Inspection on 07/09/06 for Somerley

This inspection was carried out on 7th September 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 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 7th September 2006 10:30 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.V311527.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.V311527.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 www.norfolk.gov.uk Norfolk County Council-Community Care Sue Gregory 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.V311527.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One service user (named in the Commissions records) who is diagnosed with Dementia may be accommodated. 28th February 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 twice a week and chiropody services are also available. Somerley DS0000035474.V311527.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. Fees are charges up to a maximum of £368.72 but each service user is individually assessed according to their circumstances. What the service does well: What has improved since the last inspection? The service now has a permanent manager and although not in post for long this should allow for consistency in leadership and the opportunity to address issues which have not been progressed under the previous arrangements. As such improvement has begun in relation to the care planning system and an action plan has been established for the home as a whole. Somerley DS0000035474.V311527.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. Somerley DS0000035474.V311527.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.V311527.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is adequate. This judgement has been made based on evidence from the site visit and other information available to the Commission. When the process of revision of care plans is finished it will be possible to judge if the assessment process consistently underpins the plan of care and should this be the case then a good quality outcome should be achievable. EVIDENCE: The service has recently had a change of manager and as a result the statement of purpose and service user guide have been updated and this was confirmed at the site visit and from information obtained from the providers visit reports. These documents are displayed in the entrance area and are given to prospective residents. Recent admissions to the service were tracked at the site visit and it was evident that a needs led written assessment has been introduced by the new management and that this information is being used to develop plans of care. The services admission process is consistent with the desired outcomes in this area, with information provided to Somerley DS0000035474.V311527.R01.S.doc Version 5.2 Page 9 prospective residents and visits to the service encouraged. Sample files were seen and statements of terms and conditions are provided for residents. Somerley DS0000035474.V311527.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This judgement has been made based on evidence from the site visit and other information available to the commission. If the process of revision of care plans is continued to a satisfactory conclusion then a good quality outcome should be achievable. EVIDENCE: Although the number of comment cards received was relatively low in relation to the size of the service almost all of those received were very positive about the delivery of care in the home. The last inspection of the service indicated that were shortcomings in the care planning system with plans lacking detail and failing to prescribe how particular care needs were to be addressed by staff. At this site visit the inspector looked at sample plans and discussed this issue with the service manager. The manager has been in post for a short period of time and therefore has had little time to effect change, however she has developed an action plan for change and this includes revising the approach to care planning. This has begun although there is still a long way to go and the inspector accepts that this will be a lengthy process. Given the progress made and the commitment to change no requirements or recommendations are made. During the site visit the arrangements for the Somerley DS0000035474.V311527.R01.S.doc Version 5.2 Page 11 management of medication were inspected and found to be satisfactory. Medication is securely stored with a drugs room on each floor. The service has policies and procedures in place and staff have received training. A selection of medication administration records were inspected and were all accurately recorded. The provider recently notified of a mistake in the giving of insulin. Whilst this issue was serious the inspector is satisfied that both the initial response and the action taken to prevent reoccurrence are appropriate and thorough. Discussion with a visiting nurse during the inspection confirmed the impression gained from service users and records, that health care needs are appropriately met at the home. Somerley DS0000035474.V311527.R01.S.doc Version 5.2 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 Quality in this outcome area is adequate. This judgement has been made based on evidence from the site visit and other information available to the Commission. The service management needs to work towards re-establishing the level of activity previously available and to ensure that the needs of specific individuals are met in order to achieve a good outcome. EVIDENCE: At the site visit the inspector spoke to a variety of service users and one persons relative. All of the service users spoken to felt that they were free to exercise choice in their routine and daily lives and the inspector observed there to be a relaxed atmosphere in the home. A significant number of those who expressed a view of the food felt it was good or good enough, with people generally happy that they get a choice of food and that it suits their needs. A minority did not enjoy their meals, but this was not a widely held view. Previous inspection of the service had highlighted the provision of activity as a strength at the home and whilst activity is still taking place there was a feeling that this had declined. One significant reason for this was the retirement of the activities organiser and although the manager is exploring replacement of the post this has yet to happen and in the inspectors opinion this should be addressed in the interests of service users. Discussion took place with the manager about the meeting of needs of a service user who is deaf and blind. A Somerley DS0000035474.V311527.R01.S.doc Version 5.2 Page 13 comment card received from this person indicated that they were unhappy with the activity available to them and although the home have tried to meet need with some staff signing and visits from the sensory support service this has not produced a satisfactory outcome. As such the service is not meeting this persons needs and this must be addressed with consultation with the service user regarding their care plan. If needed the service should seek the assistance of a specialist communicator in this process and consideration should be given to external day care in a setting appropriate for these disabilities. Somerley DS0000035474.V311527.