Inspection on 22/11/06 for Norfolk Road (28)

This inspection was carried out on 22nd November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Norfolk Road (28) 25/04/08

Norfolk Road (28) 01/05/07

Norfolk Road (28) 07/03/06

Norfolk Road (28) 19/05/05

Norfolk Road (28) 11/12/04

Norfolk Road (28) 26/05/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Norfolk Road (28) 28 Norfolk Road Harrogate North Yorkshire HG2 8DA Lead Inspector Mrs Maggie Coxon Key Unannounced Inspection 22nd November 2006 10:45 Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 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 Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 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. Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norfolk Road (28) Address 28 Norfolk Road Harrogate North Yorkshire HG2 8DA 01423 871288 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) St Anne’s Community Services *** Post Vacant *** Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2006 Brief Description of the Service: 28 Norfolk Road is a care home registered 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 en-suite facilities. These are all on the first floor and are accessed by a staircase. Current information about services provided at 28 Norfolk Rd in the form of a statement of purpose, service user guide and the most recent inspection report published by the Commission for Social Care Inspection are available by contacting the home. Information provided by the manager on 16th November 2006 indicated that the current weekly fee for the home is £305.40. Additional costs include toiletries, hairdressing, newspapers, activities and holidays. Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is what was used to write this report: • • • Information about the home kept by the Commission for Social Care Inspection. Information asked for before the visit, this is called a pre-inspection questionnaire. A visit to the home that they knew was going to happen. This lasted for five hours and included talking to three residents, care staff and the manager about how the home is run. Several areas of the home were also seen and records that the home has to keep were checked. Residents’ medication was also checked to make sure that it was being properly looked after for them. Information given one day after the visit by the residents’ care manager. • People living in the home have expressed a preference to be known as residents. What the service does well: Residents and staff get to know each other very well and staff are kind and friendly so residents can be confident that they will get good help. Residents can have lots of contact with friends and family and see them at any time. Staff also spend a lot of time talking to the residents. This means that they can have company whenever they like. Residents have plenty of activities both inside and outside of the home and spend lots of time out and about in their town as well as visiting places further away. Residents are able to make many choices regardless of their age, gender or needs, they are all treated equally and respectfully by the staff. Residents are asked to say what care they need and how they would like this to be given, this gives them the chance to have a say in planning services for themselves in the future. Residents have a good choice of food and drinks so they can enjoy their meals. Residents and their relatives and friends are asked what they think about the home so that the staff team can make changes to make things better for residents. Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 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 Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 4. Quality in this outcome area is good. Information about the service provided is made available to any interested parties. A well-planned needs assessment process ensures that residents’ needs are identified and planned for before they are admitted. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home has a detailed statement of purpose and service user guide, which the manager plans to update shortly and which are both produced in an easy read format. A detailed assessment had been taken on each of the residents before they moved in. No admissions have been made since the last key inspection but it is the home’s policy that any prospective resident has introductory visits to the home and moves in on a trial basis before the placement is made permanent. Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. Quality in this outcome area is adequate. Residents make a number of decisions and choices on a daily basis but information about how residents should be helped needs to be checked and updated so that they can be confident that they are getting the best support. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Case tracking showed that residents’ individual personal plans have not been being reviewed and updated in sufficient detail or on a regular basis. Information available however identified that staff are expected to meet the different needs of the individual resident in a way that promotes their independence wherever possible. Daily records, discussions with residents and staff and observations made during the visit confirmed this to be the case. Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 Page 10 Meetings have been held for each resident in which they have had a say in how to make things better for them personally. Individuals’ wishes and agreed outcomes have been recorded. Staff say that these goals are being worked towards. Daily records showed that residents are able to make choices and decisions in their daily lives. Residents say that this is the case and were seen to make decisions during the visit. Records showed that residents can take reasonable risks subject to a personal risk assessment although these records had not been reviewed or updated for more than a year. Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16 and 17. Quality in this outcome area is good. The range of activities enjoyed by residents is varied and individually tailored and aims to increase their community presence. Residents are supported to develop and maintain personal relationships. Meals are nutritious and offer a varied diet with special diets being catered for. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Residents have a wide variety of activities that they participate in; several of them attended activities out in the community during the visit. Staff have planned activities so that residents have an increased presence in the community this includes one resident going to an FA football match. All of the Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 Page 12 residents have had a holiday of their choice and one of them was in America at the time of the visit. Residents are allowed personal space when they want it. Residents are well supported to develop and maintain personal relationships with family and friends. Relatives are kept well informed about residents’ wellbeing. Residents have a choice at mealtimes and lunchtime was very relaxed and informal and any support was provided to individuals in an unobtrusive manner. Liquid refreshments were also offered on a regular basis. Staff explained that the residents choose the menus and records of meals provided identify that meals are varied and nutritious with a health diet being encouraged. Residents said that they like the meals. Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. Quality in this outcome area is adequate. The healthcare needs of residents are recognized and appear to be being met but medical records need to be better kept so that residents can be confident that this is definitely the case. Residents are well supported with their personal care needs. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Staff were seen to provide all support, including that concerning personal care needs, in a way that promoted the residents’ privacy and dignity. Case tracking identified that each resident is registered with a GP. Whilst daily records showed that they are attending some appointments with various health care professionals and dentists their health records lack a lot of Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 Page 14 relevant, current information so it was not possible in all cases to check that all their health needs are being met. The manager explained that she has been provided with health profile forms that when completed for each resident will clearly detail all health related information. All of the residents have their medication administered by staff. This is well recorded and all medication is securely stored. Four of the care staff have undertaken appropriate medication training and others are currently undertaking it. This training has been booked for the newest recruit. Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is poor. Whilst concerns and complaints are being dealt with staff are not taking appropriate action to deal with residents’ protection so residents cannot be confident that they will be safe. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A comprehensive complaints procedure is followed. Two complaints have been made to the home since the last inspection both of which were fully and promptly addressed. Most of the residents can discuss any concerns with staff but where they are unable to do so staff observe behaviours and body language to identify any dissatisfaction. There is also an adult protection procedure in place although this had not recently been followed correctly. Information from the residents’ care manager the day after the visit identified that there had been a recent incident that might have included the abuse of one resident by another. This matter should have been reported straight away to the appropriate authority but was not. It was also identified that a similar incident had allegedly occurred some months before and once again this information had not been passed on to the appropriate authority nor had any action appear to have been taken to prevent such a circumstance happen again. Neither the manager nor staff spoken to Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 Page 16 made reference to either of these events during the site visit. All staff have some adult protection training during their induction although they have not had refresher training. During the site visit the manager explained that whilst no physical restraint is used on residents in the home at present staff have had some restraint training. She has been asked to check that the trainer is accredited with the British Institute of Learning Disabilities to ensure that the training given is to an acceptable standard. Some environmental restraints had recently been used for a short time to protect one of the residents. There was no record however of this resident having been risk assessed in respect of this danger prior to this action being taken. Twice daily checks of service users’ finances are undertaken. Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25 and 30. Quality in this outcome area is good. The standard of the environment is good and provides residents with a clean and comfortable home in which to live. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Shared areas including the kitchen, the lounge, dining room and bathrooms are well maintained, decorated, furnished and equipped. One of the residents showed me their bedroom. This was decorated and furnished to their personal taste and they said that they like it very much. The home has appropriate aids and adaptations to meet the needs of all of the residents. The home was clean, warm and tidy throughout and there is a separate laundry facility that is well equipped. Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36. Quality in this outcome area is adequate. The home is adequately staffed. Many of the staff have not however been supervized or trained well enough recently to give residents confidence that they are getting the best support possible. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Sufficient staff were on duty at the time of the visit and staff rosters indicate that the home is well staffed at all times. The manager explained that the home is fully staffed at present but that one carer is due to leave and this post will not be filled because the number of residents accommodated has dropped to four and no further admissions are planned. She confirmed however that there would be at least 2 staff on duty at any time. Personnel records of newly employed staff showed that robust recruitment procedures are followed including appropriate personnel checks. Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 Page 19 A newly recruited member of staff said he has undertaken induction and foundation training. All staff have basic training in adult protection, moving and handling, basic food hygiene and emergency aid. Refresher training has been booked for most of this training although the manager has been informed that the emergency aid course is over-subscribed so she has had to send a list of people requiring this training to the training department who will need to arrange a further course. Only two of the permanent care staff have completed their National Vocational Qualification, a further three are due to start in January 2007. The manager has given every staff member an appraisal since she has been in post but has not been able to give formal supervisions because of work commitments for St Annes Community services outside of the home. She said that she had had to offer the most recent recruit support via the telephone because conflicting work pressures resulted in her having had little time to spend in the home. Staff said the manager has held some staff meetings however. Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,41 and 42. Quality in this outcome area is poor. The home has not been managed well enough for some time resulting in some serious shortfalls in practice that could undermine the safety and quality of life of the residents. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The manager has yet to submit an application to the Commission for Social Care Inspection in order to become registered manager of the service. She has also yet to complete an appropriate management qualification. She said she has been able to spend very little time in the home since her appointment due to other work commitments for St Annes Community services outside of Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 Page 21 the home. This has impacted on the running of the home, on the quality of management of the staff team and the level and style of support available to staff members and residents. The service manager undertakes monthly quality audits of home. Residents’ views have been ascertained through person centred planning meetings and through residents’ meetings. The manager has also surveyed the views of relatives and has developed a mini plan for the home. Whilst some records are well maintained residents’ personal plans, healthcare records and risk assessments have neither been reviewed or updated well enough to provide good information about every resident. All records are securely stored. Monthly health and safety checks of the building are undertaken with any problems being reported to the maintenance department promptly. Fire safety is well maintained including regular fire safety checks and training for all staff. Other health and safety systems and records are well maintained including hot water storage and delivery temperatures. Fridge and freezer temperatures are recorded twice daily. Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 1 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 3 X 2 1 3 X 1 3 X Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 Page 23 Yes. 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 YA38 Regulation 8 (1) 9 Requirement The registered provider must submit an application for a registered manager to be processed. (This requirement remains outstanding from a previous report). Residents’ personal plans must be reviewed and updated as required but at a minimum of twice yearly. Residents’ risk assessments must be regularly reviewed and updated as required. A risk assessment must be undertaken of the resident concerned prior to any future decision being made about the use of restraint within the home. Individual health records must be completed to show that residents’ health needs are being fully met. Any witnessed or suspected incident of abuse to a resident must be reported immediately to the appropriate authority. DS0000007901.V320142.R01.S.doc Timescale for action 28/02/07 2. YA6 YA41 3. YA9 YA23 YA41 17 28/02/07 17 28/02/07 4. YA19 YA41 YA23 17 28/02/07 5. 13(6) 22/11/06 Norfolk Road (28) Version 5.2 Page 24 6. 7. 8. YA35 YA36 YA38 13(4) 18(2) 10 All staff must be provided with 28/02/07 emergency aid refresher training. All staff must be provided with 31/12/06 direct support and supervision by a manager. The home must be properly 22/11/06 managed at all times to ensure that residents get a good service and that staff are well supported. 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 YA32 YA37 YA38 Good Practice Recommendations A minimum of 50 of care staff should be qualified to NVQ level 2 or above. The manager should complete an appropriate qualification. The manager should be available to spend sufficient time in the home to manage it properly. Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Norfolk Road (28) DS0000007901.V320142.R01.S.doc Version 5.2 Page 26 - 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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