Care Home: 13 Norfolk Street

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• The Lodge Nursing Home
• Bracken House
• Sunnycroft
• Field Farm House
• Edgeview Nursing Home
• Church Terrace Nursing & Residential Home
• The Forbury

What the care home does well What has improved since the last inspection? The manager has responded to the requirements set out in the last inspection report. This includes contacting Social Services to request that annual reviews of people who are funded by them are planned for. The home now benefits from a new kitchen and the safety rail at the back is now secure. Repairs have been made to the doorway by the dining room. The home has listened and acted upon recommendations made at the last inspections and a policy on lone working is now in place, there are dates on the homes statement of purpose and a net curtain is in place in the bathroom to help maintain peoples privacy and dignity. CARE HOME ADULTS 18-65 13 Norfolk Street 13 Norfolk Street Leamington Spa Warwickshire CV32 5YQ Lead Inspector Julie McGarry Unannounced Inspection 3 September 2008 08:15 rd 13 Norfolk Street DS0000004479.V369794.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 13 Norfolk Street DS0000004479.V369794.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. 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 13 Norfolk Street Address 13 Norfolk Street Leamington Spa Warwickshire CV32 5YQ 01926 832552 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) Eden Place Limited Richard Mark Bloomer Care Home 4 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (4) of places 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th September 2006 Brief Description of the Service: 13 Norfolk Street is part of the Eden Place group of homes. It is a mid terraced property close to Leamington Spa and to all amenities and town centre shopping. The home has four bedrooms, two on the ground floor and two at the top. The lounge and dining room are located in the basement, with the bathroom and kitchen on the top and ground floors. There is a paved garden area to the rear of the building with space to sit outside, and a gated rear entrance. The service is registered and designed for four people with enduring mental health problems that are independent and self-caring in meeting their physical needs and require minimal levels of support to maintain their mental health. Information about the service is available in the home’s ‘Statement of Purpose’, which is available in the home. The residents receive differing levels of support from staff, which provides some house keeping, and domestic duties but have daily access to qualified mental health nurses from Eden Place Nursing Home, which located approximately 1 mile away. Range of fees: £456 per week. Additional charges are made for hairdressing, personal sundries such as toiletries and newspapers, and private chiropody if required. 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service 2 star. This means the people who use this service experience good quality outcomes. This Key Inspection was unannounced and carried out on 3rd September 2008. It established the outcomes for people living in the home, and to confirmed whether they are protected from harm. The pre fieldwork inspection record was completed, as well as a site visit to the home, during which time staff, people living in the home and the manager were spoken with. This process considers whether the home meets regulatory requirements, minimum standards of practice; and if the needs of those using the service are met. This report uses information and evidence gathered during the key inspection process, which involves a visit to the home and looking at a range of information. Including the service history for the home and inspection activity, notifications made by the home, information shared from other agencies and the general public and a number of case files. The manager supplied the commission with an AQAA (Annual Quality Assurance Assessment) in August 2008. Information from this has been used to make judgements about the service, and have been included in this report. On the day of the inspection, all four people who live at this home were spoken with. The manager was present throughout the inspection. Eden Place was visited in the afternoon to examine finances and medication management, which are kept at this establishment. Policies, procedures and care records were examined. Staff records, environmental checks and risk assessments were also read. During the inspection, the care of two people who live in the home were examined in detail. This included, reading assessments, care plans, and other documentation. This is part of a process known as ‘case tracking’. Where evidence is matched to outcomes for the people who live in the home. What the service does well: People living at the home see it as their own and are very relaxed in all areas of the home. The environment is welcoming and the home is clean and tidy. There are person centred assessments and care plans in place. Risks to people have been assessed and the assessments are clear and easy to follow. The staff have a good understanding of person centred care. 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 6 People are supported to gain access to advice from health professionals where they need it so their health needs can be met. People independently go out to places and are very much part of the local community. They are able to live independent lifestyles with support from staff based at Eden place. People are supported to keep in touch with their families and friends so that they do not lose relationships that are important to them. The people living at the home have good positive relationships with staff, and get on well with each other. There are two dedicated care staff members who provide support to those who live here. They are trained and have NVQ (National Vocational Qualification) level 2 or above. There is a low staff turnover and stable staff team. This means that people living at the home have a regular team of staff who have a good understanding of their needs. The home is managed so the people living there benefit from a well-run service. People’s health, safety and welfare are at the heart of how it is managed. People are satisfied their needs are met, and their privacy, dignity is respected. “If I had anything I was concerned about I would discuss it with staff – they are helpful here.” What has improved since the last inspection? What they could do better: Although care plans and risk assessments are in place, regular reviews need to occur to ensure the information remains up to date. 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 7 The manager needs to keep written records of his meetings with the people who live there to demonstrate that he is listening to the matters raised by them and responding appropriately. Staff do not have regular guidance meetings with their manager where records of discussions are kept. People living at the home would benefit from continued redecoration of the home to ensure it is well maintained. Consideration needs to be made with regard to the management of finances to ensure all monies are auditable and people’s independence is promoted. The manager needs to continue to liaise with Social Services to ensure the annual reviews of peoples care plans happen. The home needs to develop effective ways of assessing and monitoring the quality of the service. This is so that shortfalls are identified, are improved on and the quality of the service is kept under constant review. 