Inspection on 28/02/06 for Somerley

This inspection was carried out on 28th February 2006.

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 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 Mrs Marilyn Fellingham Unannounced Inspection 28th February 2006 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.V284481.R01.S.doc Version 5.1 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.V284481.R01.S.doc Version 5.1 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 Mrs Susan Brockett Care Home 40 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (40) of places Somerley DS0000035474.V284481.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user (named in the Commissions records) who is diagnosed with Dementia may be accommodated. 15th November 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.V284481.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over three and a half hours. Opportunity was taken to speak with all the staff that were on duty, service users, relatives who were visiting the home and the management. Opportunity was also taken to tour the home. Care and staff records were inspected along with duty rosters, policies and procedures. What the service does well: What has improved since the last inspection? Some paintwork has been ‘touched up’ in the corridors and new carpets have been laid in the downstairs corridor. One bedroom has been re decorated and one bathroom. Beanbags and sticky bat and balls have been purchased for service user exercises. There has been some improvement in the care planning system. Somerley DS0000035474.V284481.R01.S.doc Version 5.1 Page 6 The admission process has improved with better recording of this action in place. 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.V284481.R01.S.doc Version 5.1 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.V284481.R01.S.doc Version 5.1 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): 3. The process for admission has improved with better records. process is not always used to formulate the care plans. EVIDENCE: Paper work for a newly admitted service user was seen and found to be detailed and informative, however on examination it was clear that this information was not always used appropriately in planning care. However this Somerley DS0000035474.V284481.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7. There is improvement in the care planning system, but there is in many cases a distinct lack of detailed care in relation to needs. The care plans contain a lot of repetition and could lead to confusion. The progress that has been made needs to be extended and developed to ensure all health care needs are fully met and evaluated. EVIDENCE: Seven individual care plans were examined but it was evident to the Inspector that they were lacking in detailed prescribed care; this could in part be due to the limited space available on the plans to write in any length the care required and a recommendation is made. One service user was described as having a continence problem but the plan just stated that the service user wore pads; no other details of care were available. Somerley DS0000035474.V284481.R01.S.doc Version 5.1 Page 10 Another service user had a history of falls but once again no care was prescribed in detail as to how to care for this service user or monitor falls or even prevent. One service user had had a fall and had suffered a swollen knee, no care plan in place to meet this need. These shortfalls have the potential to put service users at risk. Assessments for nutrition are now being carried out, however the information collated from this activity does not seem to be reflected in any plans of care if an assessed need arises. Somerley DS0000035474.V284481.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12. Service users lifestyle in the home matches that of their expectations and the home offers a wide range of activities to satisfy their social and recreational needs. EVIDENCE: The Inspector noted that there was a published programme of activities available on a monthly basis, those service users and relatives that the Inspector spoke with confirmed that they felt that these were sufficient for them and found them enjoyable. A number of service users related to the Inspector that they had all been invited to birthday party of resident who had turned one hundred years old the previous day. The Lord Mayor of Norwich had visited and had joined in the celebrations; the service user herself was very pleased with the reception she was given including a cake. The service users confirmed with the Inspector that they chose what they wanted to participate in and there was always plenty “going on”. Somerley DS0000035474.V284481.R01.S.doc Version 5.1 Page 12 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. Arrangements for dealing with complaints are satisfactory. No complaints have been received by the CSCI; service users and relatives feel that their concerns are listened to. EVIDENCE: Those service users and relatives spoken with indicated that they would speak with the manager or a carer if they had any concerns; service users and their relatives are aware of how to make a complaint if they would so wish to do so. The home keeps very informative records of all complaints and how and if they have been resolved; these were examined by the Inspector who noted that there had been no complaints since the last inspection. The Inspector was able to satisfy herself that the staff were well