Inspection on 28/08/07 for Shalimar

This inspection was carried out on 28th August 2007.

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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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Bramley Avenue (73)

Paradise Lodge

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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 Shalimar Beech Avenue Taverham Norwich Norfolk NR8 6HP Lead Inspector Andy Green Unannounced Inspection 28th August 2007 11:30 Shalimar DS0000068106.V350248.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 Shalimar DS0000068106.V350248.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. Shalimar DS0000068106.V350248.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Shalimar Address Beech Avenue Taverham Norwich Norfolk NR8 6HP 01603 869713 01603 869713 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) New Boundaries Community Services Ltd Mrs Sally Cumbers Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Shalimar DS0000068106.V350248.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered manager may only be additionally responsible for those services operated by the proprietor that are situated within a two mile radius of Shalimar. 22nd August 2006 Date of last inspection Brief Description of the Service: Shalimar is a five bed roomed bungalow in Taverham providing accommodation, care and support to five people with a learning disability. The home is situated in an established residential area approximately five miles outside the city of Norwich. The service was opened in September 2002 and is provided by New Boundaries Community Services Ltd The property has been modified and extended and stands in substantial grounds within a residential housing area. Each of the bedrooms are single and ensuite. There are shared facilities including; kitchen, laundry, dining and lounge areas. There are large garden areas at the front and rear and car parking is available for visitors and staff. The home also has its own transport. There is access to local facilities including shops and pubs. Residents living in the home access a combination of day services operated by the proprietor in North Walsham and other services available locally. The weekly charges range from £1350 to £3000. Copies of CSCI reports are made available to residents and their relatives upon request. Shalimar DS0000068106.V350248.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Andy Green, Regulation Inspector, undertook this key unannounced inspection on 28th August 2007. A number of records were inspected including care plans, training records, health and safety records and staff files. A tour of the building and grounds was also undertaken. The inspector also met two residents to gather their views regarding the services offered in the home. Two members of staff were also interviewed to gather their views of the service, training and support they received. Comment cards were also received from two residents. What the service does well: What has improved since the last inspection? What they could do better: Activities/weekly programmes that residents are involved in must be recorded in care plans. A complaints log book must be implemented to ensure that all concerns and complaints are recorded and the action that has been taken. Adequate locks must be fitted to all exits to meet fire safety requirements. Shalimar DS0000068106.V350248.R01.S.doc Version 5.2 Page 6 Decoration and refurbishment in the communal areas and bedrooms must be undertaken to provide a more comfortable and homely surroundings. It is recommended that the gardens are developed to provide more planted and areas of seating. It is recommended that a computer/printer is installed to assist with the management processes in the home. 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. Shalimar DS0000068106.V350248.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 Shalimar DS0000068106.V350248.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): 2 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. There is an effective assessment process to ensure that the home can meet the resident’s needs. EVIDENCE: There have not been any admissions to the home since the last inspection. However, one person has recently been assessed and it is anticipated that they will move in by the end of September. The home makes sure that detailed assessment information is received to ensure that the home can meet the individual’s assessed needs. Reports are received from a variety of healthcare professionals. Relatives are also encouraged to be involved in the referral process where appropriate. The inspector was shown information that had been received for the person who has been recently assessed. Information was thorough and included the home’s own assessment to ensure that all health, care and support needs can be met. Staff confirmed that they were given information about the person before they moved into the home. Shalimar DS0000068106.V350248.