Inspection on 13/10/05 for Walnut House

This inspection was carried out on 13th October 2005.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Walnut House 24/05/06

Walnut House 08/03/06

Walnut House 03/03/05

Walnut House 08/07/04

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 Walnut House 49a Norwich Road Dereham Norfolk NR20 3AS Lead Inspector Clive Lucas Announced Inspection 02 November 2005 09:30 Walnut House DS0000027591.V249282.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 Walnut House DS0000027591.V249282.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. Walnut House DS0000027591.V249282.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Walnut House Address 49a Norwich Road Dereham Norfolk NR20 3AS 01362 683581 01362 683581 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) Norfolk Autistic Community Housing Association Ltd Mrs Marie Ann Large Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Walnut House DS0000027591.V249282.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to three (3) adults of either sex, with Learning Disability, not falling within any other category, may be accommodated. 3rd March 2005 Date of last inspection Brief Description of the Service: Walnut House provides accommodation and care for up to three people with a learning disability. It is managed by the Norfolk Autistic Community Housing Association and is situated in the grounds of Whitstone House, which is also managed by the organisation. Access to the Home is through the shared garden or through the larger Home. There is parking to the front of Whitstone House. The Home is situated on a main road into the market town of Dereham. The service users have single bedrooms and share the communal facilities. There is also a staff sleeping in room on the first floor. Walnut House DS0000027591.V249282.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. The manager completed a pre-inspection questionnaire and service users and families completed comment cards. The manager a member of staff and a team leader were spoken with, records were examined and the house and accommodation were inspected. There were no service users present during the inspection; however the previous inspection (3 March 2005) took place in the evening and focused on the service users. What the service does well: What has improved since the last inspection? 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. Walnut House DS0000027591.V249282.R01.S.doc Version 5.0 Page 6 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 Walnut House DS0000027591.V249282.R01.S.doc Version 5.0 Page 7 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 and 4. It was not possible to form a comprehensive judgement, as key records were unavailable. A new service user had an appropriate introduction to the home. EVIDENCE: There has only been one new service user since the previous inspection. The assessment for this person was not available as a senior member of staff had kept it in their personal locker and gone off sick. Attempts had been made to obtain the key for the locker, but these had been unsuccessful. It is not appropriate that service user records are kept in staff’s personal lockers. The registered manager must ensure that these records are retrieved as a matter of urgency The service user who moved into the home recently had an introduction, which included a visit to him by staff from the home and visits by him to the home with family and previous carers. Walnut House DS0000027591.V249282.R01.S.doc Version 5.0 Page 8 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, 7 and 9 There are care plans and risk assessments that are used to inform staff in caring for service users. While generally good, a little extra work is needed on them. EVIDENCE: Staff advised that service users are involved in devising their care plans. Service users sign their care plans. Care plans were generally comprehensive, but two looked at did not give details of contact with families. The plans are reviewed annually, rather than six monthly as required by the National Minimum Standards. The manager must ensure that care plans contain information on relationships with families, and are reviewed at least every six months. Service users take part in the daily running of the home, including cleaning, cooking and shopping. They also take part in activities that they choose to, both inside and outside of the home. There are risk assessments for service users which cover areas such as holding their own bedroom keys, self-administering medication, trips out and activities. Walnut House DS0000027591.V249282.R01.S.doc Version 5.0 Page 9 Some of the risk assessments are not reviewed as frequently as stipulated on the assessments. The registered manager must ensure that risk assessments are reviewed at appropriate frequencies. Walnut House DS0000027591.V249282.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): 12, 13, 14 and 15 Service users are supported in participating in a range of activities and education, and maintaining contact with families. EVIDENCE: A range of activities is available to service users, both inside and outside of the home. All service users attend day care and college courses. Service users are supported to use facilities within the local community but with limited involvement in the community. All service users have some contact with families. This varies depending upon individual circumstances. Walnut House DS0000027591.V249282.R01.S.doc Version 5.0 Page 11 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): 20 The storage of medicines requires attention to ensure that the safety of service users is promoted. EVIDENCE: Medicines are kept in a locked filing cabinet in a cupboard under the stairs. Previous inspection reports have recommended that a more suitable site be found. Current plans to extend the building, by adding a staff room and additional bedroom, would allow the medicines to be re-located. The keys to the filing cabinet and cupboard are kept in an unlocked drawer in the dining area. All of the service users have been risk assessed as unable to safely self-administer their medication. The registered manager must ensure that the keys to the medicine storage area are kept securely and are not readily accessible to service users. Training is provided for staff in handling medicines. The Boots monitored dosage system is used. Walnut House DS0000027591.V249282.R01.S.doc Version 5.0 Page 12 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): 23 Training for staff to help ensure that service users are protected from abuse has been provided, but it needs to be made available to all staff. EVIDENCE: The registered manager must ensure that all staff have access to POVA training. It was not possible to look at service user finances during this inspection, as the administrator who deals with these was not present. Walnut House DS0000027591.V249282.R01.S.doc Version 5.0 Page 13 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 The home provides a homely and comfortable environment for the registered use for three service users. The admission of a fourth service user has not been appropriate for the building. EVIDENCE: The house is a modern one and was purpose built and registered for three service users. It is appropriately maintained and is suitable for its purpose. The outside of the house and