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. 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 8 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 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 9 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): 1,2 Quality in this outcome area is good People’s needs are assessed and they are provided with information so that they are clear about their rights and entitlements at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose and Service User Guide are available at Eden Place. The Service User Guide has been reviewed and shortened to make it more accessible to those who live there. The manager informs us that the Statement of Purpose is also due to be reviewed and copies of both documents will be kept at the home to ensure people can easily access them. Two files of people who live at the home were looked at and contained contracts from both the home and social services for their stay there. One person living at the home moved from another home within the organisation. No pre admission assessment was needed as staff already had written care plans and risks assessments in place. In place of a pre admission assessment, staff reviewed the care plans and risks assessments of this person prior to the move to ensure that the home was able to meet this persons needs. Before agreeing to the move to Norfolk Street, they were able to visit 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 10 the home and knew both the staff and people who live there. This person told us that : “I have settled in well here… I am glad that I moved here.” “I was given the choice about the move here, or to stay at Eden Place.” The people who live at this home are funded by social services; however, they are not having annual reviews of their care plans. A review of the needs of all the residents was last undertaken by the social services reviewing team in 2003. The manager has taken steps to ensure that regular reviews are undertaken by social services. 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 11 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): 6,7,9 Quality in this outcome area is good The people living in this home are involved in decisions about their lives and are playing an active role in planning their care and the support they receive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Two people’s care records were seen. Care plans and risk assessments have recently been reviewed and include most the care and support they need. Further work however must be undertaken to ensure documents are completed in full and regularly reviewed to ensure records evidence needs are current and are being appropriately managed. For example, two people are assessed as having ‘Low’ levels of needs and risks yet staff store and manage their cigarettes and finances. There are no care plans in place to reflect the need for this type of staff support. To ensure that peoples choices and independence are promoted, there should be records in 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 12 place to show that each person is in agreement to this support, and provide details of how the support is to be managed and assessed. Some elements of the care plans were good in providing detailed guidelines for staff in supporting residents. For example, records show that one person can occasionally become anxious, information on how to support this person and recognise the signs that this person is becoming anxious are recorded in detail. A risk assessment has been carried out to provide staff with guidelines on how to support them and ensure staff respond in a consistent manner. Daily records reflect that staff are monitoring for indications of anxiety and ‘mood’ each day. This is good practice to ensure the right to good-quality physical and mental health care is being promoted for each person. People’s needs at this home have remained stable over the past year and the recent review of the care plans and risks assessments reflect this. People spoken to told us that there have been no changes to their health and wellbeing, or lifestyle in the past year. From discussion with the manager and people who live at the home, there is a focus on promoting independence and positive risk taking. For example, one person told us that they are planning to leave residential care and move into their own flat. Plans are being made with the support from staff at Norfolk Street and the outreach team to help them achieve this. ‘After Care’ plans are also being developed to ensure that appropriate support is offered once this person leaves the home. This person told us that they are ‘‘getting good support from the manager and an outreach worker to move to my own flat, … I am spending a lot of time there decorating it’’. 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 13 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): 12,13,15,16,17 Quality in this outcome area is good The people living in this home are supported to make choices about their lifestyle and to develop life skills. Daily activities promote independence and opportunity for people to live ordinary and meaningful lives in the community where they are living. This judgement has been made using available evidence including a visit to this service. EVIDENCE: All of the people spoken with were enthusiastic about how they spend their days both in the community and at home. People told us about their lives at Norfolk Street: “I am very happy living here.” “I have a good life here, and don’t want it to change.” “I keep busy through the day… I have a paper round and can go to Eden place when I want’’ “…I use the bus to go to Warwick and go to the Old Bank.” 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 14 One person told us about their planned holiday to Newquay later this month and opportunities to go out on various day trips. Another told us about their current work in a local allotment, and of their plans to return to education to develop their skills in cookery. Discussions with people told us that they can choose how to spend their time during the week and that can do what they want at the weekend. Support from staff is available to help people achieve any planned goals. Lifestyle assessments are in place detailing goals and aspiration for the future for each person. Goals identified in these plans show their wishes and preferences about what they want to do on a daily basis and how they maintain links with their local community. Two people spoken with confirmed that the goals identified in the lifestyle assessment reflects their wishes and that they are able to participate in the events recorded. Daily records showed that during the week activities to meet identified needs are regular and support ordinary and meaningful lifestyles. There is evidence in daily records that activities are wide and varied and meet their needs regarding maintaining family links and cultural needs. For example, one person’s father lives in France. He told us that he is able to go and visit his father without staff support. Another person visits and stays with their parents at the weekends. One person has recently developed links with a local church and is being supported by the manager to practise their chosen faith. One person said that they go shopping with staff. Others do their own shopping as and when they need to. There is a care plan in place for one person who needs support with their shopping, and this is part of their identified goals to improve their independent living skills. People at this home are independent in the preparation of all meals and drinks. There is the option to go to Eden Place for any of their meals should they wish to do so, and this is generally a poplar choice on Sundays for the roast dinner. All food being stored in the kitchen looked fresh. 