CARE HOME ADULTS 18-65
Norfolk Road (28) 28 Norfolk Road Harrogate North Yorkshire HG2 8DA Lead Inspector
Maggie Coxon Unannounced 19 May 2005 08:45 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. Norfolk Road (28) J53 JO4 S7901 Norfolk Road (28) V225595 190505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Norfolk Road (28) Address 28 Norfolk Road Harrogate North Yorkshire HG2 8DA 01423 871288 N/A N/A St Annes Community Services 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) Ms Sharon Elizabeth Wilcox Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Norfolk Road (28) J53 JO4 S7901 Norfolk Road (28) V225595 190505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 11/12/04 Brief Description of the Service: 28 Norfolk Road is a care home registered by by St. Annes Community Services to provide personal care and accommodation for up to four adults with learning disabilities. The home consists of a semi-detached two-storey town house with garden areas to the front and rear including an enclosed area with hard standing for parking. The home is situated on a quiet road approximately one mile from the centre of Harrogate. Local community amenities and facilities, including shops, churches and pubs are within walking distance. Each of the four bedrooms is for single accommodation, none of which has ensuite facilities. These are all on the first floor and are accessed by a staircase. Norfolk Road (28) J53 JO4 S7901 Norfolk Road (28) V225595 190505 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was the first to be undertaken between April 2005 and March 2006. It was done on 19th May 2005, at a time when all of the people living in the home would be present. It took 3.5 hours plus 2 hours preparation time. Discussions were held with the four people currently living in the home and with care staff on duty. A number of records and most areas of the home, including bedrooms and shared areas, were seen. What the service does well:
The home is well run and has a staff team who are committed to putting the needs and wishes of the residents first. There are enough staff on duty at any one time to ensure that residents are given individual attention where required, to enable individuals to be fully involved in the day to day running of the home and to support them to get out and about in their local community and beyond. Staff communicate very well with individuals and encourage them to make as many choices as possible. Residents are actively involved in the day-to-day running of the home and are encouraged to make as many decisions and choices in their lives as possible. They are also supported to join in activities in their local community and to maintain contact with families and friends. The home is well run by an experienced manager and staff team who have developed good working relationships with the residents and communicate extremely well with them treating them with respect at all times. The home is well maintained and was clean, warm and comfortable at the time of this inspection. Each resident said that they like their bedroom and explained that they are able to arrange it as they like and include their personal belongings. Staff are well trained and morale amongst the team is high. Records are well kept. Norfolk Road (28) J53 JO4 S7901 Norfolk Road (28) V225595 190505 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. Norfolk Road (28) J53 JO4 S7901 Norfolk Road (28) V225595 190505 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 Norfolk Road (28) J53 JO4 S7901 Norfolk Road (28) V225595 190505 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) None. EVIDENCE: Norfolk Road (28) J53 JO4 S7901 Norfolk Road (28) V225595 190505 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 and 9. People living in the home make as many decisions about their personal lives and about the day-to-day running of the home as possible. They also live as independently as possible, taking into account any risks that have to be considered, with the full encouragement and support of staff. EVIDENCE: Residents have active lives with the support of a committed staff team in the home. They make as many decisions and choices for themselves as possible and are involved in the running of the home. Examples of this were seen during the inspection. Staff talk to residents about any potential risks as these arise and individuals are supported to make a choice taking this information into account and looking at means of minimising any risk. These risk assessments are then included within the individual’s care plan so that all those involved can be fully aware of any issues and how any risks are to be minimised. Residents have their own meetings every month as well as regular meetings with their key worker. Norfolk Road (28) J53 JO4 S7901 Norfolk Road (28) V225595 190505 Stage 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) 12,13,14,15,16 and 17. Residents have a varied and interesting lifestyle and are fully involved in their local community. Individuals enjoy a wide range of social and educational opportunities and develop and maintain good relationships with family and friends. They enjoy a wide choice of home cooked, good quality food. EVIDENCE: Each resident has a weekly programme of varied activities within their local community, some organized by the home others accessed through a local day centre and a local college. The staff team is keen to identify new activities that the residents might enjoy and residents are taking part in more of these since the last inspection. One resident is in part time paid employment. Residents were seen to enjoy a very relaxed lifestyle in the home. They talked about recent activities, trips and outings organized by staff in consultation with them and said they were looking forward to a ‘world cup’ party in the home at the weekend. They had recently enjoyed a day at the races. Each resident has at least one holiday of their choosing each year. Norfolk Road (28) J53 JO4 S7901 Norfolk Road (28) V225595 190505 Stage 4.doc Version 1.30 Page 11 Residents are supported to maintain strong links with families and friends. One of them writes to his family on a weekly basis with assistance from staff and visits are supported. Residents are involved in menu planning and go shopping with staff. A varied and nutritious diet is provided and residents are encouraged to eat healthily. Residents said that they enjoyed the meals. Norfolk Road (28) J53 JO4 S7901 Norfolk Road (28) V225595 190505 Stage 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 and 20. Residents’ personal and health care needs are fully met. EVIDENCE: Each of the people living in the home is registered with a GP through whom specialist health services are accessed as and when required. Each has an annual health check and is supported