Inspection on 09/08/05 for Salcasa

This inspection was carried out on 9th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Salcasa 26/09/08

Salcasa 27/09/06

Salcasa 01/04/05

Salcasa 25/10/04

Salcasa 20/04/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

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Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Salcasa Coltishall Road Buxton Norfolk NR10 5HB Lead Inspector Lella Andrews Unannounced 9 August 2005, 15:15 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. Salcasa I55 s27652 Salcasa v243228 UN 090805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Salcasa Address Coltishall Road, Buxton, Norfolk. NR10 5HB. 01603 278268 01603 278268 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) Jeesal Residential Care Services Ltd Cefyn Lloyd Care Home 5 Category(ies) of Learning disability 5 registration, with number of places Salcasa I55 s27652 Salcasa v243228 UN 090805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Five (5) Service Users with Learning Disabilities may be accommodated. Date of last inspection 1st April 2005 Brief Description of the Service: Salcasa is a detached five bedroom bungalow in the village of Buxton, near to Norwich. The Home is owned and managed by Jeesal Residential Care Services Ltd. Salcasa is situated a few doors away from Ashwood House which is a larger Care Home owned by the same organisation. Over the last year the registration has increased so that accommodation is now provided for up to five service users with a learning disability. An extension has recently been completed at the Home which provides an annexe with its own ensuite bedroom, kitchen and lounge. The other four bedrooms are within the main bungalow. Salcasa I55 s27652 Salcasa v243228 UN 090805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection was unannounced and took place between 3.15pm and 5.45pm on Tuesday 9th August 2005. One of the deputy managers assisted the Inspector with information, verbally and through the provision of records. The Inspector spoke to one member of staff on an individual basis and spent time in the lounge with the tenants and staff. The Inspector saw the communal areas of the Home and also saw one of the bedrooms which has recently had an ensuite toilet and shower added. There are currently four tenants living at the Home. What the service does well: What has improved since the last inspection? One of the bedrooms has had an ensuite shower/toilet added which provides greater privacy for the tenant. A porch has been added to the front of the Home and new kitchen cupboard doors have been fitted. An additional member of staff has been employed and there are no vacancies currently in the staff team. Salcasa I55 s27652 Salcasa v243228 UN 090805 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. Salcasa I55 s27652 Salcasa v243228 UN 090805 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 Salcasa I55 s27652 Salcasa v243228 UN 090805 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) none of these standards were inspected EVIDENCE: There have been no new admissions to the Home for over a year and so Standard Two, with regard to the assessment procedure, was not inspected Salcasa I55 s27652 Salcasa v243228 UN 090805 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) 7 and 8 Tenants are encouraged to make as many decisions for themselves as possible and are given appropriate support to do so. Tenants are consulted on and participate in aspects of life in the Home. EVIDENCE: Staff understand the importance of communication to enable the tenants to have a good understanding on which to base their decisions. Staff receive training with regard to alternative forms of communication. Some staff have received training with regard to Person Centred Planning as a style of care planning and one of the tenants said that she is still working on her plan with the staff. Staff were observed offering choices in a variety of situations and encouraging tenants to make their own decisions. Explanations were provided if staff were not able to meet a request. Tenants meetings are held on a weekly basis. The tenants told the Inspector that they discuss the menus for the forthcoming week, activities that they wish Salcasa I55 s27652 Salcasa v243228 UN 090805 Stage 4.doc Version 1.40 Page 10 to do, staffing issues and any planned events within the Home. Minutes are kept of these minutes and these were seen by the Inspector. The systems for assisting tenants with their finances were not inspected on this occasion. Salcasa I55 s27652 Salcasa v243228 UN 090805 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) 11 and 16 The personal development of the tenants is encouraged in an individual way The tenants rights are respected EVIDENCE: As previously mentioned, the staff support the tenants to develop their communication skills so as to be able to make their own decisions and communicate their points of view. The staff are aware of the importance of supporting the tenants to maintain and develop their independence in a range of issues. Tenants are encouraged to take part in household tasks and are assisted to do so by staff in appropriate ways. The daily routines within the Home are flexible bearing in mind that three of the tenants attend formal day services during the week and so there is a need to be ready on time in the mornings. Three of the tenants were out when the Inspection started but they arrived shortly after and it was noted that they Salcasa I55 s27652 Salcasa v243228 UN 090805 Stage 4.doc Version 1.40 Page 12 were encouraged to talk about their day and to relax in whatever way they wished to before the evening meal. Dependent on the risk assessment, tenants have a key to their bedroom door. One of the tenants has their bedroom in the annexe but is able to spend time in the main bungalow if they wish to. Other tenants are invited to spend time in the annexe also. Tenants can choose whether to spend time in the lounges or to be alone in their room. Staff spend their time with the tenants. Everyone had their evening meal together and this was a social occasion with lots of conversation about what everyone had been doing that day. Salcasa I55 s27652 Salcasa v243228 UN 090805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 Tenants receive personal support in the way that they prefer Tenants physical and emotional health needs are met The medication procedure is a safe system but there is a need for the Manager to monitor the system to ensure that it is being adhered to EVIDENCE: The care plans contain information about how the tenants prefer their support to be provided. Staff were heard to ask tenants before offering support. Staff were observed supporting tenants in potentially difficult situations and this was done with patience, sensitivity and consistency. The Inspector was advised that on the few occasions when there are only male staff on duty one of the male staff goes to work at Ashwood House and a