Inspection on 28/06/05 for Fryers Walk

This inspection was carried out on 28th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Fryers Walk 20/02/09

Fryers Walk 23/03/07

Fryers Walk 08/12/05

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

CARE HOME ADULTS 18-65 Fryers Walk 53 Castle Street Thetford Norfolk IP24 2DL Lead Inspector Jerry Crehan Unannounced 28th June 2005 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. Fryers Walk I55 s63392 fryerswalk v233519 280605(4).doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Fryers Walk Address 53 Castle Street, Thetford, Norfolk, IP24 2DL 01842 766444 01842 821934 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) Active Care Partnerships (Fryers) Ltd Position Vacant Care Home 34 Category(ies) of Learning Disability (34), Learning Disability over registration, with number 65 (3) The total number not exceed 34. of places Fryers Walk I55 s63392 fryerswalk v233519 280605(4).doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 13th December 2004 Brief Description of the Service: Fryer’s Walk is registered to provide residential care for a maximum of 34 adults with learning disabilities, in a range of self contained units. These include 3 bungalows, 2 cottages and 2 clusters of flats (registered as one establishment). This enables accommodation of people with a range of support needs, from those requiring full physical care and support, to those who are working to achieve independence but need some assistance. Some service users have physical disabilities in addition to learning disabilities. Nursing care is not provided.Some day care is also provided, making use of facilities on and off the premises. Fryers Walk I55 s63392 fryerswalk v233519 280605(4).doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5 hours. Opportunity was taken to tour the premises, look at care records and policies, and communicate with many of the thirty-two service users accommodated at the time of the inspection. Staff members and the manager were also spoken to. The inspection took place after a period of significant change for all concerned with the home, including a relatively recent change of proprietor and a new manager appointed in May. The manager is in the process of applying to the Commission to achieve status as a registered manager. What the service does well: What has improved since the last inspection? Care staff clearly play an active role in monitoring, reviewing and updating care plans for or with service users. Despite the requirement made in this report the standard of care planning has continued to improve over the past two inspections. The recent unannounced inspection, to follow up on the pharmacy inspection undertaken at the beginning of the year, was very positive with good systems for the safe handling and administration of medication evidently implemented. A system for regular supervision for staff appears to now be well established and part of the regular professional practice of the home. Staff spoken to clearly appreciate the supervision process. Fryers Walk I55 s63392 fryerswalk v233519 280605(4).doc Version 1.30 Page 6 The manager has demonstrably looked at ways of obtaining the views of people associated with the home who may have a valuable comment or contribution to make. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Fryers Walk I55 s63392 fryerswalk v233519 280605(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 Fryers Walk I55 s63392 fryerswalk v233519 280605(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, 4 The information and admission process is satisfactory, though being updated, ensuring that there is a proper assessment prior to service users moving into the home. EVIDENCE: Fryers Walk provides clear information that would enable prospective service users to make an informed choice as to whether and how the home could meet their needs. However, this information was in the process of updating at the time of the inspection to reflect new company and management changes, in addition to changes to the procedure for complaints. Information is also available in other formats to suit individual communication requirements. An example of this was service information in a symbol format. Assessments of prospective service users needs were evident. The manager or senior staff undertakes these. The opportunity for prospective service users to visit the home prior to admission has clearly been available. This is reflected in the home’s policies and in comments made by service users. One service user spoken to indicated that they had had ‘a proper look around before I came here’ and that they had also had the opportunity to ‘stay here for a week’ before moving in permanently. Fryers Walk I55 s63392 fryerswalk v233519 280605(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, 9 There is a clear and consistent care planning system in place that enables service users to receive support, though requires expansion. Independence is promoted through care planning and assessment of risk. EVIDENCE: There is a clear and consistent care planning system with evidence of regular review in place. It was evident that the home respects service users rights to make decisions and that this takes place within a context that reflects the wide-ranging needs and abilities of the individuals living at the home. This was illustrated in discussion with a service user who spoke with support about the help they needed to meet their own needs independently, and where they needed assistance. Two care plans reviewed dealt with particular aspects of the individual’s behaviour, though did not go on to set out action required by care staff to manage the behaviour or situation. Individual risk assessments are undertaken at the home to support the independence of service users. There was evidence of this in the facility for a number of service users to maintain their independence from the home in the form of work and social outlets, and to address health and behavioural issues. Fryers Walk I55 s63392 fryerswalk v233519 280605(4).doc Version 1.30 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 standard(s) 12, 13, 15 The home caters well for the diverse lifestyle preferences of service users. There are well-supported links into the local community for leisure activities and contact with relatives and friends. EVIDENCE: Service users at Fryer’s Walk are engaged in day care activities both on and off site. At the time of the inspection a number of service users were engaged in activities on site in the dedicated day care facility in the main building. Other service users attend day services elsewhere or attend a combination of services. A number of individuals spoken to describe the work or voluntary activities they participate in within the local community, one service user indicating that ‘staff encourage me to keep my jobs going’. The home provides organised leisure activities and supports the independence of other service users to arrange and take part in appropriate leisure activities independently of the home. This was confirmed in service users describing trips out with friends to the pub or into the town. Both service users and the manager spoke about the home’s approach to supporting appropriate relationships, and that this is dealt with openly with the Fryers Walk I55 s63392 fryerswalk v233519 280605(4).doc Version 1.30 Page 11 home making it clear that their responsibility is toward the safety of service users. Service users and care staff indicated that relatives and visitors are made welcome by the home, and that meeting can take place in private if required. Fryers Walk I55 s63392 fryerswalk v233519 