informed in relation to the protection of vulnerable adults and training records for this were seen. Policies and procedures for dealing with abuse were inspected and those staff spoken with indicated that they were aware of these and also that they would not hesitate to ‘Whistle Blow’. Somerley DS0000035474.V284481.R01.S.doc Version 5.1 Page 13 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): 19,20,26. Service users appear to live in a reasonably well-maintained and safe environment. EVIDENCE: The Inspector made a tour of the home and noted that a new carpet had been laid in the downstairs corridor; a bathroom had been re decorated and one service users bedroom and also new carpet had been laid in this bedroom. Although too cold on the day of inspection the Inspector noted that there was a very pleasing sheltered area with garden furniture for the residents to utilise in the warmer weather. The gardens looked neat and tidy, as did the home. The kitchen areas in the small lounge areas were clean and tidy and no unpleasant odours were detected during the tour. Somerley DS0000035474.V284481.R01.S.doc Version 5.1 Page 14 The two downstairs lavatories next to the main office were found to be cold, and one lavatory seat cover was broken. These lavatories could be made more warm looking and less clinical and cold. Somerley DS0000035474.V284481.R01.S.doc Version 5.1 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 deployed in sufficient numbers to meet the assessed needs of the service users. Staff appear to have the necessary skills to care for the persons who live in the home. EVIDENCE: Recruitment of new staff is improving continually and examination of the duty rosters indicated that the home is always adequately staffed. On the day of inspection there were five carers on duty for the morning shift, plus one senior carer and the manager. Three carers plus one senior carer and the manager were detailed for the afternoon and evening shift and two waking carers on night duty. No employee is started at the home until all appropriate checks have been made, records for recruitment confirmed this. All those staff spoken with felt they were given many opportunities for training and up dating their skills and certainly those residents and relatives spoken with felt that the care was very good and that the always seemed to know what to do. Training records indicated that training was appropriate to meet the needs of the service users. Somerley DS0000035474.V284481.R01.S.doc Version 5.1 Page 16 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): 31,32,33,35. Service users live in a well run home and benefit from the manager’s input. The home is run in the best interests of the service users. The financial interests of the service users are safeguarded by the home’s policies and practices. EVIDENCE: The staff that were spoken to continue to state that they find the manager very approachable and professional; they also stated that it had been good to retain the same manager for some time as they felt many changes in managers had been quite disruptive. The manager has nearly completed NVQ level 4 in management and care, she feels that this has helped her in her role over the past year and supported the Somerley DS0000035474.V284481.R01.S.doc Version 5.1 Page 17 need for some changes in the home particularly in relation to the care standards. Service users financial interests are safeguarded, as the home takes no responsibility for service users monies. Bills for hairdressing, chiropody, and other services are settled by the families or by those service users who are able to manage their own finances. Small amounts of monies are held in a safe on behalf of some service users, transactions were inspected for this practice; a recommendation is made that always two signatures are required for this practice. The home appears to be run in the best interests of the service users; service user, staff and relative surveys have been carried out and records for this were seen, it is recommended however that other professional agencies be involved with the survey. Results from the survey are shared with the staff and service users and relatives at meetings and minutes were seen for this activity. It is recommended that this practice be improved and more detailed records kept of how the results have been actioned and met or where improvement has taken place. Somerley DS0000035474.V284481.R01.S.doc Version 5.1 Page 18 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 X 14 X 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 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 3 3 x 3 x x x Somerley DS0000035474.V284481.R01.S.doc Version 5.1 Page 19 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. 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 OP7 OP19 Good Practice Recommendations It is recommended that consideration be given to changing the format of care plans. It is recommended that consideration be given to refurbishing the downstairs lavatories situated by the main office. It is recommended that two signatures are obtained for all monitory transactions. It is recommended that other professional agencies are included in the quality surveys. 3 4 OP35 OP33 Somerley DS0000035474.V284481.R01.S.doc Version 5.1 Page 20 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.V284481.R01.S.doc Version 5.1 Page 21 - 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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