Inspection on 11/08/05 for Ivydene

This inspection was carried out on 11th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Ivydene 10/02/09

Ivydene 12/02/07

Ivydene 21/12/05

Ivydene 29/11/04

Ivydene 27/07/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Ivydene 1 Station Road Ormesby St Margaret Great Yarmouth NR29 3PU Lead Inspector Hilda Stephenson Announced 11 August 2005 11.00am 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. Ivydene I55 S27469 Ivydene V234048 110805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Ivydene Address 1 Station Road Ormesby St Margaret Great Yarmouth NR29 3PU 01493 731320 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) Mr Charles Martin Mrs Maureen Martin Mrs Maureen Martin Care Home 16 Category(ies) of Mental Disorder (16) registration, with number of places Ivydene I55 S27469 Ivydene V234048 110805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The home is registered to accommodate up to 16 people with mental health needs. The home can also accommodate one family member increasing the overall number to 17. Date of last inspection 29 November 2004 Brief Description of the Service: Ivydene is situated in the village of Ormesby St Margaret, close to Great Yarmouth, with a variety of facilities provided locally. It is owned and managed by the proprietors Mr and Mrs Martin. It is a two-storey house with an attached bungalow. It has ample communal space for activities and socialising with a large conservatory being the most recent addition. The home is spacious, well decorated throughout and has 16 single bedrooms. The garden is well maintained and there are car-parking facilities at the front of the building. Many of the service users have lived at the home for a number of years. (One of the service users is a relative of the proprietors and is not included in the registered numbers, increasing the overall number to 17.) The home provides long term care and support to the sixteen service users with mental health needs. Ivydene I55 S27469 Ivydene V234048 110805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit to Ivydene was undertaken as an announced inspection during the day of Thursday 11th August 2005. The evidence gathered to publish this report was obtained by speaking to eight of the seventeen residents, both proprietors, three staff, checking through care records, policies and procedures and comments received through the twenty four comment cards that were returned to the office prior to the visit. The home was found to be clean and tidy although one of the lounges was out of bounds due to a new flooring being replaced. This was a minor disruption to the residents and all of the residents knew about the minor disruption beforehand. The home is registered to provide care and support for a total of sixteen residents and one family member increasing the overall total to seventeen. What the service does well: Ivydene is a family run home providing support to residents with an assortment of mental health needs. Residents are cared for and supported by a small loyal staff team who work alongside the residents. The home creates a personal atmosphere and it was observed during this visit that the residents take ownership of their own surroundings with staff coming in to support them. One of the proprietors also manages the home, as observed in an open and transparent manner, continuously obtaining resident views in all aspects of the home such as the new flooring, ensuring a well managed comfortable home for the residents that live there. Ivydene I55 S27469 Ivydene V234048 110805 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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. Ivydene I55 S27469 Ivydene V234048 110805 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Ivydene I55 S27469 Ivydene V234048 110805 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4,5 Residents are invited to visit the home several times to meet other residents and take the opportunity to make the admission process more inviting. Each resident is encouraged to become involved with recording his or her assessment and terms of residency. EVIDENCE: The home has not admitted any new residents for over a year although the admission process has not altered. The manager confirmed that she invites all prospective residents to visit the home for a short visit to meet staff and residents, then for longer visits to help them feel more at ease with the whole process. The residents are asked their opinion whether they would feel comfortable with any new residents moving into the home. During these arranged visits the key worker would discuss their care, personal and mental health needs. When the prospective resident has decided to stay permanently at the home a contract of the terms and conditions is drawn up and signed by both parties. The terms and conditions include the house rules, room to be occupied and facilities and procedures that are offered as well as the fees and extra payments. The written information including the complaints procedure is placed in each bedroom. Ivydene I55 S27469 Ivydene V234048 110805 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9,10 Residents benefit from good care plans written about their personal care, social care and mental health needs. These are reviewed on a regular basis with input from the residents. EVIDENCE: Two care plans were examined and found to contain in depth detail of residents personal care, social, health and mental health needs. Residents are involved at the time the care plans are written by their key worker and are invited to attend regular reviews, to discuss any further development and changes with their care. When talking with residents it was confirmed that they make their own decisions regarding their daily