Inspection on 25/06/07 for Taverham Road (21)

This inspection was carried out on 25th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

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

Other inspections for this house

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Bramley Avenue (73)

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Newton Court (1-2)

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

CARE HOME ADULTS 18-65 Taverham Road (21) New Boundaries Community Services Ltd 21, Taverham Road Norwich Norfolk NR10 4DR Lead Inspector Maggie Prettyman Unannounced Inspection 25th June 2007 08:45 Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Taverham Road (21) Address New Boundaries Community Services Ltd 21, Taverham Road Norwich Norfolk NR10 4DR 01603 754915 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) New Boundaries Community Services Limited Robert James Rolland Jenner Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection N/A Brief Description of the Service: 21 Taverham Rd provides accommodation for two adults with learning disabilities. It is a detached bungalow with parking to the front and a garden to the rear. Accommodation comprises two bedrooms, a shower room and toilet, a kitchen, lounge/dining room and an office which doubles as a sleep over room for staff. The home is situated on a main road in the village. The village itself has a pub, village hall and some shops and private businesses. There are limited public transport services in the area. The range of monthly fees is £1,600 - £2,800. Taverham Road (21) DS0000068358.V344084.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 provider, some residents and their relatives as well as other who work in or visit the home. This has included a recent unannounced visit to the home. This report gives a brief overview of the service and current judgements for each outcome group. Prior to the inspection the manager completed a pre inspection questionnaire and both people living at the home and some relatives completed confidential questionnaires. Records held by the commission were reviewed. This inspection took place over the course of 7 hours during which the inspector talked in detail with people living at the home about their experience. A tour of the premises was conducted and safety records examined. People living at the home showed the inspector their private rooms and agreed that the inspector could look at their records. Two permanent staff as well as the manager were interviewed and were also observed while interacting with people using the service. What the service does well: 21 Taverham Road is a newly opened home, which has a friendly and positive atmosphere. People living at the home spoke freely and openly about how much their lives have improved since coming to live there. Areas of good practice include; • • • • • • • • • • • • The home gets good information about the people living there and their needs before they move in People living at the home feel that they are involved in planning their care People living at the home take risks that are safely managed People living at the home have opportunities for work and education Families feel included in the care offered and are helped to keep in touch Daily routines are flexible People choose menus, and help prepare the food they eat People have their healthcare needs looked after People feel able to comment about the care they receive The home is well kept, safe and pleasantly decorated Peoples’ rooms are private and have furnishing and equipment that people choose for themselves The staff and manager are approachable and kind Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The manager and staff team have worked hard to establish a responsive and caring home. As with all new homes the process of setting up and settling in is in progress. Three requirements and seven good practice recommendations have been made at the end of this report as follows; Requirements; • • • A service user guide to the organisation should be provided in an accessible form for people who live at the home A documented, confidential, quality assurance process, that includes consultation with people using the service, should be implemented Output water temperatures should be regularly checked and recorded Recommendations • • • • • • • Peoples’ individual contracts should include details of any financial contributions they make towards their own care, and should specify levels of cover provided Any incentive programmes used should have details of rewards and sanctions to be given, with time limits agreed with the person concerned A protocol for administering PRN sedative medication should be established, which includes a review process A record of comments, minor complaints and compliments should be kept and audited. A written profile of staff training and experience requirements should be given to the agency which provides staff An induction manual should be constructed for agency staff Agency staff training should be brought in line with permanent staff as planned 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. Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2 and 5 People who use the service experience adequate quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. People have limited access to information about the home. They have their needs assessed prior to living at the home, but their contracts do not tell them what financial contribution they have to make and do not specify their entitlement to levels of care provided. EVIDENCE: This small home does not have a Service User guide. Whilst it may be inappropriate for an individual document to be produced relating to the home itself, information about the organisation, its services and the rights of people living at the home should be made available in an accessible form to people using the service. A requirement has been made in this respect. Inspection of records held about people living in the home demonstrated that information is sought about them before they came to live at the home. One person had a detailed summary needs assessment on file; the other had a range of notes and information provided by their previous placement. Contracts were seen to be in place for both people living at the home. These did not specify individual financial contribution to care or the nature of care and cover that each person is entitled to. A recommendation has been made in this respect. Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Individuals are involved in decisions about their lives, and play an active role in planning the care and support that they receive. EVIDENCE: Plans of care were seen in place for both people living at the home. These plans were seen to be up to date and have been reviewed. One person has an incentive programme which was constructed by their previous placement. This programme needs to be clarified so that current staff are clear about its operation and limits. In particular sanctions relating to mobile telephone use need to be specified and time limited. A recommendation has been made in this respect. Both people living at the home confirmed that they are consulted about their needs and choices in daily life. They have weekly planning meetings to decide how their care is to be delivered. Both felt that moving to the home where they Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 10 can make supported decisions had been a significant improvement to their lives. A financial risk assessment has been conducted in respect of personal money handling. Care plans demonstrated that risk assessments are in place. Both people living at the home discussed their daily lives with the inspector and confirmed that staff help them to take new risks in a supportive and caring way. Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards12, 13, 15, 16 and 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their lifestyle and are supported to develop their life skills. Social, educational, cultural and recreational activities meet individual expectations. EVIDENCE: Both people living at the home described structured weekly programmes of work and educational opportunities. Records demonstrated that these programmes are consistently implemented. Both people enjoy what they do and said that they found their occupations satisfying. Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 12 This home is newly opened and as yet people living there are not fully accessing local community facilities. People go to the local pub, and there are links with another local home from the same organisation. Further links and community involvement will undoubtedly benefit people living at the home in the future. Inspection of care records and discussions with people living at the home demonstrated that their personal and family relationships are supported. Feedback from relatives also confirmed that they feel supported and involved in the care of their family member. Both people living at the home confirmed that their routines are developed around their needs and wishes. Both people had keys to their own rooms. Staff were seen to interact directly with people living at the home and were observed listening to people and responding to their needs. People living at the home confirmed that they are involved in planning meals, shopping and food preparation. Both people were seen choosing and preparing breakfast, and had made their packed lunches for the day. Menu records demonstrated a range of different dishes and types of food. Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20 People who use this service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. Principles of respect, dignity and privacy are put into practice. EVIDENCE: People living at the home confirmed that staff treat them with dignity and respect at all times. They said that staff help them with their daily routines and support them to look after themselves. Evidence of input from a range of social and healthcare professionals was seen. People’s healthcare needs are identified in their individual plans of care. Protocols for supporting people with epilepsy were seen. Evidence of routine healthcare appointments was seen. Medication was seen to be securely stored and accurately recorded. Sedative PRN medication was recorded but a protocol for its administration and monitoring needs to be established. A recommendation has been made in this respect. Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 and 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns and are protected from abuse. EVIDENCE: No formal complaints have been made about this service. Observation of people living at the home and staff demonstrated that daily grumbles and comments are listened to and acted upon. The home may benefit from auditing comments, minor complaints and compliments so that patterns and trends can be identified. A recommendation has been made in this respect. People living at the home spoke positively about staff and that they treat them appropriately and respectfully. Discussion with staff and staff training records demonstrated that people are trained in, and are aware of, adult protection issues. Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 26 and 30 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: A tour of the premises demonstrated that the home is suitable, well maintained and meets the needs of people living there. The home is safe, comfortable and clean. It is in keeping with the local community. Evidence of an initial fire risk assessment was seen. Records are kept of fire drills and appliance testing. Both people living at the home confirmed that they have been involved in fire drills. The inspector was invited by residents to view their rooms. Both were individual and contained items and equipment that reflect their personal taste and interests. One person had been helped by staff to put up a new shelf in their room over the previous weekend. The manager plans to draw up an inventory of personal items purchased with each person. Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 16 The home was clean, pleasant and hygienic. People living there use a domestic washing machine to do their own laundry with the support of staff. Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 32, 33, 34 and 35 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Permanent staff working at the home are trained and skilled. Agency workers provide a consistent service, and are going to be offered service specific training by the organisation. EVIDENCE: Permanent staff working at the home have all gained, or are in the process of gaining NVQ qualification to an appropriate level. Records of agency staff used showed that, although trained, they have not always achieved NVQ qualification. A recommendation has been made in this respect. Inspection of the rota as well as discussion with the manager demonstrated that good levels of staffing are in place at the home. The manager, team leader and care worker met during the inspection are all permanently employed. Currently at least three agency staff are being used. The agency involved provides staff profiles detailing experience and training. The home has Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 18 managed to achieve consistency in agency staff used. The home is in the process of recruiting permanent staff. In the interim period it would benefit the home to have an induction file for agency staff to access key policies, procedures and care protocols. A recommendation has been made in this respect. The lead inspector for this service has inspected a sample of files held at head office and found standards of permanent recruitment to meet the requirements of the care standards. Evidence of ongoing and updated training in respect of permanent staff was seen. Information sheets for agency staff showed levels of training for each person. The training levels of agency staff were not found to be as good as permanent staff. The home has identified this as an issue and plans to give appropriate supplementary training to agency staff. A recommendation has been made in this respect. Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management of the home is based on openness and respect. Quality assurance systems are being implemented. EVIDENCE: People living at the home and staff feel that the homes manager is kind, supportive professional and caring. He is in the process of achieving his NVQ level 4. A programme of staff meetings and supervision is being instigated. Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 20 Due to its recent opening, the home has yet to implement a documented quality assurance process. An example of a quality assurance report from another home was shown to the inspector. This process needs to contain more feedback from people using the service. A requirement has been made in this respect. A tour of the premises, inspection of records and observation of working practices demonstrated that the home is run in a safe way. Suitable COSHH records and procedures for handling cleaning products are in place. Output water temperatures are not tested. A requirement has been made in this respect Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 2 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 1 X X 3 X Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? N/A 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 YA1 Regulation 5 Requirement Timescale for action 30/09/07 2 YA39 24 3 YA42 13.4a A Service user guide to the organisation must be provided that is in an accessible format for people who may wish to live at the home. A quality assurance system that 31/10/07 includes confidential consultation with people living at the home should be established. Output water temperatures 15/07/07 should be regularly checked and recorded 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 3 Refer to Standard YA5 YA6 YA20 Good Practice Recommendations People’s contracts should include details of any financial contributions that they make to their care, and should detail the level of staff cover which is to be provided. Any incentive programme of care used should have clear protocols for staff intervention, with details of sanctions identified and time limits agreed and in place. A protocol for the administration and monitoring of DS0000068358.V344084.R01.S.doc Version 5.2 Page 23 Taverham Road (21) 4 5 6 7 YA22 YA32 YA33 YA35 sedative PRN medication should be written. An audit of comments, minor complaints and compliments should be kept in order that the service may identify patterns, trends and issues. The home should provide a written profile of staff to the agency. This profile should include a preference for NVQ qualified staff. An induction manual including key policies, procedures and care protocols should be developed for agency staff. The plan that agency staff should receive training in line with permanent staff working at the home should be implemented Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Taverham Road (21) DS0000068358.V344084.R01.S.doc Version 5.2 Page 25 - 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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