CARE HOME ADULTS 18-65
Old Rectory Somerton Road Winterton On Sea Great Yarmouth Norfolk Lead Inspector
Hilary Shephard Announced 11 August 2005 2.00pm
th 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. Old Rectory I55 s27438 oldrectory v236552 110805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Old Rectory Address Somerton Road, Winterton On Sea, Great Yarmouth, Norfolk, NR29 4AW 01493 393576 01493 393576 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) Royal Mencap Society Mrs Gillian Smith Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Old Rectory I55 s27438 oldrectory v236552 110805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: Up to seven (7) Service Users who have a learning disability may be accomodated Date of last inspection 3rd February 2005 Brief Description of the Service: The Old Rectory is a large Victorian house surrounded by gardens situated on the outskirts of the village of Winterton-on-Sea. Accommodation is on the first floor offering single bedrooms and spacious communal rooms. Old Rectory I55 s27438 oldrectory v236552 110805 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This planned announced inspection was carried out over six hours during which time the inspector spoke with six residents and 2 staff. Nine completed questionnaires were received from relatives/visitors and four from residents. The views of residents and staff, where appropriate, are reflected in the report. Information was also gathered from the homes records and the pre-inspection questionnaire completed by the manager. At the end of the inspection feedback was given to a member of staff. What the service does well: What has improved since the last inspection?
Improvements have been made to the way certain medication is stored and recorded. The manager has introduced a new format for supporting the residents with the development of independent living skills, and good documentation has been implemented with lots of input from the residents about how they want their lives to be. Old Rectory I55 s27438 oldrectory v236552 110805 Stage 4.doc Version 1.40 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. Old Rectory I55 s27438 oldrectory v236552 110805 Stage 4.doc Version 1.40 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 Old Rectory I55 s27438 oldrectory v236552 110805 Stage 4.doc Version 1.40 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) Not assessed at this inspection. EVIDENCE: Old Rectory I55 s27438 oldrectory v236552 110805 Stage 4.doc Version 1.40 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 and 9 Care plans are comprehensive and person centred providing clear guidelines enabling staff to understand and meet the residents’ needs. Risks are assessed and measures are put in place to promote residents safety. EVIDENCE: Three care plans were looked at and these contained very good assessments covering all aspects of the residents physical, emotional and social needs with guidelines in how these needs are to be met. The home has also introduced an active support programme, which is tailored to individual residents wishes for the future and indicates how they want to be supported in certain aspects of their lifestyle. Care plans were discussed with the residents who said that they make decisions about what they do each week and were helped by staff to make choices about their lifestyle. Risk assessments are in place for residents’ individual tasks, and these were discussed with two of the residents who wanted to talk about the possibility of them being left unaccompanied in the home for short periods of time. Although the risk assessments were comprehensive, they were very lengthy, and repeated information previously recorded in the care and active support plans, and a recommendation has been made.
Old Rectory I55 s27438 oldrectory v236552 110805 Stage 4.doc Version 1.40 Page 10 Old Rectory I55 s27438 oldrectory v236552 110805 Stage 4.doc Version 1.40 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) 17 Residents enjoy the food provided which was healthy, tasty and appealing. EVIDENCE: The residents invited the inspector to join them for their evening meal, which one of the residents had prepared (with staff support) and was enjoyed by all. Residents advised that meals were mostly prepared from fresh ingredients and that they helped to cook and clear away. Old Rectory I55 s27438 oldrectory v236552 110805 Stage 4.doc Version 1.40 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 are confident that staff monitor their health needs, will act upon changes, and provide good support as required. With the exception of creams and lotions the medication is managed and administered safely. EVIDENCE: Medication was inspected and was in good order with the exception of creams and lotions. These have been prescribed by the GP to be “given as directed” but there are no specific instructions for staff in how they are to be administered and a recommendation has been made. One resident administers his own medication under supervision and this has been risk assessed. Residents advised that the staff look after them very well, particularly when they have been poorly. Good interaction was observed between staff and residents. Comment cards received from residents, relatives and visitors indicated that they were satisfied with the care provided. Old Rectory I55 s27438 oldrectory v236552 110805 Stage 4.doc Version 1.40 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 The complaints procedure is good and available in different formats, residents know who to raise concerns with and staff have a good understanding about protecting residents from harm. EVIDENCE: The home has a standard MENCAP complaints procedure, which is available in text, pictures and on audiocassette, and residents advised they would take their concerns to staff. The home also has textural and pictorial details of how to contact the inspector. Seven out of the nine comment cards received from relatives/visitors indicated they were aware of the homes complaints procedure. The home has a standard MENCAP adult protection policy, which is detailed but lengthy and advises that reporting issues to social services will be in accordance with local multi-agency procedures. Staff couldn’t locate the homes copy of the local multi-agency procedure (Norfolk Adult Protection protocol) but were aware of the correct reporting procedure. Old Rectory I55 s27438 oldrectory v236552 110805 Stage 4.doc Version 1.40 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) Not assessed at this inspection. EVIDENCE: Old Rectory I55 s27438 oldrectory v236552 110805 Stage 4.doc Version 1.40 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) 33, 34 and 35 Residents are currently well supported by adequate numbers of experienced and trained staff, and a low staff turnover makes it difficult to properly assess the homes recruitment practices. EVIDENCE: Staffing levels were adequate and eight out of the nine comment cards received from relatives/visitors indicated they were always sufficient numbers of staff on duty. The pre-inspection questionnaire indicated that one member of staff had left since the previous inspection and new staff have been transferred from other MENCAP homes making it difficult to assess whether the home followed the correct checking procedures before staff commenced. The pre-inspection questionnaire indicates that staff have undergone a variety of training in the past year, staff advised they receive training from MENCAP in areas relevant to their work and demonstrated a good understanding of the residents needs. Old Rectory I55 s27438 oldrectory v236552 110805 Stage 4.doc Version 1.40 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) 39 and 42 The home monitors and reviews the quality of service provided, and is good at providing residents with a safe and well-maintained environment. EVIDENCE: A formal quality audit is undertaken each year and the results are compiled by MENCAP and fedback to staff and residents. The home completes monthly safety checks in the home and addresses any maintenance issues. Records of fire alarm testing, accidents and water temperatures were inspected and were satisfactory. Old Rectory I55 s27438 oldrectory v236552 110805 Stage 4.doc Version 1.40 Page 17 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 x 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x x x x x x 3 Standard No 31 32 33 34 35 36 Score x x 3 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Old Rectory Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x I55 s27438 oldrectory v236552 110805 Stage 4.doc Version 1.40 Page 18 None 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 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 9 20 Good Practice Recommendations The registered person is recommended to review all risk assessments to try and make them less repetitive and complicated. The registered person is recommended to review and amend all medicines that are prescribed to be given as directed with the homes GP, to ensure proper administration directions are completed on the medication administration records. Old Rectory I55 s27438 oldrectory v236552 110805 Stage 4.doc Version 1.40 Page 19 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
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