needs, with several going out during the day. The care plans contained individual risk taking with the relevant assessment details in place, which is good practice to ensure that both the resident and the staff are aware of their commitment to each other. Ivydene I55 S27469 Ivydene V234048 110805 Stage 4.doc Version 1.30 Page 10 Within the care plans were records of support given by the visiting Community Psychiatric Nurses and GPs, although the majority of the time the residents visit the GP at the surgery or visit the Consultant Psychiatrist at the local hospital. Ivydene I55 S27469 Ivydene V234048 110805 Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,16,17 Residents live in a communal setting and meal times are included as part of their socialising. Private individual time is also recognised. Social activities are arranged during the week. EVIDENCE: While speaking to several residents they confirmed that they go out to work, day care, college or to visit relatives or friends. Their individual interests are included within the care plan and staff encourages residents to continue with their social interests and hobbies. Several of the residents continue with quite an active social life visiting the local pub, shopping, swimming and several take part in the local bowls club. Staff encourages all of the residents to continue to go out and assist those who require supervision. Ivydene I55 S27469 Ivydene V234048 110805 Stage 4.doc Version 1.30 Page 12 Each evening a social activity is arranged by the evening staff ranging from pool nights, ladies night including a manicure and skin care, a music and video night, ending with a game of bingo on a Friday night. During the monthly residents meetings these activities are arranged for the following month. A night out at a local nightclub cabaret has been arranged for later this month. A resident stated ‘we had a barbecue on my birthday, Maureen asked me what I wanted to do, so luckily the weather was good and we had a lovely time’. The residents arrange their own breakfast and lunch with the staff assisting with the teatime meal when the majority of the residents meet up in the dining room. Staff are sensitive towards residents who wish to eat in their own rooms although presently all the residents meet up regularly during this mealtime. Again during the residents monthly meetings the menu is discussed and arranged for the following month. A copy of this was seen prior to the visit. The proprietors supply adequate amounts of alternative meals with fresh fruit and vegetables bought frequently to ensure residents nutritional needs are supplied. Within the conservatory, a small area of the room has been converted for tea and coffee facilities and has a refrigerator for residents’ use. Ivydene I55 S27469 Ivydene V234048 110805 Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20 Residents are well supported by staff and visiting professionals. Medication is stored and administered safely. EVIDENCE: Residents confirmed that they speak regularly with staff either on their own or within a group to discuss their personal needs and social aspects of their life. The care plans contained records of visits from the Community Psychiatric Nurse who visits some of the residents to help monitor their mental health needs, with some attending appointments with a Consultant Psychiatrist. It was observed that one resident was in a state of distress at times and the staff treated her in a stable, polite and patient manner constantly reassuring her and introducing diversion therapy when appropriate, confirming that the staff knew how to treat and care for residents with a mental health problem. One resident who has lived at the home for several years stated ‘the staff are very kind and I can talk to them whenever I feel low’. Any medical needs are arranged through the local GP surgery with residents visiting the surgery themselves. Ivydene I55 S27469 Ivydene V234048 110805 Stage 4.doc Version 1.30 Page 14 The medication charts for three residents were checked and had been completed satisfactorily. Three residents continue to self medicate with relevant risks having been assessed, with lockable facilities in place for safe keeping within there own rooms. The staff have attended medication administration training, with medication stored and checked safely. Written procedures are in place for staff to ensure that safe practices are followed. Ivydene I55 S27469 Ivydene V234048 110805 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 Residents are assured that their views and concerns are taken seriously where the home follows their own complaints procedure. The home has adult protection procedures in place to ensure the safety of the residents. EVIDENCE: The complaints procedure is displayed in the hall and each resident has a copy in his or her rooms, this also confirms that residents can complain directly to the Commission if necessary. The home retains copies of past complaints with the action taken. Residents and staff commented that they prefer to speak to the Proprietor if they had any concerns. No complaints were received during this inspection. One resident stated ‘I haven’t got anything to complain about here because we have everything we want’. Another resident stated ‘the staff are lovely and always have time to sit and listen if I’m feeling a bit low’. A procedure for responding to allegations of abuse is in place, staff have six monthly adult protection updates and new staff are taught the guidelines during the induction programme. Staff who were spoken to had a very good understanding of the various forms of abuse and how to deal with this. Several of the adult protection policies were seen during this visit, and staff signs these when they have read and understood them. Ivydene I55 S27469 