in having regular checks with their dentist, chiropodist and optician. Whilst none of the residents is able to take their own medication, those who are able to, said that they are satisfied with staff administering this to them. There is a monitored dosage system in operation, which is securely stored. Medication administration records are well maintained and all staff have received some medication training that is to be expanded on in the near future. Bedroom and bathroom doors have locks fitted and staff were seen to give support to residents with personal care needs in a way that respected the individual’s dignity. Staff study the respecting of individuals’ rights to privacy and dignity during their induction and NVQ training. Norfolk Road (28) J53 JO4 S7901 Norfolk Road (28) V225595 190505 Stage 4.doc Version 1.30 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 standard(s) 22 and 23. Residents’ concerns safeguarded. EVIDENCE: are appropriately dealt with and their interests There is a comprehensive complaints procedure in operation that is available in various formats and is made available to anyone who wishes to see it. Several of the people living in the home are not able to make a formal complaint but are able to make any dissatisfaction known to staff, who try to address this promptly and appropriately. Staff were seen to have developed very good relationships with residents and to communicate very well with them. No complaints have been made to the home or to the C.S.C.I. within the last twelve months. There is also a good adult protection procedure in place and the staff member who was asked had a good understanding of this and was committed to putting the safety of residents first at all times. Some staff will be undertaking further adult protection awareness training in the near future. Norfolk Road (28) J53 JO4 S7901 Norfolk Road (28) V225595 190505 Stage 4.doc Version 1.30 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 standard(s) 24,25,26,27,28,29 and 30. The standard of the environment of the home is good and provides residents with a comfortable, clean and homely place in which to live. EVIDENCE: The home is well maintained and pleasantly decorated and furnished. All of the bedrooms are pleasantly decorated and furnished and residents said that they are happy with them. They are all for single accommodation, are of a suitable size and are situated on the first floor close to a shared bathroom; none of them has en suite facilities. Appropriate aids and adaptations are fitted throughout the home. A good standard of cleanliness is maintained throughout. Norfolk Road (28) J53 JO4 S7901 Norfolk Road (28) V225595 190505 Stage 4.doc Version 1.30 Page 15 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 and 35. The residents receive a good standard of care from a highly skilled and motivated staff team. EVIDENCE: The care staff are working hard towards achieving NVQs to level 3 in care. One has completed the award since the last inspection and three more are currently undertaking it and making steady progress. The team is therefore moving towards reaching the target of having 50 of care staff trained to NVQ level 2 or above by 2005. Staff members have also attended other training within the last year covering topics including Makaton communication, manual handling, fire safety, food hygiene, emergency aid, working with people who self-injure and worker/client relationships. The staffing roster for the week including the inspection shows that staff are employed in sufficient numbers and are deployed in such a way as to ensure that the needs of people living in the home are met at all times. Norfolk Road (28) J53 JO4 S7901 Norfolk Road (28) V225595 190505 Stage 4.doc Version 1.30 Page 16 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 and 42. The residents benefit from a well managed home in which their needs and wishes are put first. EVIDENCE: The registered manager is highly experienced in the management of care services and is appropriately qualified. Residents said that she is very kind, friendly and easy to talk to. Staff described her as a very approachable manager with good management and leadership qualities. St Anne’s Community Services has a quality assurance and monitoring system that includes regular unannounced inspections of the service by a service manager. The reports from these inspections are fed back into the overall quality assurance system. It has previously been recommended that this system be further developed to include ascertaining the views of individuals in the community who have contact with home. Staff understood that this had
Norfolk Road (28) J53 JO4 S7901 Norfolk Road (28) V225595 190505 Stage 4.doc Version 1.30 Page 17 not yet been done, it is understood however that the organization is making some progress in developing a system to do so. Comprehensive systems and procedures to ensure the safety and well being of residents are in place within the home. These include regular health and safety checks of the premises and of equipment. Staff are appropriately trained in health and safety matters including Emergency Aid, Fire Safety and Food Hygiene. Whilst the organization has undertaken a check of the hot water storage system in respect of the prevention of Legionella, it has been identified that hot water stored in the home is done so at less than the required 60 degrees Celsius. The registered manager had previously explained that the organization was aware of this and that the matter was being dealt with. Norfolk Road (28) J53 JO4 S7901 Norfolk Road (28) V225595 190505 Stage 4.doc Version 1.30 Page 18 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
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 3 3 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 2 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Norfolk Road (28) Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 x x 2 x J53 JO4 S7901 Norfolk Road (28) V225595 190505 Stage 4.doc Version 1.30 Page 19 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. 2. Refer to Standard 32 39 Good Practice Recommendations A minimum of 50 of care staff should be qualified to NVQ level 2 or above. The views of families, friends, advocates and others involved with the home, in respect of the quality of services, should be ascertained and incorporated into the quality assurance system currently in operation. Hot water should be stored at a temperature that safeguards against Legionella (at a minimum of 60 degrees Celcius). 3. 42 Norfolk Road (28) J53 JO4 S7901 Norfolk Road (28) V225595 190505 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection York Area Office Unit4, Triune Court Monks Cross York, YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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