Inspection on 16/11/05 for The Annexe

This inspection was carried out on 16th 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

The Annexe 24/09/07

The Annexe 26/02/07

The Annexe 11/09/06

The Annexe 11/11/04

The Annexe 26/04/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 The Annexe 161 Wootton Road Kings Lynn Norfolk PE30 4BU Lead Inspector Mrs Lella Andrews Announced Inspection 16th November 2005 12:00 The Annexe DS0000027605.V259387.R01.S.doc Version 5.0 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 The Annexe DS0000027605.V259387.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 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. The Annexe DS0000027605.V259387.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Annexe Address 161 Wootton Road Kings Lynn Norfolk PE30 4BU 01553 673194 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) One-Six-One Limited Care Home 3 Category(ies) of Learning disability (3) registration, with number of places The Annexe DS0000027605.V259387.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 3 people, of either sex, with a Learning Disability, may be accommodated. 22nd July 2005 Date of last inspection Brief Description of the Service: The Annexe is a care home providing care to three people with learning disabilities. It is situated within the grounds of One-Six-One another residential care home owned by the proprietors. The Annexe is in a residential area of Kings Lynn, within approximately a mile of the town centre. There are local shops, library and other amenities within the immediate vicinity of the home. The premises consist of accommodation on two floors accessed by the stairs. There is a lounge, kitchen, dining area, utility area, bathroom and one bedroom on the ground floor. Two further bedrooms are located on the first floor in addition to the staff sleep-in room. There is also a patio and garden area. The home provides care for ambulant people who may require consistent support for their behavioural needs. The Annexe DS0000027605.V259387.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Inspection was announced and took place between 12 and 4.15pm on Wednesday 16th November 2005. The Inspector spoke to the Manager, Service Manager and one of the Proprietors at the office and then spent approximately an hour at The Annexe observing staff working with tenants. The Inspector spoke to one of the tenants briefly and to two members of staff on an individual basis. The presence of the Inspector in the Home can cause anxieties to the tenants and so it can be difficult to obtain feedback from the tenants. Two completed comment cards were received from relatives and the Inspector spoke to one of the relatives by telephone. Both relatives stated that they are always made to feel welcome in the Home, that there are always enough staff on duty and that they are satisfied with the overall care provided. What the service does well: What has improved since the last inspection? The staffing review has identified improvements that can be made to the structure of the staff team supporting the clients The care plans have recently been reviewed and updated and provide detailed guidance to staff about how to meet the needs of the clients The Annexe DS0000027605.V259387.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. The Annexe DS0000027605.V259387.R01.S.doc Version 5.0 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 The Annexe DS0000027605.V259387.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The organisation has an assessment procedure for any prospective clients EVIDENCE: There are currently no vacancies within the Home. The organisation has appropriate assessment procedures which would be put in place if there was ever a vacancy at the Home. The Annexe DS0000027605.V259387.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9 The care plans contain clear information about the individual clients needs The clients are supported to take risks as part of an independent lifestyle EVIDENCE: The Inspector saw all three of the care plans. These have all recently been reviewed and updated. The care plans contain detailed guidance to staff about how to meet the client’s needs and the reasons why actions should be taken in certain situations. The care plans also contain information about seemingly small, but very important, information relating to the clients. For example, one of the care plans states that the client really likes to have a cup of tea on waking. These details mean that staff are able to support the clients in a very individual way. The staff are aware of the care plans and clearly use them as a working document. The importance of risk assessments is understood by the staff and the care plans contain relevant risk assessments for each client. The staff said that they were told about care plans and risk assessments in their induction. The team meeting minutes show that the care plans are discussed on a regular basis. The Annexe DS0000027605.V259387.R01.S.doc Version 5.0 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15, 16 and 17 The clients are supported to maintain relationships with their family as appropriate The client’s rights are respected The clients are offered a healthy diet and staff are aware of individuals needs at mealtimes EVIDENCE: The comment cards received from relatives stated that they are always made to feel welcome when they visit the Home. One of the relatives said that the staff provide the transport for their relative to visit them at home as they are unable to do this. The content of the induction programme for the staff focuses on the needs of the clients and the importance of staff respecting the client’s rights. Staff who spoke to the Inspector were clear about this and the importance of obtaining the views of the clients when making any decisions. The Annexe DS0000027605.V259387.R01.S.doc Version 5.0 Page 11 The routines that are in place in the Home are mainly due to the clients need for routine due to autism. The staff are aware of the routines that are in place and of the need for these. The care plans also provide guidance to staff about these and also record any restrictions on the client’s ability to make their own choices about something. Staff were seen to spend time with the clients, talking to them about their day and involving them in what was happening in the Home. Clients were seen to move freely around the Home. They have access to all areas of the Home, except for each others bedrooms and the kitchen. Clients are able to go into the kitchen if staff are present and it is assessed as being safe for them to be in there. Clients also have access to a large garden. The organisation has clear procedures in place for managing the client’s money. One of the senior members of care staff is responsible for administering this system and the Manager audits this on a regular basis. Records were seen which show that it is possible to audit client’s money from being received in their bank account to being spent. Appropriate receipts are kept for transactions. A cook provides the main meal for this Home and the Home next door, which is also owned by the organisation. The cook also prepares a menu on a weekly basis and the shopping is undertaken by one of the Proprietors. Staff said that this system works well as the cook knows what the clients like and don’t like but that there is always other food available if a client doesn’t want what is on the menu. The care plans contain information about the arrangements which should be in place at mealtimes to ensure that the needs of individual clients are met. The minutes of the team meetings show that meals and mealtimes are discussed on a regular basis. The Annexe DS0000027605.V259387.