Inspection on 07/03/06 for Norfolk Road (28)

This inspection was carried out on 7th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 2 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) 22/11/06

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 Irene Ward Unannounced Inspection 7 March 2006 09:30 th Norfolk Road (28) DS0000007901.V282628.R01.S.doc Version 5.1 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.V282628.R01.S.doc Version 5.1 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.V282628.R01.S.doc Version 5.1 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.V282628.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th May 2005 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. Norfolk Road (28) DS0000007901.V282628.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report relates to an unannounced inspection carried out on the 7 March 2006, which started at 09.30 until 12.00. All four-service users were in at the time, but were in the process of getting ready to attend various day centres and training schemes. Individual discussions were held with all service users before they left the home. The homes manager was not available at the time of inspection. Both residential care officers on duty were able to assist throughout the process. A tour of the home was carried out which included all of the service users private accommodation. A selection of records was looked at and time was spent observing activity in the home, talking to service users and staff on duty. The focus of the inspection was a number of key standards. There were also discussions with the registered manager who was on duty. What the service does well: What has improved since the last inspection? Service users continue to enjoy various activities with support from the staff team. Staff training has been ongoing, which has strengthened the knowledge and understanding of staff in meeting the needs of service users living at 28 Norfolk Road. Norfolk Road (28) DS0000007901.V282628.R01.S.doc Version 5.1 Page 6 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) DS0000007901.V282628.R01.S.doc Version 5.1 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.V282628.R01.S.doc Version 5.1 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): 1,2 and 5 Prospective service users can be confident before moving into the home that their needs can be met. EVIDENCE: No new resident has been admitted to the home for a number of years. Care managers prior to service users moving into the home a number of years ago, as some of the service users have lived together since 1988 had carried out assessments. Regular reviews have been held to ensure that the home continues to meet the needs of service users living at the home. The Statement of Purpose and the Service User Guide are in the process of being updated. Both these documents are available in appropriate formats. Terms and Conditions of residency or Licence Agreements are held on individual service users files. Norfolk Road (28) DS0000007901.V282628.R01.S.doc Version 5.1 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 and 10 Service users are supported in making decisions about their personal lives. EVIDENCE: All four service users files were inspected. There are comprehensive plans of care in place, which have been regularly reviewed. Care plans were documented well and showed clearly that service users are consulted and where they themselves have made choices about their lives. The plans contained details of the service users daily living skills, personal care needs, interests and dietary needs. Risk assessments have been completed on different activities and the assessments are held on each service users file. Staff were observed to enable service users to be as independent as possible and also available to assist where necessary. The organisations policy regarding confidentiality is in place. All records regarding service users were in a locked cupboard in the office. Service users’ understanding of confidentiality is limited. Norfolk Road (28) DS0000007901.V282628.R01.S.doc Version 5.1 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 the following standard(s): 17 Service users dietary needs are met. EVIDENCE: The lunchtime meal is usually a snack. The main meal is in the evening as it is generally eaten when all the service users are home from activities and day centres. Service users said that the meals at the home are very good. Service users are involved in menu planning, shopping and the preparation of meals. From the records of food provision the home provides service users with a good varied diet. In discussions held with staff, service users are asked weekly as to what they would like to eat. However a new menu is to be introduced, which will also incorporate healthy eating. Norfolk Road (28) DS0000007901.V282628.R01.S.doc Version 5.1 Page 11 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): 19 and 21 Service users health care needs are well met. EVIDENCE: Care plans inspected indicated that the service users had contributed to them and in agreement with how their personal support needs were to be met. Arrangements are in place for service users to access health and social care professionals. The Harrogate District Hospital is accessed for any emergencies via the A & E department. Outpatient appointments are also made. In discussions held with the staff regarding the age range of service users. It was clear that they were aware of the needs of service users because of the ageing process. Discussions were also held in respect of death and dying. The organisations policy is in place. Staff stated that all the service users had funeral plans in place and that they are supported to attend funerals when there is a family bereavement. Norfolk Road (28) DS0000007901.V282628.R01.S.doc Version 5.1 Page 12 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 Service users complaints are listened to. EVIDENCE: The organisations complaints policy and procedures are in place. Service users are unable to make a formal complaint, however they are able to make their unhappiness known to staff, who address their concerns promptly. There have be no complaints received by the Commission For Social Care Inspection. One on-going complaint is being dealt with by appropriately by the organisation. Norfolk Road (28) DS0000007901.V282628.R01.S.doc Version 5.1 Page 13 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 and 30 The environment of the home is maintained to a good standard and provides service users with a clean and homely place in which to live. EVIDENCE: All four-service users bedrooms were inspected. Service users were all very proud of their rooms. They had been furnished to a good standard. Service users have personalised their own bedrooms. All communal areas of the home were warm, well lit, ventilated and clean. The home has sufficient bathrooms and toilets that were clean and well maintained. Norfolk Road (28) DS0000007901.V282628.R01.S.doc Version 5.1 Page 14 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): 32 Service users receive a good standard of care from a skilled and motivated staff team. EVIDENCE: No staff files were inspected on this occasion, as the homes manager was not available. The staff roster was inspected. This showed that there is two care staff on duty each shift. This does not include the manager. There is one staff member that sleeps in each night. There were a number of staff on sick leave and agency staff had covered shifts. The home currently has one full time vacancy and the recruitment for a staff member to join the team has been carried out. Norfolk Road (28) DS0000007901.V282628.R01.S.doc Version 5.1 Page 15 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 and 42 Service users’ health safety and welfare are not always promoted and protected. EVIDENCE: Throughout the time spent in the home and from discussions held with service users and staff and through observation, 28 Norfolk Road continues to be managed well with a committed staff team. The Commission has not yet received the manager application from the organisation for processing. The organisations health and safety policies and procedures are in place. A number of health and safety records were inspected which on the whole were up to date and accurately maintained. However weekly fire alarm tests had not been carried out in line with the requirements of North Yorkshire Fire and Rescue Service. Norfolk Road (28) DS0000007901.V282628.R01.S.doc Version 5.1 Page 16 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 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 X 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X 3 1 X X X X 1 X Norfolk Road (28) DS0000007901.V282628.R01.S.doc Version 5.1 Page 17 Are there any outstanding requirements from the last inspection? NO 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. The registered provider must ensure that fire alarms are tested in line with the requirements of North Yorkshire Fire and Rescue Service. Timescale for action 29/04/06 2 YA42 23(4) 07/03/06 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. Refer to Standard YA32 YA39 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 Celsius). 3. YA42 Norfolk Road (28) DS0000007901.V282628.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Norfolk Road (28) DS0000007901.V282628.R01.S.doc Version 5.1 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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