Inspection on 03/05/07 for Carrow Hill

This inspection was carried out on 3rd May 2007.

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 no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Carrow Hill 25/05/06

Carrow Hill 07/12/05

Carrow Hill 11/05/05

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 2-4 Carrow Hill Norwich Norfolk NR1 2AJ Lead Inspector Mrs Marilyn Fellingham Unannounced Inspection 3rd May 2007 10:00 Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 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 Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 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. Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carrow Hill Address 2-4 Carrow Hill Norwich Norfolk NR1 2AJ 01603 632626 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) St Martins Housing Trust Mrs Jacqueline Hursey Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20) of places Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th May 2006 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 detached 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 DS0000027439.V339589.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over eleven hours. Opportunity was taken to tour the home. Five service users were spoken to and four members of staff. A senior support worker was present on the first day of the inspection and the manager being present on the second day. Six service user comment cards were received prior to the inspection. On the second inspection visit the manager was interviewing applicants for a support workers position and two service users were also taking part. What the service does well: What has improved since the last inspection? What they could do better: It is necessary for better records to be kept when administrating medicines. Continual evaluation of those persons who self medicate. Increase staffing levels to meet individual service user’s changing needs and enable the service users to engage in appropriate leisure activities. Initiate a robust system for recruitment. Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 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 Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who enter the home and significant others have adequate information to make an informed decision about admission to the home. EVIDENCE: Six case notes were examined and these confirmed good practice, they also confirmed that the service user’s needs was done over a period of time to allow the home to establish whether the needs of these sometimes complex cases can be met. The prospective service users are enabled to make a number of visits to the home. Newly admitted service users confirmed that they felt that they had been given sufficient information and time to make an informed choice before admission to the home. Case tracking also confirmed involvement from other agencies and specialist nurses. The admission records showed that the service user’s mental, physical and social health care needs were taken into consideration as well as what was needed in relation to therapeutic intervention for care. Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to lead independent lifestyles and take risks. Care plans indicate goals and support given by staff. The service users are involved as much as possible in decision making in the home. EVIDENCE: The Inspector examined six care plans; the assessment of needs and information from other agencies has been used to formulate the plans of care. These plans of care also included therapeutic intervention that was agreed to by the service users. The care plans were informative and it was noted that review of care was carried out and care altered according to the changing needs of the service users. Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 Page 10 Risk assessments were in place and service users are encouraged to take responsible risks in relation to their care and move towards more independence. Those service users spoken to indicated in their conversations with the Inspector that they were supported to take risks in their daily lives as part of their intervention for care. Meetings are held with the residents once every four weeks where they are given the opportunity to participate in decisions about the home and information is exchanged by them and the staff. Minutes were seen for these meetings and are posted on the notice board for those residents who choose not to attend the meetings. The Inspector noted that on the day of inspection two service users were being involved with the selection process for a new staff member; they informally met all the applicants and then fed back to the interviewers their assessment of the candidates. It was also noted that the service users perceptions of the candidates were listened to and taken into consideration. Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Activities could be managed much better. Meals are managed well. EVIDENCE: One service user said that they were able to visit their family and that the staff supported them to do this. A new menu has been put in place for the service users allowing them a much more varied choice of food at any given mealtime. Those service users spoken to said that they felt that the food was good and much better now they have more choice. The change of menus came about as a result from one of the meetings with the service users and a survey done by the manager in relation to menus and choice of food. Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 Page 12 The Inspector noticed that there was a bowl of fresh fruit that the service users could have at any time; the facility was also available to allow the service users to make hot drinks when they wished. Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are very well supported by staff. The health care needs of the service users are well attended to. Although generally the administration of medication is handled well, there are small improvements to be made to ensure a safe practice. EVIDENCE: All the service users spoken to felt that they were very well supported by all members of staff. One service user commented that although they had only been in the home for one month they had made progress and this was with the support of the staff. It was evident after discussion with service users and examination of care plans that a number of health care agencies were involved including social workers, an orthopaedic consultant, and specialist nurses and GPs. It was noted that on the day of inspection a specialist nurse was visiting the home also a Social Worker; a resident had also been taken to his chosen dentist. Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 Page 14 A number of service users self medicate and risk assessments were seen for this activity; however there was no evidence of evaluation of the service user’s ability to continue this practice. The Inspector observed medication being administered and it appeared to be in a safe well-controlled way, however examination of the records for administration revealed a number of discrepancies where medication had not been recorded as given or not given. It was also noted that the appropriate codes were not always used to signify the reason for non administration, this could place the service users at risk as it may not always be possible to be sure whether the service users have received their medication as prescribed. Two types of medication records were being used and different formats, this could lead to mistakes being made, as one set of records did not adequately describe how often the prescribed medication had to be given. The service users who self medicate are given their medication in separate dockets on a daily basis, this action could be described as secondary dispensing and it is recommended for best and safe practice for two members of staff to carry out this activity. Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are aware of the complaints process. Residents are protected from abuse, self harm and self neglect. EVIDENCE: The Inspector examined the records for complaints, there were none of import and the Commission has not received any. The service users are aware of the complaints procedure, they are all given a copy on admission and it can also be located on the home’s notice board. Those service users spoken to stated that they knew who to go to if they had any concerns and they also felt that they were listened to. One service user commented that most concerns were discussed at the residents meetings that seemed a good forum for this activity. Staff spoken to were very aware of all matters related to the protection of vulnerable adults and training records showed that they had received training in this area. Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is suitable to meet its clients’ needs. Windows without restrictors pose a hazard. EVIDENCE: The home was found to be clean, tidy and homely. The service users spoken to said that they were satisfied with their accommodation. The rooms were suitable for the clients who live in the home and it was noted that many had been personalised. Some rooms have been re decorated as new residents move in. It was noted by the Inspector that the first floor windows do not have restrictors in place and this can be seen as a hazard. Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a well-trained team, however consideration needs to be given to the deployment of more staff. The system for recruitment needs to be more robust. EVIDENCE: Examination of duty rosters confirmed that there is a minimum of staff on day and night duty; it is common practice to have only two support workers and the manager during the week and two support workers at the weekends. It has been recommended in the past that the deployment of staff during the week is increased to allow for the changing needs of the residents and especially when one member of staff is out with a resident. This would also give more flexibility in providing more suitable activities for the residents. Records for newly appointed staff were examined, these contained appropriate proof of staff identity and the acquisition of two references before employment: however it was noted that one recent member of staff had been employed way beyond the receipt of a CRB or POVA check. This member of staff had been employed on the 21/06/06 and the CRB check was received on Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 Page 18 in March: unfortunately the other CRB and POVA check had been destroyed so it was impossible for the Inspector to date this accurately. Staff must not be employed until the appropriate checks are in place and the documentation must not be destroyed until the appropriate checks have been made by the Inspector. The Inspector understands that the Charities personnel department is responsible for obtaining the necessary checks. The staff spoken to stated that they felt the provision of training opportunities in the home were good and the training records confirmed this. The manager confirmed that all new members of staff receive a thorough induction and was shown records to support this. Formal supervision has been initiated but does not always take place six times a year; the increase in staffing levels would in part go some way to support this activity to happen more frequently. The manager does not receive formal supervision. Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home. A more formal system needs to be introduced for monitoring the service the home provides. EVIDENCE: The inspection process, discussion with staff and service users led the Inspector to form the opinion that the home is very well run, with the manager continually striving to ensure the best for the residents. The service users and staff definitely benefit from the ethos and leadership of the manager; she also ensures good safe working practices. Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 Page 20 The staff and service users feel that they are well managed and supported and that the manager encourages an open and transparent environment. Although some activities for monitoring the services offered in the home exist they need to be more formalised and written records kept. Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 3 4 3 5 3 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 3 26 3 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 4 3 3 LIFESTYLES Standard No Score 11 3 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 3 3 3 3 3 3 Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 Page 22 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 2 Standard YA33 YA24 Regulation 18(1) 13 (a) Requirement Sufficient staff must always be on duty to ensure that the needs of the service users are met. First floor windows have restrictors fitted to ensure service users are free from hazards and safe. When medication is being administered it must be appropriately prescribed and recorded. This will ensure that people receive the correct levels of medication. No person is employed in the home until the satisfactory police check and POVA are in place. This is to ensure that the service users are protected. Timescale for action 09/06/07 09/07/07 3 YA20 13 (2) 10/05/07 4 YA34 19 (b) 09/05/07 Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 Page 23 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 YA36 Good Practice Recommendations It is recommended that the incidence of formal supervision sessions be increased to six times a year for all staff. 2 3 YA20 YA39 People who are able to manage their own medication should be risk assessed more frequently to ensure that they are still safe. Better records should be kept for the home’s quality assurance system. Carrow Hill DS0000027439.V339589.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000027439.V339589.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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