Ivydene V234048 110805 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,27,28,30 Residents benefit from living within a clean and tidy home with plenty of homely communal space. EVIDENCE: Ivydene is a two-storey building with an attached bungalow within the village of Ormesby St Margaret, close to local amenities. A partial tour of the home was undertaken with all of the communal rooms seen. Each resident has their own bedroom where they have their own colour scheme. The home has adequate bathing and toilet facilities situated on both floors. Residents can smoke if they wish although the designated smoking area is now situated outside within a separate glass conservatory or on the patio area. The home has three lounges, a large conservatory that contains dining facilities and coffee making area; a separate dining room is next to the main kitchen. All of the communal rooms are on the ground floor. The leather lounge had been closed off due to the flooring being replaced. Residents who spoke to the Inspector were aware of the small upheaval and had also chosen the flooring surface. Ivydene I55 S27469 Ivydene V234048 110805 Stage 4.doc Version 1.30 Page 17 During the inspection a second maintenance task was being carried out, the proprietor was having two tunnel solar lights added to the main corridor to introduce more light to this area beside ten bedrooms. This was completed before the end of this visit and the corridor was much lighter, so improving the area for the residents. The kitchen was of a good clean hygienic standard, the home does not employ a cook, the care staff having acquired the food hygiene certificate supervises residents when cooking the evening meal. The proprietors have a good clear maintenance plan for improving the home during the next twelve months, the residents were aware of these plans and some of their suggestions had been included which should be commended as good practice. Residents undertake their own laundry, with the staff assisting when required. Ivydene I55 S27469 Ivydene V234048 110805 Stage 4.doc Version 1.30 Page 18 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) 31,32,33,34,35,36 Residents benefit from being looked after by caring, well trained staff who acknowledge their individual needs. A good recruitment procedure ensures that residents are safe. EVIDENCE: Copies of the duty rota were supplied prior to the inspection, confirming that two care staff are on duty during the day reducing to one overnight. The night staff sleeps in with the manager being on call and situated only two minutes from the home. Two staff sleep in on a Saturday night in case the residents organise a social evening and to allow the proprietors one night off. The home is cleaned on a daily basis by domestic staff. Ivydene I55 S27469 Ivydene V234048 110805 Stage 4.doc Version 1.30 Page 19 The manager follows the recruitment procedure when employing new staff; the last two new staff’s records were seen and were satisfactory. The induction programme for both staff had been complete. The training records for the majority of the staff team was also seen with adequate training for adult protection, medication, infection control, fire, first aid and food hygiene had been completed. More than half of the care staff team have achieved the recommended NVQ training, which is good practice. The deputy manager continues to monitor the training needs of the staff with a regular supervision with staff to discuss personal and training issues to be arranged during the following year. Ivydene I55 S27469 Ivydene V234048 110805 Stage 4.doc Version 1.30 Page 20 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) 37,38,39,40,41,42,43 Residents live in a well managed home that has their well-being and health and safety needs in place. EVIDENCE: Both proprietors visit each day with Maureen Martin managing the home. Barry and Maureen Martin have owned the home for several years and have delegated some of the practices to senior care staff. One member of staff organises the residents meeting each month and monitors the quality assurance system reporting back the findings to the proprietors. These results are recorded and are included within the yearly plan for improvements. The residents confirmed that they meet each month and that they all discuss arrangements and plans for the following month. Ivydene I55 S27469 Ivydene V234048 110805 Stage 4.doc Version 1.30 Page 21 The home has good health and safety procedures in place to ensure the safety of residents and staff. The fire records, infection control, missing person, challenging behaviour and medication policies were examined during this visit and were satisfactory. The home is well managed with good practices in place. A loyal well-trained staff team treat residents as individuals within a communal setting, highlighting the risks when appropriate, supporting resident’s individual needs and lifestyle. The Inspector left with the impression that the residents enjoy the freedom and support offered at this home from both their peers and staff. Ivydene I55 S27469 Ivydene V234048 110805 Stage 4.doc Version 1.30 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 3 x 4 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 4 4 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ivydene Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 3 3 3 I55 S27469 Ivydene V234048 110805 Stage 4.doc Version 1.30 Page 23 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 Regulation None Requirement Timescale for action 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 None Good Practice Recommendations Ivydene I55 S27469 Ivydene V234048 110805 Stage 4.doc Version 1.30 Page 24 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. 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