Inspection on 08/12/05 for Fryers Walk

This inspection was carried out on 8th December 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 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

Fryers Walk 20/02/09

Fryers Walk 23/03/07

Fryers Walk 28/06/05

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 Mr Jerry Crehan Announced Inspection 8th December 2005 11:00 Fryers Walk DS0000063392.V260510.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 Fryers Walk DS0000063392.V260510.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. Fryers Walk DS0000063392.V260510.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Fryers Walk Address 53 Castle Street Thetford Norfolk IP24 2DL 01842 821933 01842 821934 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) Active Care Partnerships (Fryers) Ltd Mrs Christine Anne Hamilton Care Home 34 Category(ies) of Learning disability (34), Learning disability over registration, with number 65 years of age (3) of places Fryers Walk DS0000063392.V260510.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2005 Brief Description of the Service: Fryers 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 DS0000063392.V260510.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over 8 hours. Opportunity was taken to tour the internal and external premises, look at care records and policies, and communicate with many of the service users accommodated at the time of the inspection both individually and in small groups. Relatives of service users, staff members and the manager were also spoken to. The home is commended on its promotion of inspection comment cards for service users and their relatives. Forty-one comment cards were received, these were largely complementary about the home and the care it provides. Matters of criticism arising from comment cards are addressed within the inspection and the report. What the service does well: What has improved since the last inspection? There has been further improvement in the clarity of care planning. Those reviewed clearly set out the action to be taken by care staff to meet individual need. It is evident that considerable effort has been made to improve and personalise the quality of the environment for service users. This is especially evident in bedrooms and reflects the choices and preferences of service users. Fryers Walk DS0000063392.V260510.R01.S.doc Version 5.0 Page 6 There has been further policy development in respect of complaints. 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 DS0000063392.V260510.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 Fryers Walk DS0000063392.V260510.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): 3&5 The information and admission process is effective. There are individual contracts for each service user that meet the required standard. EVIDENCE: Assessments have been completed by the home that address service users aspirations and needs. They contain evidence of individual contributions from the service users. Signed contracts (‘agreement to occupy’) were evident. The home has made efforts to make this information available in other formats including ‘Boardmaker’. Fryers Walk DS0000063392.V260510.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): 6, 8 &10 Individual needs and choices are promoted by the home. Care planning clearly reflects the care needs of service users. EVIDENCE: Service users spoken to appeared aware of their individual plans and evidently assisted in their completion. Care plans are evidently regularly reviewed and contain individual aspiration and goal setting. Evidence of work towards achieving goals was seen as service users participated in household activities, and personal care tasks. This was confirmed by observation of several service users undertaking such activities during the inspection. Care plans for two service users, one with diabetes and one who has assessed and specific behavioural support needs are commended. These contain clear information for care staff as to their responsibilities in providing safe and appropriate care. Care for an older service user who is identified as at risk from developing pressure areas is also commended. However, care planning should be extended to include clearer monitoring of fluid intake. Service users spoken to described their participation in contributing toward the running of the home, and that monthly residents meeting are held at the home that are a forum for resolving difficulties, and for planning. Fryers Walk DS0000063392.V260510.R01.S.doc Version 5.0 Page 10 Confidentiality issues are evidently understood at the home. There are secure arrangements for the storage of records. Fryers Walk DS0000063392.V260510.R01.S.doc Version 5.0 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 the following standard(s): 11, 14, 16, 17 The home caters satisfactorily for the lifestyle preferences of service users, and promotes independence. EVIDENCE: Service users participate in developmental programmes followed at their day care provision on and off site. There was evidence of independent living skills being supported within the home, and this was confirmed in discussions with service users and relatives. Relatives spoken to indicated that service users independence is also supported by staff in activities outside of the home, for example with shopping trips or undertaking voluntary work. A wide range of activities was being undertaken on the day of the inspection. It was evident from information contained within care plans that these were part of a weekly programme developed for each service user. The home is commended for its varied programme of activities that is suitable to the needs of service users with varied needs and interests. Service users have access to an annual holiday; these have included trips abroad in some instances. Fryers Walk DS0000063392.V260510.R01.S.doc Version 5.0 Page 12 Rights and responsibilities are respected and recognised at the home; service users have unrestricted access to most areas except other people’s bedrooms. All bedroom doors are lockable. A range of foods was evident in units, including healthy options and staff explained how a balanced diet is offered and maintained. A healthy eating club meets weekly at the home to provide education, advice and encouragement on diet. Fryers Walk DS0000063392.V260510.R01.S.doc Version 5.0 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 the following standard(s): 20 Service users medication needs are well