Inspection on 13/07/07 for Somerley

This inspection was carried out on 13th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Somerley 07/09/06

Somerley 28/02/06

Somerley 15/11/05

Somerley 01/03/05

Somerley 28/09/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Somerley Somerleyton Street Norwich NR2 2BT Lead Inspector Mr Pearson Clarke Unannounced Inspection 13th July 2007 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 Somerley DS0000035474.V346848.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 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. Somerley DS0000035474.V346848.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Somerley Address Somerleyton Street Norwich NR2 2BT 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) 01603 623582 01603 621802 somerley@norfolk.gov.uk www.norfolk.gov.uk Norfolk County Council-Community Care Mrs Susan Gregory Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Somerley DS0000035474.V346848.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. People who need wheelchairs to assist with independent mobility at point of admission can only be accommodated in rooms 5, 25, 105, 125. 7th September 2006 Date of last inspection Brief Description of the Service: Somerley is owned by Norfolk County Council and provides residential care for 40 older people. It is was purpose built in the 1970s, and is divided into small living units which house 6 to 8 residents with a shared sitting room and dining room. In addition to this there is a large lounge with a bar on the ground floor where larger social gatherings take place. This room has a pleasant view of the front garden. The Home is located on the main road and close to shops and facilities, and the busy community of Unthank Road area of Norwich. A hairdresser visits once every two weeks and chiropody services are also available. The current fee levels for the home are individually assessed with a maximum weekly charge of £368.72. Somerley DS0000035474.V346848.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 by 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 and this report gives a brief overview of the service and current judgements for each outcome. What the service does well: What has improved since the last inspection? The process of continuing to improve care planning is a significant area of improvement, although some work needs to be completed and the service needs to ensure that recording is maintained at a good level. Since the last inspection of the home the system for management and delivery of medication has changed. As with the providers other homes, a system of internal audit has been introduced resulting in a safer process. Somerley DS0000035474.V346848.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Somerley DS0000035474.V346848.R01.S.doc Version 5.2 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 Somerley DS0000035474.V346848.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. The service is admitting people it has confidence it can care for, as a result of a sound assessment process. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Analysis of the provider’s regular visiting reports over the last year, indicate that the service has continued to improve its assessment and care planning process. During the site visit the inspector tracked two recent admissions to the service and found that these admissions had been based on a clearly recorded assessment of need which had been used to underpin the creation of an individual plan of care. One of the residents concerned was spoken to and was happy with the process - feeling reassured that their needs could be met. Discussion with the service manager indicated an awareness of the needs the service was able to meet and a recognition of the need to consider the restrictions posed by the home’s small bedrooms when assessing for suitability. Somerley DS0000035474.V346848.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9and 10 Quality in this outcome area is good. Residents benefit from having a clear plan of care which enables staff to understand how best to meet their needs. Personal and medical care is effectively delivered with a sound approach to medication and an approach to care based on a respect for privacy and dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The providers visiting reports show a picture of improving care planning being established since the last inspection. Although staff sickness within the management team has delayed progress in this respect, most plans are now at a satisfactory level. Likewise these reports indicate that medicine management within the home is sound, with a satisfactory internal audit process taking place. During the site visit four plans of care were inspected. In each case they were well organised with clear and comprehensive recording in place. All of the plans had been reviewed and contained necessary risk assessments. Residents had signed to indicate their acceptance of the plan. The one area missing from the plans was the use of nutritional care plans to help ensure that service Somerley DS0000035474.V346848.R01.S.doc Version 5.2 Page 10 users were not at risk of malnutrition. This was acknowledged by the manager who confirmed that there was work to be done and gave assurances that this would happen in the near future. Medication management was inspected and the inspector found secure storage, and accurate records maintained. Inspection of the manager’s audit records showed a robust process to be in place. Observation during the visit indicated that residents are routinely treated with respect and those talked to by the inspector felt that their privacy and dignity was protected. Somerley DS0000035474.V346848.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. Residents feel they live in a relaxed home where they can exercise choice and control over their lives. The provision of activity and choice of food is consistent with most peoples wishes and expectations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The picture gained from the providers visiting reports is of more effort to provide activity and stimulation although there is still no designated activity organiser. During the site visit the inspector spoke to a number of residents most of whom were happy with staff effort in this area. Written comment received, was consistent with this, although one relative felt that it would be nice if staff could take residents out more. The service manager discussed activity provided and records were seen of a regular programme of group activity supported by work with individuals. At the last inspection concern was raised in respect of the isolation suffered by a resident with sensory impairments. From discussion with the resident concerned and the manager and staff it was apparent that efforts have been made to address this through exploration of opportunities for external day care. However this has not been acceptable to the individual concerned. The resident was keen to stress that he Somerley DS0000035474.V346848.R01.S.doc Version 5.2 Page 12 was very happy at the home and that staff and particularly his key worker were superb, however a real issue for him was his perception that specific staff hours allocated for one to one time with him had disappeared into the overall staffing in the home. This is an issue that the inspector is not best placed to judge, however it was discussed with the service manager who undertook to pursue the matter. The home is well placed for access to the shops and public transport links to the city and the inspector observed some service users going out independently. In such cases a risk assessment has been completed as part of the plan of care. Residents told the inspector the home was a relaxed place to live and they felt able to exercise choice and control in their lives. This was born out through observation on the day of the site visit. Residents continue to report a broad degree of satisfaction with the food served although some of those spoken to said quality varied at times. Somerley DS0000035474.V346848.