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 15 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): 18, 19,20,21 Quality in this outcome area is good The health and personal care that people in this home receive is based on their individual needs. Staff respect the people and promote their dignity and privacy. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There were positive relationships and interactions observed between staff and the people who live at the home. The staff and manager encourage and support people in a relaxed way. All of the people living in the house said that they like, and get on well with the staff. Two people spoken with knew whom their named nurse was. At the current time, all of the residents living in the home are able to undertake their own personal care with a minimal level of support and encouragement. 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 16 Health records and care plans showed each person’s right to good-quality physical and mental health care. The records show that as part of promoting their health people make regular visits to a dentist, optician, specific health consultants, their GP and a chiropodist when needed. The staff have recently reviewed all care plans. However further work needs to be done to ensure that records are completed and up to date. For example, one person receives support in medication management through blood tests every four weeks. The care plan tells staff how to support this person and daily records show that these blood tests are being arranged. There are documents for staff to record when blood tests are carried out and the outcome of the tests, however this is not always completed and there are gaps in the recording. The manager told us that this medication is not prescribed if there are concerns from the blood tests, however agrees that records need to reflect the good medication management practices at the home. There is an amount of ‘positive risk taking,’ taken into consideration to promote independence. Each person is assessed and monitored to ensure the safety of looking after and taking their own medicating. Two people at this home collect their tablets from staff at Eden Place each week. Their medication is stored in a secure place at the home. Both people have been assessed as being able to administer their own medication with minimal staff support, one person’s care plan states that staff need to carry out ‘periodic checks’ to ensure medication is stored safely and taken as prescribed. The two dedicated staff members who provide daily support to those who live there have not received training in relation to medication management. It would be good practice for staff to receive training in medication management as this will ensure that staff are competent and confident in carrying out the periodic checks. It will also ensure staff are equipped to recognise potential side effects of medication. During the inspection, the manager has agreed that he will extend this training to the two staff members who provide support at Norfolk Street. Medication records were correctly completed. The manager and staff at Eden Place have recently started to actively monitor the completion of the medication records. There was no record of temperature recording of medication stored at Eden Place or Norfolk Street. Medication must be stored below 25°C to ensure the stability of the medicines. A medicines fridge was available with daily recordings of the temperature using a maximum-minimum thermometer. Medication plans have been developed for the two people who self-administer, however these need to be further developed to accurately reflect the system in place for safe storage and administration of medication. One person said, “I look after all of my own tablets, I collect them from Eden place each Monday”. 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 17 The manager and staff continue to be proactive at meeting the specific social, health and personal care needs of the people who live at the home. There are good systems in place for monitoring people’s physical well being. 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 18 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): 22,23 Quality in this outcome area is good The people who live in this home are able to express their concerns and know whom to speak to if they are unhappy or feel unsafe. They are supported by a staff team who have a good knowledge of how to respond to any suspicion of abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There have been no complaints or allegations of abuse received by the home or us since the last inspection. Following discussions with the manager, it is evident that people living at the home are able raise any concerns should they need to do so. It is good practice that these day-to-day concerns are recorded on the complaints log, as it shows that people’s issues and concerns are taken seriously and addressed as soon as they are raised. People said they felt safe and would know whom to talk to if they were unhappy. One person commented, ‘If there was something I could complain about, I would’. People have access to a complaints policy, which is displayed within the home. This has been recently reviewed and updated to reflect current policies and procedures. 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 19 Staff spoken to were able to show that they know how to support people to make a complaint. Their knowledge of safeguarding practices was also evident. All staff are trained in the protection of vulnerable adults policies and procedures. This training has also been extended to maintenance and housekeeping safe. An adult protection procedure is in place at the home so that staff know how and to who they can report any suspicions of abuse. The staff and manager spoken with were confident of how to use these procedures. The whistle blowing policies would benefit from being updated to contain the local authority details about safeguarding contacts. 