attended to. EVIDENCE: On review of medication records no discrepancies were identified. Both records and storage arrangements were satisfactory. Staff have access to appropriate safe handling of medicines training. Service users at the home with responsibility for managing their own medication do so within a risk management framework that is subject to ongoing review. Fryers Walk DS0000063392.V260510.R01.S.doc Version 5.0 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 the following standard(s): 22 &23 The home’s arrangements for protecting service users, and responding to the concerns of service users are satisfactory. EVIDENCE: The home has a newly revised complaints procedure a copy of which is available in the reception area. Following a recommendation made at the last inspection the manager has developed the procedure to include arrangements for service users to make complaints whilst on holiday with the home. Service users (and relatives) spoken to appeared clear as to whom they could speak to at the home if they had a concern or complaint. 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. Fryers Walk DS0000063392.V260510.R01.S.doc Version 5.0 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 the following standard(s): 25, 26, 27, 28, 29 The home is well equipped to meet the needs of its service users and provides a very good standard of accommodation. EVIDENCE: The home is furnished and decorated to a very good standard. Evidence of recent efforts to redecorate bedrooms to reflect individual tastes, interests and preferences has enhanced the quality of the environment for service users, whose bedrooms have a noticeably individual and homely feel. Every bedroom is lockable and has a lockable storage facility for safe storage of belongings. Several service users have elected to look after their own room keys. There are adequate toilet (including some en-suite) and bathroom/shower facilities to meet individual need and that promote privacy. An example of good practice was noted in the rearrangement of furniture and bed in a service users bedroom in order that they may maximise their independent mobility to its full potential. Telephones provided in the bungalows do not provide sufficient privacy for service users wishing to make or receive telephone calls, as they are situated in the hallway. An alternative to this arrangement must be explored that provides sufficient privacy. Fryers Walk DS0000063392.V260510.R01.S.doc Version 5.0 Page 16 The provision of communal facilities varies between units on the site. However, they are domestic in scale and well furnished. Relatives and service users spoken to stated that they could meet in private if required. Outside space and gardens are available for all units. The home has a variety of specialist equipment including suitably positioned grab rails, portable and overhead hoists. Fryers Walk DS0000063392.V260510.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 35 & 36 Staff at the home are well supported. Staff training satisfactorily meets the needs of service users. EVIDENCE: Staff spoken to were clear about their roles and responsibilities had been issues with job descriptions, and confirmed that they knew who they report to. An effective staff team, who are well supported and supervised supports service users. Service users benefit from staff access to a variety of appropriate training. It was not clear that staff training to adequately address service users needs in relation to sensory impairment is provided. However, the manager provided evidence that this training was in the process of being sourced. It is recommended that staff supervision training is made available to those staff that have responsibility for providing formal supervision. There are currently over 30 of NVQ 2 trained staff, however, the successful completion of this training by staff who are currently registered, or already undertaking the training will achieve the 50 requirement by January 2006. Fryers Walk DS0000063392.V260510.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, 40, 41, 43 The home is well run by an experienced, and qualified registered manager. Service users are supported by appropriate policies, procedures and record keeping. EVIDENCE: Communication with service users and relatives throughout the inspection suggests that they are satisfied with the way the home is run, and have confidence in the staff and manager. The manager has recently achieved status as a ‘Registered’ manager with the Commission, and has recently successfully completed her ‘Registered Managers Award’. A range of appropriate policies and procedures has been developed, and continues to be developed by the home and the proprietor to satisfactorily safeguard service users. The home demonstrated good record keeping practices ensuring service users confidentiality. There are no issues of concern associated with the effectiveness, financial viability or accountability at the home. Fryers Walk DS0000063392.V260510.R01.S.doc Version 5.0 Page 19 Fryers Walk DS0000063392.V260510.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 3 X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score X 3 2 3 3 3 X LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 3 X X X 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fryers Walk Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X X 3 3 X 3 DS0000063392.V260510.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 YA26 Regulation 16(2)(b) Requirement The registered person must ensure that service users have access to telephone facilities in private. Timescale for action 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3. Refer to Standard YA6 YA32 YA35 Good Practice Recommendations It is recommended that where appropriate, care planning should be extended to include clearer monitoring of fluid intake. It is recommended that the registered person ensure continued progress toward meeting the 50 NVQ training requirement by 2005. It is recommended that staff supervision training is made available to those staff who have responsibility for providing formal supervision. Fryers Walk DS0000063392.V260510.R01.S.doc Version 5.0 Page 22 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. Extracts may not be used or reproduced without the express permission of CSCI Fryers Walk DS0000063392.V260510.R01.S.doc Version 5.0 Page 23 - 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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