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): 6,7,9 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. Care plans contain information and guidelines to ensure that assessed needs can be met. EVIDENCE: Since the last inspection the organisation has implemented a new care planning process which is presented in a more person centred format. The home is in the process of completing all care plans in this new format. Two of the care plans were seen. They contained detailed information about the residents and how their care and support needs should be met. The care plans contain information about the individual residents preferred choices about a range of issues. There was evidence to show that residents participate as much as possible in the care planning process and their personal needs, preferences and dislikes are clearly recorded. There was also evidence that reviews of care and support take place to include any updates or changes in care. Shalimar DS0000068106.V350248.R01.S.doc Version 5.2 Page 10 It was noted, however, that the range of activities that residents are involved in during the week were not recorded in care plans. The manager stated that a new sheet would be added to detail the variety of regular activities undertaken and the social activities and interests that each resident prefers. The staff were observed to support residents in an appropriate and social manner including domestic and social interactions. One of the residents also continues to receive support from an advocate. Staff confirmed that they were involved in the care planning process and completed daily notes regarding what residents had been involved in during their day both in and outside the home. Evidence was seen to support this. During the inspection the manager stated that one of the residents had not received a review from his placing authority since 2005. The resident in question has a variety of complex needs and the manager stated that she is pursuing this outstanding review with the placing authority. Shalimar DS0000068106.V350248.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. The residents are enabled to take part in a range of activities to maintain their independence and lifestyle. EVIDENCE: A number of residents attend the day centre owned by the Proprietor. Staff from the Home support the residents whilst they are at the Centre on a one to one basis. Sessions include social skills, cookery and horticulture. One of the residents attends another day service in Norwich and one resident does not attend any formal day service due to personal choice. Residents also participate in trips to the local pubs, car boot sales and daytrips to local towns and resorts at weekends with support from staff. The home has its own transport to ensure residents can easily access the community. Shalimar DS0000068106.V350248.R01.S.doc Version 5.2 Page 12 The staff receive training with regard to communication to ensure that they are skilled in assisting residents to maximise their independence and be able to make their own choices. The staff were heard to assist residents in making choices throughout the day. Residents are encouraged to take part in household tasks as much as possible including washing up and assisting with laundry. Residents are also involved in the preparation and cooking of the evening meal where possible. Meals are a sociable occasion with staff eating with the residents. Residents can choose meals that are provided and contribute to the planning of menus and can make drinks and snacks throughout the day. The care plans contain details about any particular dietary needs that the residents have. The residents are encouraged and supported to maintain relationships with their friends and relatives. Shalimar DS0000068106.V350248.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. The residents receive healthcare and personal care in a respectful way to meet their assessed needs EVIDENCE: Residents are assisted with personal care as required including bathing and hair washing. Staff were observed to respect residents privacy and dignity and knocked on bedroom doors prior to entering. The care plans have guidelines for staff detailing how the residents like to receive support with personal care. The staff spoken to were aware of the healthcare needs of the residents and ensure that care plans are kept up to date so that healthcare needs are well monitored. Residents have regular appointments with dentist and opticians. The care plans contain information from other health professionals involved in the resident’s life. The medication system was inspected and records were accurate. Staff receive medication training which is updated every two years. Shalimar DS0000068106.V350248.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): 22,23 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. There is a procedure for ensuring that all complaints and concerns are adequately dealt with but they are not adequately recorded. EVIDENCE: The home’s complaints procedure ensures that all concerns are fully investigated and actioned appropriately. The complaints policy/procedure is explained to residents and their relatives. There have been no complaints raised with the home since the last inspection. CSCI has also not received any complaints since the last inspection. It was noted, however, that a complaints recording book needs to be implemented to ensure that all concerns and complaints are recorded detailing the actions/investigations that have been taken. The manager stated that this would be actioned. A requirement will be made regarding this issue. Shalimar DS0000068106.V350248.