Inspection on 07/12/05 for Carrow Hill

This inspection was carried out on 7th December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Carrow Hill 03/05/07

Carrow Hill 25/05/06

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 Mr Roger Andrews Unannounced Inspection 7th December 2005 03:00 Carrow Hill DS0000027439.V272865.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Carrow Hill DS0000027439.V272865.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Carrow Hill DS0000027439.V272865.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Carrow Hill Address 2-4 Carrow Hill Norwich Norfolk NR1 2AJ 01603 632626 01603 663845 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.V272865.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th May 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 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.V272865.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. The inspection looked at things that were mentioned in the last inspection report and some other standards that were not covered on that visit. Some of the residents were chatted with informally and a new member of staff was talked with in private. The comments below refer to what was seen on this occasion. For more information please read the last inspection report. However, the Commission thinks that Carrow House offers a supportive place to live to people who need help with specific problems such as homelessness and alcohol related problems. What the service does well: What has improved since the last inspection? What they could do better: A number of recommendations have been made. One is to check that, at certain times, sufficient staff are available to support residents and deal with any difficult situations Some inside areas need painting and this could also be an opportunity to look at colour schemes that will help liven up some areas for the residents. The toilet and bathroom arrangements for staff need to be looked at so that staff that sleep in have better access and don’t have to go through the residents’ areas. The office is very small and makes it difficult for the manager to see people privately, (such as social workers or visitors), or get on with her work without being interrupted on a regular basis. Carrow Hill DS0000027439.V272865.R01.S.doc Version 5.0 Page 6 The manager needs to complete the NVQ 4 in ‘care’ element in order to meet the qualification set out in the National Minimum Standards document. The manager needs to make sure that fire tests are carried out every week so that residents are protected. 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 DS0000027439.V272865.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Carrow Hill DS0000027439.V272865.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. EVIDENCE: Carrow Hill DS0000027439.V272865.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. EVIDENCE: Carrow Hill DS0000027439.V272865.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15 & 17 Residents are assisted and supported by staff. Residents can maintain family and other relationships. There is a varied menu and residents like the food. EVIDENCE: A relatively new member of staff was talked with and she described the ways in which the staff assist residents. This includes help with housing applications, benefits, going out and supporting residents with their alcohol management plans. Where possible, residents are helped with independent living skills and one resident has moved on to more independent accommodation. Residents are fully able to maintain links with their friends and family. One resident was visited by his son during the course of the inspection. The residents have constant access to hot and cold drink making facilities in the dining room. The residents spoken to said they liked the food and a ‘food comments’ book is located in the dining room for people to give their views. Carrow Hill DS0000027439.V272865.R01.S.doc Version 5.0 Page 11 The comments observed reflect a good level of satisfaction with the food served and a good variety of meals on offer. Carrow Hill DS0000027439.V272865.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. EVIDENCE: Carrow Hill DS0000027439.V272865.R01.S.doc Version 5.0 Page 13 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 & 23 Complaints are dealt with appropriately and adult protection processes are in place. EVIDENCE: Residents have a complaints procedure. There are also periodic residents’ meetings where they can put their views forward. The Commission has not received any complaints since the previous inspection took place. The manager reported that one written complaint had been received from a resident. Discussion took place about the nature of the complaint and how it was dealt with. The manager is aware of the adult protection procedure and the process of referral to appropriate agencies such as police and social services. The organisation provides training for staff on adult protection issues. A member of staff confirmed that she had received training on this topic. Carrow Hill DS0000027439.V272865.R01.S.doc Version 5.0 Page 14 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): 24 & 30 The building has character, but could benefit from some internal redecoration. The staff sleep-in facilities and the manager’s office space could be improved. EVIDENCE: The driveway of the house has just been resurfaced, making a vast improvement