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The clients receive personal care support in an appropriate way The clients physical and emotional health needs are met There are appropriate procedures in place to ensure that medication is administered accurately EVIDENCE: The care plans contain information about how each client wishes their personal care to be provided. There is always a male and female member of staff on duty and so personal care can be provided by staff of the same gender as the client. The clients are encouraged to maintain and develop their independence with regard to personal care. The staff are aware of how to support the clients with personal care and of the particular need to respect privacy and dignity at these times. The care plans also contain information relating to the physical and mental health needs of the clients. Other health professionals, such as psychologists are involved in the clients care. A record of health appointments is kept in the care plans. The Annexe DS0000027605.V259387.R01.S.doc Version 5.0 Page 13 The Inspector was unable to spend much time looking at the medication system due to the needs of the clients but a member of staff did explain the system in place and show where medication is stored. Only staff who have received training are able to administer medication. A communication book is kept in the medication cupboard, which is used to record any changes in medication, which is good practice. The Annexe DS0000027605.V259387.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The organisation has a complaints procedure Procedures and training are in place to protect the clients from abuse and from self-harm EVIDENCE: The organisation has a complaints procedure but it would be difficult for the clients to access this due to communication difficulties. However, the staff spend time with the clients on an individual basis and work hard to ascertain their views about issues. The Service Manager and Proprietors also visit the clients on a regular basis and so any concerns may be picked up at these times. The staff receive training about the protection of vulnerable adults within their induction training. Staff who are undertaking NVQ training also cover this subject within one of these modules. The staff are aware of the whistle blowing procedure and are confident that any allegations will be dealt with appropriately by the management team. The care plans contain information relating to protecting the clients from selfharm or from harm from the other clients. The Annexe DS0000027605.V259387.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The clients live in a comfortable and safe environment, which is clean and hygienic. EVIDENCE: The Inspector saw the communal areas of the Home and these were clean with no unpleasant odours. There are few ornaments around the Home due to the behaviour of the clients but the Home is attractively decorated and furnished. The Annexe DS0000027605.V259387.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 and 35 The clients are supported by competent staff who receive appropriate training and support. EVIDENCE: The staff seen by the Inspector were enthusiastic about their roles and appeared to enjoy working with the clients. They were knowledgeable about the needs of the clients and understood the Homes policies and procedures when asked about some of them. The rotas show that there are always two staff on duty at the Home, one of either sex. One of the clients goes to a day service for three days per week and one client is supported away from the Home for part of the week. The staff advised that the staffing levels are appropriate and enable them to meet the client’s needs. The induction programme has recently been reviewed and updated and now provides a thorough induction which is linked to the Skills for Care standards. The Service Manager advised that some staff continue on to the Foundation standards whilst others start to do NVQ level 3. The Home has plans in place to ensure that at least 50 of the care staff have achieved NVQ at least at level 2. The management team are currently reviewing the training needs of the staff so that updates can be provided for those staff who need them. The Annexe DS0000027605.V259387.R01.S.doc Version 5.0 Page 17 Training is provided by the Service Manager and the Manager using a mix of direct teaching and the use of videos with questionnaires. Staff said that they receive good induction and ongoing training. They also said that they feel well supported by the management team and their colleagues. The Annexe DS0000027605.V259387.R01.S.doc Version 5.0 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 The clients benefit from living in a Home, which is well run There are systems in place for reviewing the service provided and there is a need to further develop these into a full quality assurance process The health, safety and welfare of the clients and staff are promoted and protected EVIDENCE: The Manager also manages the Home, which next door which is owned by the same organisation. The management team have reviewed the staffing provision to the Home recently and have made some alterations to this and have plans about how the team needs to develop. The Manager, Service Manager and Proprietors meet on a very regular basis and so are able to discuss issues and make decisions quickly when needed. The Annexe DS0000027605.V259387.R01.S.doc Version 5.0 Page 19 The staff receive health and safety training within their induction and the Home has policies and procedures relating to health and safety issues. The Inspector was shown the maintenance records for the emergency lighting and the fire extinguishers. The Home does not have a full fire alarm system but does have smoke detectors. As the Home provides accommodation for only three clients the Manager advised that the Fire Officer has agreed that the use of smoke detectors is appropriate. The Manager advised that the smoke detectors are checked regularly. It is recommended that a record is kept of these checks. The Manager advised that the electrical items have recently been tested for safety. The Annexe DS0000027605.V259387.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 X 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Annexe Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 3 X DS0000027605.V259387.R01.S.doc Version 5.0 Page 21 no 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 39 42 Good Practice Recommendations It is recommended that the quality assurance process is formalised and that an annual report is produced It is recommended that a record is kept of the smoke detector tests The Annexe DS0000027605.V259387.R01.S.doc Version 5.0 Page 22 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 The Annexe DS0000027605.V259387.R01.S.doc Version 5.0 Page 23 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!