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): 24,25,30 Quality in this outcome group is adequate. This judgement has been made using available evidence including a visit to the service. The home is comfortable and well furnished to meet the needs of the residents. Improvements need to be made to the decor and flooring so that residents have a more pleasant environment in which to live. EVIDENCE: A tour of the home was undertaken. The home is comfortably and attractively furnished throughout and meets the needs of the residents who live there. Each resident has an ensuite bedroom which is personalised to meet their preferences. There is also a large lounge, dining area, kitchen, laundry room and a large conservatory for communal use. There are gardens to the front and rear of the premises for residents to use. It was noted that the decor in the communal areas is now in need of an upgrade as the paintwork is scuffed and damaged in a number of areas. The home would benefit from a wider range of colours as the current decor has drab appearance. A requirement will be made regarding this issue. Shalimar DS0000068106.V350248.R01.S.doc Version 5.2 Page 16 The carpets in bedrooms are deteriorating and looking worn in a number of areas. An audit must be undertaken by the provider and carpets must be replaced as required. A requirement will be made regarding this issue. It is also recommended that the gardens are redeveloped in a more creative way including more areas of seating. Although they are well maintained, in a basic manner, the gardens would benefit from landscaping and more colourful planted areas. The manager agreed with this recommendation and will discuss ideas with the maintenance department. Shalimar DS0000068106.V350248.R01.S.doc Version 5.2 Page 17 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): 33,34,35,36 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. Staff receive appropriate training and supervision to carry out their roles effectively. EVIDENCE: The rotas show that there was adequate staffing provided to meet the assessed needs of service users. During the inspection there were sufficient staff to assist residents. Three of the personnel files were seen and these contained the required records including references, CRB/POVA checks and proof of identity. The training records show that staff continue to receive appropriate induction and training. The organisation’s training co-ordinator organises regular updates and refreshers regarding mandatory health & safety and care issues and on an ongoing basis throughout the year. A new induction programme has been implemented which is in line with Skills for Care guidance. Shalimar DS0000068106.V350248.R01.S.doc Version 5.2 Page 18 Supervision of staff has improved since the last inspection and records show that staff have received regular formal supervision. Staff confirmed that they felt supported by the manager and the team leader and that they were able to raise any issues or concerns regarding the service. Shalimar DS0000068106.V350248.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Quality in this outcome group is good. This judgement has been made using available evidence including a visit to the service. The home is well managed and the manager provides supportive leadership to ensure that good quality care and support is delivered. EVIDENCE: The home is run by an experienced, enthusiastic and knowledgeable manager. She is completing an NVQ Level 4 and will be enrolling on the RMA soon. She continues to undertake all other relevant training that is provided. The training co-ordinator, who was visiting during the inspection, stated that a package of management courses was also being devised to provide all of the organisation’s managers with improved skills and knowledge. The manager also has responsibility for managing three other, smaller, homes that the organisation owns but she is based within this home. She confirmed that she receives regular supervision from her line manager. The team leader Shalimar DS0000068106.V350248.R01.S.doc Version 5.2 Page 20 continues to provide management support when the manager is not present in the home. An on-call manager is available to staff during out of office hours. Regular monthly management visits are made and evidence of reports were seen during the inspection. Health and safety records were seen and evidenced that regular testing, and servicing is carried out for equipment, including fire safety equipment. A recent fire risk assessment of the premises has been undertaken which highlighted that appropriate locks need to be installed to all exits. A requirement will be made regarding this issue. It was noted that the home does not have sufficient resources to undertake some management/administrative processes. It is recommended that a basic computer and printer set up would improve the ability to create and complete appropriate documents needed in the home rather than waiting for this to be dealt with by the head office. The ability to access e-mail would also enhance processes in the home and give a more professional presentation. Shalimar DS0000068106.V350248.R01.S.doc Version 5.2 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 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 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 2 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Shalimar DS0000068106.V350248.R01.S.doc Version 5.2 Page 22 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. 2 3 Standard YA22 Regulation 17(2) 23(2)(b) Requirement A record of all complaints received must be kept in the home. Decoration of communal areas must be undertaken and worn carpets in bedrooms must be replaced. Appropriate locks must be fitted to all exits in line with fire safety guidelines. Timescale for action 30/10/07 30/11/07 YA24 4 YA42 13(4)(a) 30/09/07 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 YA24 YA43 Good Practice Recommendations It is recommended that the gardens are developed to provide more planted areas and a variety of seating. It is recommended that a computer/printer is installed to assist with management processes in the home. Shalimar DS0000068106.V350248.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 Shalimar DS0000068106.V350248.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. 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