female member of staff from Ashwood comes to this Home. This situation is not ideal but the Inspector was advised that it does not happen on a regular basis and it does ensure that the female tenants have female staff to support them with personal care. The Inspector looked at the health care plan for one of the tenants who has recently required two stays in hospital. The staff provided 24 hour support to Salcasa I55 s27652 Salcasa v243228 UN 090805 Stage 4.doc Version 1.40 Page 14 the tenant whilst they were in hospital as well as ensuring that the Home had enough staff. The staff should be commended for the support that was provided to the tenant whilst they were unwell. The care plans shows that other professionals have been involved on an ongoing basis to assess and plan care to meet the tenants health care needs. The Home has a medication procedure which states that two staff are involved in the administration of medication at all times. Medication is stored appropriately and the Inspector was advised that all staff who administer medication have received training. The organisation has recently implemented a new, detailed form of medication training which the new member of staff is due to attend shortly. It is recommended that a written record is kept of the medication that is provided when a tenant goes home for the weekend and of the staff who have prepared this. Medication was present in a small pot which had a handwritten label. The deputy manager advised that this medication is no longer in use, and had not been for over a month. It is required that medication which is no longer in use is returned to the pharmacy as soon as possible. Salcasa I55 s27652 Salcasa v243228 UN 090805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Neither of these standards were inspected EVIDENCE: N/A Salcasa I55 s27652 Salcasa v243228 UN 090805 Stage 4.doc Version 1.40 Page 16 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) 24 and 30 The tenants live in a homely and comfortable home which is clean and hygienic EVIDENCE: The Inspector looked around the communal areas of the Home and also saw one of the bedrooms as it has recently had an ensuite shower and toilet added. The Home was clean and tidy at the time of the Inspection. The tenants share a lounge/dining room which has a conservatory area attached to it. One of the tenants has a bedroom in the annexe and there is also a lounge which they have use of. The Inspector was advised that other tenants are often invited to share the lounge in the annexe. The Home has a small laundry room which is kept locked although tenants are encouraged to assist staff with laundry tasks. Laundry has to be taken through the lounge/dining room to the laundry and staff are aware of appropriate hygiene precautions. The Home has an ongoing plan of maintenance and refurbishment. The kitchen cupboard doors have recently been replaced and a porch has recently been added to the front of the Home. Salcasa I55 s27652 Salcasa v243228 UN 090805 Stage 4.doc Version 1.40 Page 17 The addition of the ensuite bathroom to one of the bedrooms is positive and increases the privacy afforded to that tenant. The Home has a large garden which is well maintained. It is recommended that the patio area is made more level to reduce the risk of trips/falls. Salcasa I55 s27652 Salcasa v243228 UN 090805 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 The tenants are supported by an effective staff team EVIDENCE: The Inspector was advised that there are currently no vacancies as a new member of staff started work at the Home two months ago. The rotas show that there are times when there are three members of staff on duty during the evenings which enables tenants to go out during the evening if they wish to. However, there were many evenings when this was not taking place due to staff annual leave over the summer. On alternative fortnights there are only three tenants at the Home as one of the tenants goes away at those times. The staffing levels are not reduced at those times and so there is a higher staff ratio which makes it easier to go out and access social activities. Staff advised that they feel that they are able to support tenants to take part in social activities on a regular basis. The majority of the staff working at the Home have worked there for some time and know the tenants well. Observations show that there are relaxed and friendly relationships between tenants and staff. Salcasa I55 s27652 Salcasa v243228 UN 090805 Stage 4.doc Version 1.40 Page 19 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) 42 The health, safety and welfare of the tenants are promoted and protected EVIDENCE: The staff are aware of health and safety issues and all receive training within their induction with regard to this area. The Inspector was advised that the Home has a COSHH manual and cleaning materials were seen to be stored appropriately. Staff are aware of risks associated with individual tenants, including those associated with behaviours which can be challenging. Risks are assessed and written guidance is available for staff. The Inspector saw the certificates for the maintenance and servicing of the fire safety equipment. A record is kept of fire training provided to the staff. It is recommended that a record is kept of the names of staff involved in fire drills to ensure that all staff take part in one on a regular basis. Recently there was Salcasa I55 s27652 Salcasa v243228 UN 090805 Stage 4.doc Version 1.40 Page 20 a small fire at the Home caused by workmen and the staff dealt with this appropriately. Staff undertake Food Hygiene training as they are responsible for preparing meals. Salcasa I55 s27652 Salcasa v243228 UN 090805 Stage 4.doc Version 1.40 Page 21 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 x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 3 x x x x 3 x Standard No 31 32 33 34 35 36 Score x x 3 x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Salcasa Score 3 4 2 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x I55 s27652 Salcasa v243228 UN 090805 Stage 4.doc Version 1.40 Page 22 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 20 Regulation 13 (2) Requirement The registered person must ensure that medication that is no longer in use is returned to the pharmacy as soon as possible Timescale for action Immediate and ongoing 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. Refer to Standard 20 Good Practice Recommendations It is recommended that a record is kept of medicaton which is given to relatives when tenants go away for the weekend and the name of the staff who were responsible for this It is recommended that the patio is levelled out so that it reduces the risk of trips/falls It is recommended that a record of the names of staff attending fire drills is kept 2. 3. 24 42 Salcasa I55 s27652 Salcasa v243228 UN 090805 Stage 4.doc Version 1.40 Page 23 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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