280605(4).doc Version 1.30 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 standard(s) 18 & 19 Service users personal and healthcare needs are well attended to by a robust approach taken by the home. EVIDENCE: Service users care plans seen contained clear information as to where personal support was required, and how it should be delivered. Service users appeared satisfied that care staff could provide care required and understood where independence in personal support could be maintained. A specific plan concerning the management of a service users needs should they require hospital admission was seen. This was a comprehensive document proposed from the perspective of the service user (who’s communication methods may not be understood by an unfamiliar carer), and would assist in the delivery of appropriate care to the individual. The manager advised that this information is being developed for other service users where appropriate also. The home is commended for this work. There is evidence of access to a variety of health professionals for service users at the home, including the community nurse and district nurse. Pharmacy inspections have already taken place this year; consequently medication arrangements were not inspected on this occasion. However, a discussion took place with a service user and later with the manager about the merits of the service user retaining responsibility for their own medication. It Fryers Walk I55 s63392 fryerswalk v233519 280605(4).doc Version 1.30 Page 13 was agreed that the matter was to be taken further in liaison with all relevant parties. Fryers Walk I55 s63392 fryerswalk v233519 280605(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) 22 & 23 The home has a complaints system in place that is partly, but not yet fully satisfactory. EVIDENCE: The home has a detailed complaints procedure. The complaints procedure seen appears in the form of procedural advice for staff, and not information for service users, their relatives or others. It is not therefore clear whether service users (or others) would feel that their views would be listened to and acted on. However, a revised complaints procedure is in the process of development as indicated in Standard 1 of this report, and is the subject of a recommendation. A recommendation that the complaints procedure specifies arrangements for service users to make complaints whilst on holiday with the home is also made. The home had received one complaint concerning adult protection, which was outstanding at the time of this inspection. A procedure for responding to allegations of abuse is in place. Staff spoken to appeared aware of the procedure and its function, and had received appropriate training. Service users spoken to appeared clear as to the action they would take in the event of a concern or complaint. Fryers Walk I55 s63392 fryerswalk v233519 280605(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 & 30 A comfortable, accessible and safe standard of accommodation is provided, both internally and externally. EVIDENCE: The home provides a homely, comfortable and safe environment for service users that is furnished to a reasonable standard and decorated to a good standard. The manager provided evidence of a number of forthcoming repairs to the property and investment in replacing furniture and fittings. Garden areas were reasonably maintained and accessible for service users. The home is kept very clean; there are good practices (and appropriate policies) to maintain hygiene. The home is free from offensive odours throughout. Fryers Walk I55 s63392 fryerswalk v233519 280605(4).doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34 Staff at the home are well supported, employed in sufficient numbers and recruited with appropriate safeguards to meet the service users needs. Staff training programme addresses service user needs. EVIDENCE: An effective staff team, who are well supported and supervised supports service users. Service users benefit from the access that staff has to a comprehensive and varied training programme. This includes mandatory training with evidence of refresher training where appropriate, and access for some staff to specialist training to meet health or other requirements of service users. The home currently has a compliment of almost 50 of NVQ level 2 trained staff, with further staff about to undertake training. Records were reviewed with supporting evidence that the home’s recruitment practices afford service users with protection this. A recruitment procedure is demonstrably in place ensuring the protection of service users. Fryers Walk I55 s63392 fryerswalk v233519 280605(4).doc Version 1.30 Page 17 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) 38, 39, 42 The manager provides clear leadership and is well supported by the staff team. The systems for service user consultation are good with evidence that the views of others associated with the home are also sought. EVIDENCE: It is evident that service users and staff have respect for, and confidence in the manager. Comments from both were positive about her professionalism and approachability, with one service user indicating that ‘I think since she’s been the manager this home has been fantastic’. The home employs a number of methods to ensure service users views underpin the self-monitoring and review of its services. These include questionnaires and service users meetings. The manager has extended the use of questionnaires to incorporate the views of others associated with the home following a recommendation made at the last inspection. A number of policies are in the process of development and review following the homes change of ownership. Progress as to their status and implementation will be followed up at the home’s next inspection. Fryers Walk I55 s63392 fryerswalk v233519 280605(4).doc Version 1.30 Page 18 Records reviewed (including fire records) were well maintained and evidence that the home seeks to promote the health, safety and welfare of service users. There was evidence of appropriate health and safety training for staff. Fryers Walk I55 s63392 fryerswalk v233519 280605(4).doc Version 1.30 Page 19 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 x 3 x Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x x Standard No 31 32 33 34 35 36 Score x 3 3 3 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fryers Walk Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x 3 3 x x 3 x I55 s63392 fryerswalk v233519 280605(4).doc Version 1.30 Page 20 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 6 Regulation 15(1) Requirement The registered person must ensure that individual care plans set out action required by care staff to manage behaviour and meet needs. Timescale for action Immediate and Ongoing 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 22 Good Practice Recommendations It is recommended that that the complaints procedure for service users should be revised to ensure that it is clear about its audience and purpose and is directed to service users (e.g. by using “you”, and “your” complaint). It is recommended that the homes complaints procedure specifies arrangements for service users to make complaints whilst on holiday with the home. It is recommended that the registered person ensure continued progress toward meeting the 50 NVQ training requirement by 2005. 2. 3. 22 32 Fryers Walk I55 s63392 fryerswalk v233519 280605(4).doc Version 1.30 Page 21 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 Fryers Walk I55 s63392 fryerswalk v233519 280605(4).doc Version 1.30 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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