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made based on evidence from the site visit and other information available to the Commission. EVIDENCE: The services complaints process and records were looked at during the site visit and were satisfactory. There are few complaints received and complaints are taken seriously and addressed. Staff are aware of adult protection and the providers policy and procedure in this area are supported by training. Service users spoken to felt safe and well cared for and were confident they could raise any complaints that they might have. Somerley DS0000035474.V311527.R01.S.doc Version 5.2 Page 15 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): 19,23,24,26 Quality in this outcome area is poor. This judgement has been made based on evidence from the site visit and other information available to the Commission. The provider needs to address issues such as the inability of service users to control the heating in their rooms and to consider how the needs of increasingly dependant service users can be safely met in bedrooms which do not easily allow the use of aids to moving and handling. EVIDENCE: The providers internal reporting system identifies the need for some redecoration and new flooring in certain areas. The last inspection resulted in a recommendation that the toilets near the office were improved and the providers report identifies this as needing to happen. The service manager confirmed that she is pursuing these matters. Feedback from service users was that the home is clean and fresh and this was confirmed by a tour of the building. The home would benefit from continued redecoration as the décor is generally looking tired. The service was built before current standards and as such has some of the disadvantages of older provision. Although bedrooms are Somerley DS0000035474.V311527.R01.S.doc Version 5.2 Page 16 single occupancy they are small and the shape of the room does not allow for variation in the layout, however none of the service users spoken to saw this as a significant issue. Of more concern is the fact that beds have to go against a wall and this in conjunction with the size of the room makes moving and handling very problematic. Staff members spoken to commented on the difficulty of using a hoist or standaid in service users bedrooms and given the steady increase in dependency levels the provider needs to ensure that the needs of service users can be safely met in the environment. Although the home has a conventional radiator system , radiators are not fitted with individual thermostatic valves and as such service users cannot control the temperature in their room. This inspection took place at a time when the heating was not in use and as such it was difficult for the inspector to gauge the impact of this, however in his opinion this is unlikely to produce a good outcome for residents and the provider should fit such valves to allow for individual control. The homes gardens were overgrown although this issue was being addressed at the time of the site visit. Somerley DS0000035474.V311527.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is adequate. This judgement has been made based on evidence from the site visit and other information available to the commission. Should the service fail to demonstrate that staffing levels are sufficient to meet need at all times then an the outcome would change to poor. EVIDENCE: The responses from service users at the site visit confirmed the impression gained from consultation before the visit. As such people felt that they received good care from hard working staff. Staff members were concerned that the increasing levels of dependency made it more and more difficult to give the individual care needed. The provider has just carried out a dependency exercise at the home, however the results of this are not yet known. It was noted from the staff rotas submitted by the home that on occasions there are only three staff on duty and this appears low for a home accommodating 40 service users. Likewise there are only two waking night staff. As such the provider is required to submit information to the commission to evidence that current staffing levels are sufficient to meet need at all times. Employment and training records were checked and the inspector is satisfied that the provider has a satisfactory approach in this area and it was noted that the service manager is improving the way information is held in the home in order that this can be better monitored. Somerley DS0000035474.V311527.R01.S.doc Version 5.2 Page 18 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): 31,33,35,38 Quality in this outcome area is good. This judgement has been made based on evidence from the site visit and other information available to the Commission. EVIDENCE: Information available before the site visit confirmed that the newly appointed manager has developed an agenda for change and improvement at Somerly. This picture was confirmed by the site visit with the manager demonstrating areas in need of attention and how this will be done. Service users felt they were in a well run home in which ran in their best interests and were aware and welcoming, of the new manager. The home has operated without a permanent manager for some time and people generally welcomed the fact that this has now been resolved. The provider has sound systems for managing financial matters relating to residents. Likewise the approach to health and safety is good with centralised support available to the home. The home has a quality audit process, although the last audit was carried out by Somerley DS0000035474.V311527.R01.S.doc Version 5.2 Page 19 the previous management and this will soon be repeated. The service manager confirmed that she will expand the scope of the survey process in line with the recommendation arising from the last inspection. Somerley DS0000035474.V311527.R01.S.doc Version 5.2 Page 20 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 2 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 x 18 3 2 x x x 3 3 x 3 STAFFING Standard No Score 27 2 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.V311527.R01.S.doc Version 5.2 Page 21 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. 1 Standard OP12 Regulation 12 Requirement That the service review the care available to a service user who is deaf and blind, to ensure that they are able to fully meet assessed needs and the individuals wishes. That the provider submit a timed programme for improvements to the service heating system, which allows for the individual control of temperature in service users rooms. The registered person must demonstrate to the commission that staffing levels are adequate to safeguard the health and welfare of service users. Timescale for action 31/10/06 2 OP25 23 p 30/11/06 3 OP27 18 31/10/06 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. Somerley Refer to Standard OP19 Good Practice Recommendations It is recommended that consideration be given to DS0000035474.V311527.R01.S.doc Version 5.2 Page 22 refurbishing the downstairs lavatories situated by the main office. 2. OP33 It is recommended that other professional agencies are included in the quality surveys Somerley DS0000035474.V311527.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: 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.V311527.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. 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