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is (good). The service takes complaints seriously and appropriate arrangements are in place to help protect service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Examination of the service’s complaints record and discussions during the site visit showed the home to continue to have an effective complaints process. As such there have been few recorded complaints, although the manager stated that they tended to record only the most serious issues and that they were looking to provide better evidence that they addressed minor concerns. The provider continues to have a robust approach to adult protection with sound procedures supported by staff training. Residents told the inspector that they would be confident to complain if they needed to and staff were confident they could report any possible bad practice. Somerley DS0000035474.V346848.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is ( adequate ). Residents still live in an environment which needs improvement; however plans developed by the provider - when fully implemented - will address most issues This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the site visit the inspector toured the building and discussed the environment with the manager. It was noted that all areas were clean and fresh and most residents felt that this reflected the normal situation. Whilst there has been some redecoration throughout the year, the majority of issues identified at the last inspection are still outstanding; however the provider has developed a plan to address these issues over the next few years. Since the last inspection the garden area has been cut back to improve access and the manager confirmed that they have been successful in obtaining grant money for major improvement in this area. Somerley DS0000035474.V346848.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. Residents benefit from well trained, hard working staff who have been properly recruited. The commitment to provide extra staffing on late shifts will help ensure a consistently good service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Once again the inspector was made aware of how highly the residents value the staff and the care that they offer. Examination of staff training records and discussion with staff, residents and the manager showed that staff training is generally well provided although the numbers of staff qualified to NVQ level 2 or above has fallen below the expected 50 target. This was discussed at the site visit and the inspector is satisfied that there are more staff currently training and the manager hopes to meet this target again in the foreseeable future. The inspector looked at sample employment records and was satisfied that a suitably robust system is in place. Somerley DS0000035474.V346848.R01.S.doc Version 5.2 Page 16 At the last inspection staffing levels were of concern, although it seemed likely that they would improve as a result of a review of staffing taking place. It was therefore disappointing to find staffing largely unchanged from that found last year on this occasion. When discussed with the manager it was her view that no change had happened because of low occupancy levels throughout the year; however at the time of site visit there had been a lot of recent admissions and as such the home was full. In the inspectors opinion this leaves particularly low staffing on the later shifts each day and whilst staff and residents who were spoken to felt the staff coped it was acknowledged that it can result in a service of less quality than would be desired. Consideration was given to a formal requirement in this respect, however during the inspection a commitment to immediately provide extra hours on the late shift was made by the provider and as such no requirement is made. Somerley DS0000035474.V346848.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is good. That the home is safely managed in the best interests of residents; however the failure to maintain a settled management team has led to some gaps in management delivery. This judgement has been made using available evidence including a visit to this service. Somerley DS0000035474.V346848.R01.S.doc Version 5.2 Page 18 EVIDENCE: From discussion during the site visit it was clear that staff sickness and other issues have impacted on the ability of the management team to move as quickly in response to some issues as they would wish. One example of this was the failure to establish regular supervision for all staff and although staff spoken to felt well supported this is an area that needs addressing. Residents and staff told the inspector that they felt the home was well managed and that the manager was approachable. The provider has an annual quality process based on survey and the inspector was shown the plan arising from the analysis of results. In his opinion the plan was unlikely to be as effective as might be as it did not identify how things would be achieved, or for instance what action needed to happen and who would be responsible. The provider continues to manage any financial matters relating to service users in a sound manner and sample records supported this. The provider has well established systems to promote and ensure health and safety and policies procedures and other records were seen and in conjunction with discussion with the manager demonstrated that this is a safe service. Somerley DS0000035474.V346848.R01.S.doc Version 5.2 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 2 18 3 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Somerley DS0000035474.V346848.R01.S.doc Version 5.2 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. 1 Refer to Standard OP7 Good Practice Recommendations That the service ensures that all residents have their nutritional needs tracked through the use of specialist care plans. 2 OP27 That regular staff supervision is established and maintained. Somerley DS0000035474.V346848.R01.S.doc Version 5.2 Page 21 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. 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