Inspection on 22/09/05 for Olive House

This inspection was carried out on 22nd September 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

Olive House 26/07/06

Olive House 12/01/06

Olive House 07/02/05

Olive House 23/08/04

Similar services:

Henrietta House

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Olive House Olive Avenue Newton Flotman Norwich Norfolk NR15 1PF Lead Inspector Kim Patience Unannounced Inspection 22nd September 2005 09:30 X10015.doc Version 1.40 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 Olive House DS0000027517.V252704.R01.S.doc Version 5.0 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 Older People. 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. Olive House DS0000027517.V252704.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Olive House Address Olive Avenue Newton Flotman Norwich Norfolk NR15 1PF 01508 471718 01508 471719 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) Mr Richard Gray Mrs Elizabeth Gray Mrs Elizabeth Gray Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35) of places Olive House DS0000027517.V252704.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2005 Brief Description of the Service: Olive House was erected in 1996 and is a purpose built residential home designed to provide accommodation to 35 older people. Accommodation is on the ground floor and all rooms are single with en suite facilities. The home is situated in the south Norfolk village of Newton Flotman in a quiet residential street and stands in its own grounds with a landscaped garden to the rear and a large car park to the front. Olive House DS0000027517.V252704.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took approximately 4 hours to complete. During the visit the inspector took a tour of the premises, inspected records held in relation to service users, interviewed service users and staff and observed service users and staff engaged in their normal daily routines. The manager was available throughout the inspection and was proactive in its execution. What the service does well: What has improved since the last inspection? What they could do better: No areas for improvement were identified on this occasion and as such, no requirements or recommendations have been made. Olive House DS0000027517.V252704.R01.S.doc Version 5.0 Page 6 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. Olive House DS0000027517.V252704.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Olive House DS0000027517.V252704.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4,5 Prospective service users and their relatives are provided with information about the home and given the opportunity to visit before making a decision to move in. The management ensure that pre-admission assessments are completed in order to provide clear information about peoples needs and to ensure that the home has the capacity to meet them. EVIDENCE: The home currently has a waiting list for people wishing to live there. When a referral is made to the home, either the manager or her deputy will conduct a home visit in order to assess the needs of the service user. The assessment contains all aspects of care and health needs, details of which are ascertained through discussion with the service user and/or relatives. The initial assessment is only brief and provides enough information to assess whether the home can meet the individuals needs. When the prospective service user reaches the top of the waiting list, a more detailed assessment is carried out. All prospective service users are invited to visit the home along with their Olive House DS0000027517.V252704.R01.S.doc Version 5.0 Page 9 relatives or friends if they wish; this enables them to make a judgement as to whether the home is suitable for them. In addition, the home provides detailed information about the service and facilities offered that includes the qualifications held by staff. Olive House DS0000027517.V252704.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Each service user has an individual service user plan that shows all their needs in respect of care and how the service should be delivered to meet those assessed needs. Health needs are written in the plan of care and detailed records show that the home has processes in place to ensure that needs are met appropriately. The home has systems in place to ensure the safe storage and administration of medication. Service users are treated with respect and their privacy is upheld. EVIDENCE: Service user records were inspected and contained detailed information about the individual and their needs. The plans were found to be well organised and information was easy to access. The pre-admission assessment or care needs assessment was available and formed the framework for the construction of further information. A general information sheet provides an overview of the residents needs leading to further information such as, a personal profile, health profile and a social profile. The information showed that people’s Olive House DS0000027517.V252704.R01.S.doc Version 5.0 Page 11 individual needs were being taken into consideration and areas such as preferred routines, hobbies and activities, likes and dislikes were noted. It is good practice to take the person-centred approach to care planning and shows respect for the individual’s rights. The preliminary care plans are signed by the service user where possible, and shows that they have been fully involved in the process. Care plans are subject to regular reviews involving the managers, care assistants and the residents. Care records are stored securely in the staff room. The records are easily accessed by staff and this is essential in order to ensure that staff have up to date knowledge concerning residents needs. Staff are responsible for keeping the records updated on a daily basis and daily records show that this is achieved. Current health care needs were included in the plan of care, along with medical history and current medication. Medical appointments were recorded when necessary and showed details of any medical intervention. Risk assessments were in place for areas such as, risk associated with behaviour and physical limitations. The home also has access to the falls clinic where residents can be referred if problems have occurred with falling. The clinic aims to support good practice in managing the risk of falls and will give advice on ways to reduce the risk. The medication procedures in the home were assessed in brief, and those elements inspected were found to be satisfactory. Medication is stored in a locked treatment room. For the most part medication is supplied by the dispensing GP in blister packs and dispensed from a lockable trolley that is fit for purpose. The medication administration records were inspected in conjunction with the blister packs and no errors were found. Medication that is required to be kept at a low temperature was stored appropriately in the fridge and the fridge temperature was being monitored daily. The assistant manager is responsible for the self-audit of medication on a regular basis and the PCT pharmacist carries out an annual audit. Staff with the responsibility for the administration of medication have been provided with Boots training initially and subsequent in-house training and up dates. During the inspection, four service users were interviewed. Each discussed their experience of living in the home and the care provided by staff. Overall, living in the home was a positive experience. Each felt that their needs were being met to their standard and that their rights were upheld. Staff were described as kind and caring and always considered issues of privacy. Staff were observed to knock before entering rooms and to approach people in a respectful manner. Olive House DS0000027517.V252704.R01.S.doc Version 5.0 Page 12 The service user records showed that people’s needs in respect of privacy and dignity were considered. (See above) Olive House DS0000027517.V252704.