of the previous surface. The house, being an old building, has some character. The communal facilities are mainly on the ground floor, though there is a small lounge and kitchen upstairs. There is some redecoration going on, but a number of areas require decorative attention as paintwork has become scuffed. The colour scheme could also be reconsidered. A mix of colours might well give a more attractive visual appearance in areas where large expanses of wall have only one colour scheme. See recommendation. It was noted that the staff bedroom does not have its own en-suite facility. The member of staff has to pass through a resident lounge and kitchen to access a toilet or bathroom facility on the first floor. This is not ideal for the staff and also impacts on the residents’ space. Consideration should be given to ways in which this situation could be improved. See recommendation. Carrow Hill DS0000027439.V272865.R01.S.doc Version 5.0 Page 15 It was also noted that the manager has a very small office which is also in regular use by other staff to access records, money and other necessary items. This gives the manager very little privacy to have private conversations and carry on with work uninterrupted for any length of time. See recommendation. No obvious safety hazards were noted. The manager has addressed an external hazard relating to some steps and she wrote to the Commission to say what action had been taken in this respect. The premises appeared clean and tidy. Carrow Hill DS0000027439.V272865.R01.S.doc Version 5.0 Page 16 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 & 36 Staffing levels at particulars times needs to be considered based on the needs of the resident group accommodated and the ability of staff to respond to challenging situations. Formal supervision is now underway. EVIDENCE: There are a minimum of two staff on duty during the day and night. During the week the manager will also be present. Two staff should be viewed as a minimum and ideally three staff should be considered, especially at times when one member of staff is out with a resident as this leaves just one member of staff with potentially a high number of residents. The contingency to have additional staffing should also be present when specific residents are likely to pose challenging behaviours for staff to deal with. See recommendation. A member of staff described the induction training she had undertaken following her appointment. This including several shifts shadowing existing staff. The member of staff confirmed that she had received supervision and was shortly due to have another formal session. Supervision is taking place on a six to eight weekly basis. As a new member of staff she felt there was a good level of communication within the staff team. Carrow Hill DS0000027439.V272865.R01.S.doc Version 5.0 Page 17 Carrow Hill DS0000027439.V272865.R01.S.doc Version 5.0 Page 18 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): 37 & 42 The manager needs to complete the care component of NVQ 4. A system is needed to ensure essential records are kept up to date. EVIDENCE: The manager has a professional qualification that meets the management requirements of NVQ 4 and requires to undertake the care component of this qualification to meet the standard. See recommendation. The fire records were checked. Weekly tests are being carried out in most instances, though there are some occasions where this has not happened such as in August and September when on two tests were carried out each month. The manager has reminded staff about doing these and a sign has been put up in the office. See requirement. Carrow Hill DS0000027439.V272865.R01.S.doc Version 5.0 Page 19 Since the previous inspection the manager has been notifying the Commission of any incidents that occur in the home. This satisfies a requirement made in that report. Carrow Hill DS0000027439.V272865.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 X X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Carrow Hill Score X X X X Standard No 37 38 39 40 41 42 43 Score 2 X X X X 2 X DS0000027439.V272865.R01.S.doc Version 5.0 Page 21 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA42 Regulation 23 Requirement Fire tests must be carried out and documented on a weekly basis. Timescale for action 07/12/05 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 YA24 Good Practice Recommendations It is recommended that the interior of the home be redecorated and that consideration is given to the colour scheme. It is recommended that changes be made to the staff sleep-in facilities to improve their access to toilet and bathroom facilities. It is recommended that the manager be provided with more appropriate facilities to carry out her role and enable a place where she can have private conversations with staff and visiting professionals. It is recommended that staffing at particular times be reviewed to ensure staff can respond to situations and also be available to accompany individual residents without DS0000027439.V272865.R01.S.doc Version 5.0 Page 22 2 YA24 3 YA24 4 YA33 Carrow Hill 5 YA37 leaving the house without enough staff cover. It is recommended that the manager take steps to undertake the outstanding component of the NVQ 4, (Care). Carrow Hill DS0000027439.V272865.R01.S.doc Version 5.0 Page 23 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. 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