Inspection on 15/11/05 for Somerley

This inspection was carried out on 15th November 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

Somerley 13/07/07

Somerley 07/09/06

Somerley 28/02/06

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 Mrs Marilyn Fellingham Unannounced Inspection 15th November 2005 10:00 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.V266013.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Somerley DS0000035474.V266013.R01.S.doc Version 5.0 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 Norfolk County Council-Community Care Mr Phil Faife Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places Somerley DS0000035474.V266013.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered to accommodate 40 Service Users who are Older People not falling within any other category. People who need wheelchairs to assist with independent mobility at point of admission can only be accommodated in rooms 12, 19, 34 and 41 (Numbering as at 31st March 2002. 1st March 2005 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. Somerley DS0000035474.V266013.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over five hours. Opportunity was taken to tour the home, speak with service users, relatives and staff. Care records and policies were inspected. What the service does well: What has improved since the last inspection? There has been some improvement in the care planning system. Some areas of the environment have been refurbished. Record keeping has improved. Deployment of more staff. The appointment of a permanent manager. Better records in place for handling and administering medication. Somerley DS0000035474.V266013.R01.S.doc Version 5.0 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. Somerley DS0000035474.V266013.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Somerley DS0000035474.V266013.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,4,5. Prospective service users are given sufficient information to make an informed decision prior to admission; they also are confidant that their needs will be met. The admission procedure is adequate, giving prospective service users opportunity to visit the home where possible. EVIDENCE: The service users guide and statement of purpose has been updated and examination of these confirmed that they contained enough pertinent information prior to admission. This documentation set out very clearly the services offered by the home. Somerley DS0000035474.V266013.R01.S.doc Version 5.0 Page 9 The home has an admission procedure that adequately guides the manager or senior staff through the assessment for admission; however better records of this action could be kept. Relatives spoken to during the inspection process confirmed that the assessment process was thorough and that they felt that their relatives’ needs would be met. These relatives also confirmed that they had been offered the opportunity for their relative to visit prior to moving into the home. Somerley DS0000035474.V266013.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. The care planning system is clear, but there is room for improvement with more detailed information relating to care needs. Service users health and personal care needs are mostly well attended to and the handling and administration of medication is managed well. EVIDENCE: Examination of care plans revealed that there had been an improvement in the care planning system, however they did reveal that not all needs, as assessed, were being identified in care plans. For example one resident was prone to falls but no care had been prescribed for this. Another resident was identified as having to be turned two hourly, but no prescribed care was evident or record of this. The care plans highlighted that there was a need for assessing the service users’ nutritional status. Somerley DS0000035474.V266013.R01.S.doc Version 5.0 Page 11 It was noted that eye drops did not have a record for date of opening and to ensure best practice is this advisable as some drops have a very short ‘shelf life’. It was however noted by the Inspector on examination of medications and the policy and procedure for the administration and handling of medication that there had been a vast improvement in this activity. The Inspector observed during the course of the inspection that the service users were treated with respect and that the staff had an understanding of how to promote the service user’s dignity and privacy. Communication between staff and service users was observed and appeared to be appropriate to the individual needs of the service users. Service users and relatives spoken to confirmed this to be true. Somerley DS0000035474.V266013.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. The home manages activities very well and offers a wide range of options to satisfy service users’ social and recreational needs. Meals are managed well. EVIDENCE: There is a published programme of activities and the manager and most of the staff are very motivated and enthusiastic about the provision of activities and see it as an important adjunct to the service users care and meeting their needs. Those service users and relatives spoken to confirmed that there was always something going on and that service users exercised choices in relation to what they participated in. A number of residents who were spoken to were happy about the presentation and quality of the food. Some changes had been made to the menus of late and the chef confirmed that he was home baking much more now and using far less bought in meals. Examination of menus revealed what appeared to be a range of well thought out well-balanced meals. Somerley DS0000035474.V266013.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18. No complaints have been received by the CSCI; service users and relatives feel that their concerns would be listened to. It would appear that arrangements for dealing with complaints are satisfactory. EVIDENCE: Service users spoken to indicated that they would speak with the manager or with one of the carers if they had a complaint or a concern, they also felt that they would be listened to and this was also the opinion of those relatives spoken to. Information about complaints is readily available in the home and is issued to each service user. The home keeps a record of all complaints; this was reviewed at the inspection. These records indicated that responses are provided within twenty-eight days as indicated in the home’s procedure. Somerley DS0000035474.V266013.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Service users live in a well-maintained and safe environment. EVIDENCE: A tour of the home took place and it appeared safe and suitable to meet the needs of the service users. However on the day of inspection the home was in a state of disarray due to builders replacing the floor in one of the main corridors. There was obviously a lot of dust present but everything was being done to ensure the safety of the residents. There was an offensive odour at the end of the main corridor but the manager stated that it was in hand and being addressed. Somerley DS0000035474.V266013.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29,30. Staff are employed in sufficient numbers to adequately meet service users needs. Service users appear safe and the staff have a very good understanding of service users support needs, they also maintain positive relationships with service users. EVIDENCE: Examination of duty rosters revealed that there were adequate numbers of skilled staff to support and care for the service users in residence. Consideration is given to one service user who is blind and deaf and an extra carer is often allocated for this gentlemen, to ensure all his health care needs are being met. Staffing levels have improved and four new carers have been employed. Recruitment records for these new members of staff were examined and confirmed that the home’s recruitment policies and practices are robust with all POVA and CRB checks in place before employment commenced. Two references are always obtained and employment history checked. Those staff spoken with stated that they had had a considerable amount of training sessions and the new members of staff described the induction process that they had received which appeared to cover all the mandatory training that is required. Somerley DS0000035474.V266013.R01.S.doc Version 5.0 Page 16 Although it was obvious after discussion with various members of staff that the home ensures that all staff are competent to meet the needs of the service users, it was difficult to check the records for this training and it is recommended that better training records are kept and maintained. Those service users spoken to indicated that they felt in safe hands. Seven carers have achieved NVQ level 2, two have NVQ level 3 and the manager is undertaking NVQ level 4. Somerley DS0000035474.V266013.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,36,38. The home is managed well. There is clear leadership within the home, this results in practices that promote and safeguard the welfare and safety of the residents and staff. EVIDENCE: The staff that were spoken to stated that the manager is very approachable, professional and that there are clear lines of communication between her and all levels of staff. One carer stated that “ the manager is very responsive and listens and that her door is always open”. The manager is undergoing NVQ level 4 in management and care and hopes to finish soon. Somerley DS0000035474.V266013.R01.S.doc Version 5.0 Page 18 Regular meetings are held where information is exchanged and new policies introduced; minutes were seen for these. Staff are formally supervised and records were seen for this activity. Somerley DS0000035474.V266013.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 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 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X x 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 3 X X X 3 X 3 Somerley DS0000035474.V266013.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP8 OP9 Good Practice Recommendations A recommendation is made to encourage the completion of nutritional assessments. It is recommended that dates of opening be inserted on individual eye drop containers. Somerley DS0000035474.V266013.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Somerley DS0000035474.V266013.R01.S.doc Version 5.0 Page 22 - 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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