110505 Stage 4.doc Version 1.30 Page 24 - 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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