the garden are also well maintained However, at the time of the inspection there were four service users living in the home, which meant that the member of staff had to sleep in the living room. It is not appropriate for a member of staff to sleep in a service user’s communal area and the admission of a fourth service user has been outside of the home’s registration. The fourth service user moved into the home in late July 2005 and the application for a change of registration was not made until October 2005. The registered manager must ensure that the home operates within its registration. One cupboard had a “Fire Door Keep Locked Shut” sign on it, but was unlocked. The cupboard contains some cleaning materials and the electrical fuse box. The registered manager must ensure that the Fire Officer be Walnut House DS0000027591.V249282.R01.S.doc Version 5.0 Page 14 consulted as to whether this door needs to be kept locked. If it does not the sign should be removed. One bedroom is on the ground floor and has clear glass in the window, with curtains, but no net curtains or voiles. It is recommended that consideration be given to the privacy of the service user in this room, and whether some form of net curtain would be of benefit. Walnut House DS0000027591.V249282.R01.S.doc Version 5.0 Page 15 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): 33, 34 and 36 The staff team are experienced EVIDENCE: Staff who work in Walnut House are taken from the staff group at Whitstone House and are all senior care staff. There is a low turnover of staff. Staff meetings are held for Whitstone House and matters relating to Walnut House may be discussed there. There are not specific staff meetings for Walnut House. It is recommended that regular staff meetings take place for Walnut House. A fourth service user has moved into the home. The staffing levels (one member of staff on duty) are not appropriate to meet the needs of four service users. Weekend shifts can be from 0900hrs on Saturday to 2100hrs on Sunday; the length of weekend shifts is being looked at by senior staff. The registered manager must ensure that the staffing levels are reviewed to make sure that service users have their needs fully met and that shifts are not overly long for staff to be able to work effectively. The home’s recruitment procedures are not safeguarding service users. Regulation 19 and schedule 2 of the Care Homes Regulations 2001 require that staff are not allowed to work in a care home unless specified information has been obtained. Staff have been employed without this information, in some Walnut House DS0000027591.V249282.R01.S.doc Version 5.0 Page 16 cases without Criminal Records Bureau checks. This is a major failing and places service users at risk. However, since this matter was identified at Whitstone House the manager has begun to address the matter for staff at both Whitstone House and Walnut House. The registered manager must ensure that staff currently in post, who do not have the required checks, must be rostered to work under supervision of named and appropriately checked members of staff. ‘Missing’ statutory staffing records must be obtained. Supervision of staff has not been taking place at the frequency set out in the National Minimum Standards. The registered manager must ensure that all staff (including the registered manager) have regular, recorded supervision meetings at least six times a year. Walnut House DS0000027591.V249282.R01.S.doc Version 5.0 Page 17 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): 39 Service users are listened to, but a more structured system of seeking their views as part of reviews of quality of care is needed. EVIDENCE: Walnut House is accredited with the National Autistic Society. The accreditation is reviewed annually and includes feedback from service users. The manager spends time working in the home with the service users and will speak with them about their views. This is commended. However, the registered manager must ensure that more structured reviews of the quality of care are undertaken at appropriate intervals and that these reviews are consistent with regulation 24 of The Care Homes Regulations 2001. Walnut House DS0000027591.V249282.R01.S.doc Version 5.0 Page 18 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 2 X 3 X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 1 X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 1 X 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Walnut House Score X X 2 X Standard No 37 38 39 40 41 42 43 Score X X 2 X X X X DS0000027591.V249282.R01.S.doc Version 5.0 Page 19 Yes 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. 1 Standard YA2 Regulation 14 & 17 Requirement The registered manager must ensure that the records of assessment are retrieved as a matter of urgency The manager must ensure that care plans contain information on relationships with families, and are reviewed at least every six months. The registered manager must ensure that risk assessments are reviewed at appropriate frequencies. The registered manager must ensure that the keys to the medicine storage area are kept securely and are not readily accessible to service users. The registered manager must ensure that all staff have access to POVA training. The registered manager must ensure that the home operates within its registration. The registered manager must DS0000027591.V249282.R01.S.doc Timescale for action 31/12/05 2 YA6 15 & 17 31/12/05 3 YA9 12 31/12/05 4 YA19 13 09/12/05 5 YA23 18 28/02/06 6 YA24 10 and 23 09/12/05 7 YA24 23 09/12/05 Page 20 Walnut House Version 5.0 ensure that the Fire Officer be consulted as to whether this door needs to be kept locked. If it does not the sign should be removed. 8 YA33 18 The registered manager must ensure that the staffing levels are reviewed to make sure that service users have their needs fully met and that shifts are not overly long for staff to be able to work effectively. The registered manager must ensure that staff currently in post, who do not have the required checks, must be rostered to work under supervision of named and appropriately checked members of staff. The registered manager must ensure that ‘missing’ statutory staffing records be obtained. The registered manager must ensure that all staff (including the registered manager) have regular, recorded supervision meetings at least six times a year (previous timescale of 30/9/05 not met). The registered manager must ensure that more structured reviews of the quality of care are undertaken at appropriate intervals and that these reviews are consistent with regulation 24 of The Care Homes Regulations 2001. 09/12/05 9 YA34 19 09/12/05 10 11 YA34 YA36 19 18 31/12/05 09/12/05 12 YA39 24 31/03/06 Walnut House DS0000027591.V249282.R01.S.doc Version 5.0 Page 21 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 Refer to Standard YA24 Good Practice Recommendations It is recommended that consideration be given to the privacy of the service user in the ground floor bedroom, and whether some form of net curtain would be of benefit. It is recommended that regular staff meetings take place for Walnut House. 2 YA33 Walnut House DS0000027591.V249282.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 Walnut House DS0000027591.V249282.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. 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