Inspection on 14/02/07 for Oliver Court

This inspection was carried out on 14th February 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Oliver Court 05/02/08

Oliver Court 27/02/06

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

CARE HOME ADULTS 18-65 Oliver Court Bath Hill Terrace Great Yarmouth Norfolk NR30 2LF Lead Inspector Maggie Prettyman Unannounced Inspection 14th February 2007 09:20 Oliver Court DS0000065549.V330684.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 Oliver Court DS0000065549.V330684.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. Oliver Court DS0000065549.V330684.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Oliver Court Address Bath Hill Terrace Great Yarmouth Norfolk NR30 2LF 01493 332552 01493 334380 john.matheron@ntlworld.com 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) Mrs Jane Allison Matheron Mr John Edward Matheron Mr Roger Laurence Beevis Care Home 11 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (11) of places Oliver Court DS0000065549.V330684.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. In the absence of the manager, a senior member of staff must be on duty during the waking day (between the hours of 8am and 10 pm) 7 days per week. The registered numbers will be increased to 11 allowing one of the flats to be used by a co-habiting couple. 27th February 2006 Date of last inspection Brief Description of the Service: Oliver Court opened in October 2005 and is situated adjacent to the owners other care home, Appleton Lodge. Oliver Court is a three-storey building comprising of 10 flats situated near to the centre of Great Yarmouth. Oliver Court provides care and accommodation for up to 11 people aged between 18 and 65 who have mental health problems. The home provides residents with individual flats, which include a small kitchen with washing machine, fridge, freezer and cooker. The flats also have their own bathroom, separate bedroom and living room. Two flats are situated on the ground floor; the others are on the first and second floors. The weekly range of fees is £380 - £1110. Oliver Court DS0000065549.V330684.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups, which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out using information from previous inspections, information from the providers, the residents and their relatives as well as others who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the home and current judgements for each outcome group. What the service does well: What has improved since the last inspection? This home has made many improvements since its first inspection. Requirements and recommendations made about the system of medication have been implemented. Staff are now more fully vetted prior to employment and fire safety has been improved. In addition the home, its staff and service users, have worked hard together to develop community links and to access local facilities. People who live in the home have made a positive and constructive input into how this new resource has developed to meet their needs and those of prospective service users. Oliver Court DS0000065549.V330684.R01.S.doc Version 5.2 Page 6 What they could do better: Some requirements and recommendations have been made at the end of this report as follows; Requirements; • • • Requirement CRB and POVA checks must be in place for all staff before they undertake unsupervised duties. Mandatory training must be given and updated for all staff All notifiable incidents must be reported to the Commission and other relevant organisations Recommendations • • • Health care notes should be separate to facilitate review. Adult protection training should be given to all staff. Good recruitment practice given in “Safe and Sound” should be implemented. 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. Oliver Court DS0000065549.V330684.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 Oliver Court DS0000065549.V330684.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): Standard 2 Prospective service users individual needs and aspirations are assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of service users files as well as discussions with the manager and service users demonstrated that comprehensive assessments are made prior to service users moving in to the home. Oliver Court DS0000065549.V330684.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): Standards 6, 7 and 9. Service users know that 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 supported to take risks as part of an independent lifestyle. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of service users personal files demonstrated that comprehensive care plans are in place for service users. Discussion with service users and staff as well as examination of personal files and records of service user meetings demonstrated that service users make decisions about their lives with assistance as needed. Individual and detailed lifestyle risk assessments were found in all service user files examined. Oliver Court DS0000065549.V330684.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17 Service Service Service Service Service users users users users users take part in activities that suit them. are part of the local community. have appropriate personal relationships. rights and responsibilities are recognised. are supported with advice about healthy diet. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Discussion with service users and staff demonstrated that a wide variety of occupational and educational activities are offered to service users. College courses are attended and qualifications achieved, employment and meaningful activity is encouraged. Oliver Court DS0000065549.V330684.R01.S.doc Version 5.2 Page 11 Service users report that the local community is supportive and accepting. The home is not seen as being different to other houses in the street. It is well situated and accessible to local shops and the wider community. Examination of service user files and discussion with service users and staff demonstrated that personal relationships are well supported. Service users children are encouraged to visit, and the staff go to great lengths to support service users in maintaining these essential family and personal links. Discussion with service users and examination of personal files and procedures in the home demonstrated that service users have individual and personal routines. Independent lifestyle decision and personal choice is fully supported. Most service users cook independently for themselves. Those service users identified to be at risk of poor nutrition or those developing cooking skills are provided with cooked food from Appleton Lodge or offered dietary supplement as appropriate. Complete choice of diet is available in both instances. Oliver Court DS0000065549.V330684.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 Service users receive personal support in the way they prefer and require. Service users physical and emotional health needs are met. Service users are supported to be self-medicating where appropriate and are protected by the homes medication policies and procedures. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of personal files as well as discussion with service users and staff demonstrated that service users are supported to maximise their privacy, dignity and personal control. A key worker system is in place and service users express satisfaction in the way that staff work alongside them. Examination of service users files demonstrated that health care needs are continually being monitored, supported and recorded. It is recommended that these elements of service user support be recorded separately to ensure that a clear medical history is maintained for each service user. Oliver Court DS0000065549.V330684.R01.S.doc Version 5.2 Page 13 The requirements and recommendations made in the last inspection report have been implemented. Service users manage their own medication within a risk-assessed framework. Medication records and storage were inspected and found to be satisfactory. Oliver Court DS0000065549.V330684.R01.S.doc Version 5.2 Page 14 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): Standards 22 and 23 Service user comments and concerns could be better recorded and audited. The home needs to address adult protection training issues in order that service users are fully protected. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No complaints have been recorded in the home since the last inspection. However one serious complaint about a worker and other minor complaints and concerns were identified during the inspection. The homes records and discussion with service users demonstrated that these issues had all been dealt with effectively by the home. The home is in the process of developing a system of recording and auditing such issues. It is recommended that the home implements this system of recording and auditing concerns, complaints and compliments about the service. Examination of staff training records and discussion with the manager demonstrated that staff do not have specific adult protection training. It is recommended that specific adult protection training be given to all staff. Oliver Court DS0000065549.V330684.R01.S.doc Version 5.2 Page 15 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): Standards 24 and 30 Service users live in a homely, comfortable and safe environment. The home is clean and hygienic. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A tour of the premises as well as a service user inviting the inspector to see their flat demonstrated that the environment is of a high standard and that service users have their personal and private possessions around them. The home is well situated close to local amenities. All areas of the home are accessible to service users. Requirements and recommendations made at the last inspection relating to fire safety have been implemented. Examination of care plans demonstrated that service users at risk of selfneglect are properly risk assessed and supported with life skill development. Infection control training is taking place shortly for all staff. Oliver Court DS0000065549.V330684.R01.S.doc Version 5.2 Page 16 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): Standards 32, 34 and 35 Service users are supported by competent and qualified staff. Service users are not fully protected by the homes recruitment policies and practices. Mandatory training is not always in place for staff. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Inspection of staff files as well as discussion with service users and staff and observation of interaction during the inspection demonstrate that staff have the right personal skills and experience. They are accessible, approachable, interested, committed and listen carefully to service users. A high level of understanding, respect and compassion is demonstrated. Approximately 60 of staff have NVQ qualifications, with other staff having commenced or commencing training in the near future. Oliver Court DS0000065549.V330684.R01.S.doc Version 5.2 Page 17 Examination of staff files demonstrated that some improvements in staff vetting required at the last inspection have been implemented. However CRB and POVA clearance is not always in place prior to staff commencing unsupervised work. It is required that the home ensures that CRB and POVA clearance is gained on all staff prior to commencing unsupervised work at the home. It is recommended that the good practice guidelines identified in the CSCI document “Safe and Sound” be implemented by the home to further strengthen its recruitment procedures. Inspection of staff files and training records demonstrated that induction training is in place for all staff, and that training is recorded and planned. However not all mandatory training is being provided for staff. It is required that all mandatory training is in place for staff and is renewed according to the regulations. Oliver Court DS0000065549.V330684.R01.S.doc Version 5.2 Page 18 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): Standards 37, 38, 39, 41 and 42 Service users benefit from a well run home. Service users benefit from the ethos, leadership and management of the home. Service users views underpin the development of the home. Not all notifiable incidents are reported. The health, safety and welfare of service users are mainly promoted and protected. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Oliver Court DS0000065549.V330684.R01.S.doc Version 5.2 Page 19 EVIDENCE: The manager of the home is an experienced and competent person. He has yet to achieve his NVQ 4, but this is in process and he is being given the time and space to study by the proprietors of the home. Discussion with service users, pre inspection information and observation of the home by the inspector demonstrate that the manager and his team have created an exceptionally open, positive and inclusive atmosphere. Regular meetings and daily interaction encourage feedback and comment. The style of management is open and warm, with senior staff implementing and encouraging this positive management style at all times. An independent Quality Assurance assessment has been undertaken, with comments and views of service users recorded. Information from the Pre Inspection Questionnaire and evidence on the day demonstrated that not all notifiable incidents are reported. It is required that all notifiable incidents are reported to the Commission and other relevant authorities without delay. A tour of the premises and examination of records demonstrated that the home is well maintained in respect of Health and Safety. Requirements about implementation and update of staff mandatory training have been made elsewhere in this report Oliver Court DS0000065549.V330684.R01.S.doc Version 5.2 Page 20 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 X 3 4 3 X 2 2 X Oliver Court DS0000065549.V330684.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? YES 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 YA34 Regulation 19 Requirement REPEATED REQUIREMENT The registered person must ensure that two written references and a POVA first check is received PRIOR to staff’s commencement. A designated person must also supervise staff until a satisfactory enhanced CRB is received. Mandatory training in Health and Safety must be given and updated in accordance with the regulations All notifiable incidents must be reported to the Commission and other relevant authorities without delay. Timescale for action 31/03/07 2 YA35 13 30/06/07 3 YA41 37 31/03/07 Oliver Court DS0000065549.V330684.R01.S.doc Version 5.2 Page 22 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. 4. Refer to Standard YA19 YA22 YA23 YA34 Good Practice Recommendations It is recommended that service user healthcare notes be separated to improve clarity of recording and to assist review. It is recommended that the home records and audits concerns, complaints and compliments about the service. It is recommended that specific Adult Protection training be given to all staff. It is recommended that the good practice recommendations of “Safe and Sound” be implemented by the home. Oliver Court DS0000065549.V330684.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Oliver Court DS0000065549.V330684.R01.S.doc Version 5.2 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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