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14,15 People living in the home are encouraged to be autonomous and selfdetermining through a culture of involving people in the planning of the service and providing choice in respect of daily living. Meals provided at the home are of good quality and based on the nutritional needs of the residents and there are systems in place to consult with service users about the range and quality of meals offered. EVIDENCE: Service users interviewed talked about the way in which the home involved them in decision making on a daily basis. All stated that they could choose what time they wished to get up and go to bed and how they wanted their care delivered. Staff were described as considerate and always gave people the opportunity to make their own choices in respect of daily living. In order to assess the meals provided at the home, the cook was interviewed and the records in respect of food storage, preparation and meal planning were inspected. Menus are planned on a four-weekly basis and drawing information from various sources makes the decision about the meals offered. Service users are consulted using a questionnaire, which is sent out monthly and feedback is taken following every meal. Service users are given the opportunity to state what they would like to see on the menu and any Olive House DS0000027517.V252704.R01.S.doc Version 5.0 Page 14 individual requests are catered for. A menu sheet is distributed every day and staff ask service users what they would like to select from the menu planned for the following day. Alternatives are offered at this stage, allowing the cook to plan for any changes. Accurate records of dietary intake are kept on the menu sheets allowing the home to track changes in diets and any health issues arising from dietary intake. Nutritional needs assessments are carried out at the pre-admission stage and any special requirements are passed onto the cook so that she can meet those individual needs. The menu offers two main meal choices, two desserts and two teatime choices, however as mentioned previously, alternatives are offered if people wish for something different. Overall, the menus offer a wide variety of choice including fresh local produce. Service users reported the meals to be very good, well prepared and nicely presented. The records relating to fridge and food temperatures were inspected and in good order, food was seen to be appropriately stored. The home was awarded a gold award by environmental health for its overall high standards, which include those in the kitchen and those associated with food preparation. The cook has recently completed an intermediate food hygiene course and all staff involved in food preparation have completed the basic food hygiene training. Service users are given a choice of place they wish to eat and can take meals in their own room or in the dining room if they prefer. The dining room is nicely set out with tables seating small groups of people. It is pleasantly decorated and furnished, creating a nice comfortable place to take meals and socialise with others. Olive House DS0000027517.V252704.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 The home has systems in place to ensure that people’s views about the service are listened to and acted upon where necessary. The home has systems in place to ensure that service users are protected from the risk of abuse. EVIDENCE: The home has a complaints procedure that is included in the service users guide. Service users spoken with were aware of how to make a complaint if they wished to but had no cause to do so. There is a comments book in the reception area for visitors and relatives to make comments or complaints and a compliments book that was seen with numerous thankyou notes inside. No complaints have been made since the last inspection. The home has an adult protection policy and procedure in place for dealing with suspected incidents of abuse. The registered manager is very clear about the importance of the protection of vulnerable people and is undertaking the one-day adult protection training in order to be able to train others in this respect. All staff currently employed, have received adult protection training. There have been no incidents of adult protection in the last 12 months. Olive House DS0000027517.V252704.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 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, 26 This home offers accommodation and facilities of a high standard and has systems in place to ensure that standards of cleanliness and hygiene are maintained. EVIDENCE: A tour of the premises was conducted. The home features a large communal lounge where the majority of activities and entertainment takes place. In addition, there is a conservatory and a quiet lounge. All communal areas are nicely decorated and furnished to a good standard. To the rear of the home is a landscaped garden with garden furniture providing a pleasant place, for those who prefer to be outdoors, to sit. The building is well maintained throughout and a team of domestics are employed to ensure that good standards of cleanliness are maintained. As mentioned in standard 15, in August 2005, the home was awarded the gold award by environmental health for the overall high standards within the home. Olive House DS0000027517.V252704.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0 Standards not assessed on this occasion. EVIDENCE: Standards not assessed on this occasion. Olive House DS0000027517.V252704.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32, Service users and staff benefit from a manager who provides clear leadership and management creating a culture of continuous improvement and development. EVIDENCE: The manager, Liz Gray, is registered with the commission and has undergone a fit person assessment in order to determine that she is of good character and integrity and able to fulfil her responsibilities as a manager. Mrs Gray has completed her registered managers award and is an NVQ assessor. She holds values and principles that are consistent with providing choice and enabling people to be autonomous and self-determining and clearly demonstrates the ability to influence others to the same effect. Olive House DS0000027517.V252704.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 N/A 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 N/A 13 N/A 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 N/A 18 3 4 N/A N/A N/A N/A N/A N/A 4 STAFFING Standard No Score 27 N/A 28 N/A 29 N/A 30 N/A MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 N/A N/A N/A N/A N/A N/A Olive House DS0000027517.V252704.R01.S.doc Version 5.0 Page 20 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. 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. Refer to Standard Good Practice Recommendations Olive House DS0000027517.V252704.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Norfolk Area Office 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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