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 20 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): 24,30 Quality in this outcome area is good The home is well maintained and furnished so that people live in a clean, comfortable and homely environment to live in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a warm and welcoming atmosphere in the home and at the time of the visit, it was homely, comfortable and safe. People living there were able to move around easily and freely and to come and go as they wished. Since the last inspection, the manager has replaced the kitchen and the safety rail at the back door is now secure. Additional work inside the home has been carried out as recommended at the last inspection, for example, a net curtain is in place in the bathroom to ensure peoples privacy and dignity are maintained. 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 21 One of the people who lives at the home gave us a tour of the communal areas of the house and their bedroom. The house was clean and tidy, some further maintenance and decoration work in the bathroom would improve the environment further, for example, a rail near the sink has been replaced with a smaller hand towel rail, leaving an area of missing wall paper. An area of skirting needs to be replaced near the bath, and the bath surround should be free from mould. The home did not have any offensive odours. Three of the people who live there smoke. There is a designated room with an extractor fan where people can go to smoke. An additional lounge room is available for all people in the house; this is non-smoking to accommodate the needs of the one person who does not smoke. All of the people living in the home were happy to show us their bedrooms. The bedrooms reflected their individual lifestyles, interests and tastes. One person’s bed needs to be replaced and the head board of another person bed needs to be replaced. The manager and maintenance personnel told us that plans are already in place to address theses points. People at the home said that they are involved in cleaning and tidying alongside staff. Cleaning products are stored under the kitchen sink in a unlocked cupboard. Staff are going to carry out a risk assessment to determine the need for which products can be stored in locked cupboards. There are established policies and procedures in place for the control of the risk of infection in the home and staff practices during the visit were seen to be safe. Infection control training is included in mandatory training for all staff. 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 22 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): 32,34,35 Quality in this outcome area is good The people living in this home are protected by robust recruitment practices and supported by a skilled and competent staff team. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has a very low turnover of staff. Staff sickness levels are also very low and this means that a consistent staff team supports the people living at the home. There are currently two members of staff who are attached to the Home to provide daily direct support (Monday – Friday). Residents also have twentyfour hour support from the staff at Eden Place. Staff visit the home each evening to provide support and assistance should it be needed. Daily records also show that staff telephone the house during the day to enquire if support is needed and ask how people are. There are no fixed number of hours that these two staff members provide support in the home, and the manager was able to demonstrate that the hours staff provide 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 23 direct support in the home is flexible according to the needs of the residents at any one time, and are in response to trips, outings or appointments. Discussion with staff and examination of the staffing rota shows that there continues to be good levels of staff support for the people living in the home that reflect the levels of independence and abilities of the people who live there. Four staff files including the housekeeper and maintenance staff were looked at. The recruitment records sampled showed that appropriate checks had been made to make sure that staff were suitably experienced and qualified to work with vulnerable adults. Criminal Records Bureau checks had been made and written references received before the employee began work so that people were protected from the risk of having unsuitable staff work in the home with them. The training chart in the home shows that staff have accessed training in the full range of mandatory, health and safety related training, (e.g. first aid, food hygiene, adult protection and fire safety). Training that is relevant to their role, is made available, which helps them understand and meet the individual needs of the people who live there and keeps them up to date with new ways of working. Staff were not receiving formal supervision at the time of this inspection. The manager has informed us that this will now become standard practice for staff. People living at the home said they know all of the staff and who work each day. People spoken to told us that staff treat them well and they act and listen to what they say. 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 24 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): 37,39,42 Quality in this outcome area is good People continue to benefit from living in a well run home. They are able to express their views of the service provision and know that their views will be listened to and acted upon. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The manager of the home is also the manager for Eden Place and another small home in the group. He has now been in post for over four years. He is a qualified nurse with experience working with people with a broad spectrum of psychiatric conditions. He continues to work towards achieving his NVQ level 4 in management. 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 25 The Annual Quality Assurance Assessment (AQQA) completed by the manager was not completed to a good standard. Information provided was not fully supported by a range of evidence, and the Annual Quality Assurance Assessment (AQAA) partly informed us about changes that have been made, and where improvements still need to be made. From discussion with people living at the home, staff, the manager, the examination of records and observation of care practices show that a competent and skilled manager runs the service. People living at the home are surveyed for their views every two years. This is due to be undertaken this year. An effective way of assessing and monitoring the quality of the service should be developed. This is so that shortfalls are identified, are improved on and the quality of the service is kept under constant review. For example, people said that they have regular contact wit the manager where they can say what they want about the running of the home; however this is not currently being documented. The manager tells us that records will be maintained to reflect any wishes, concerns or suggestions made by the people who live there. A representative of the organisation carries out monthly monitoring visits and copies of the reports are kept at the home, these were not available on the day of the inspection. There was an audit trail of how finances are managed at the home with statements and receipts evident. Each person’s money is pooled, and it was not possible to determine if the balance on the finance sheet for each individual could be accounted for in the pool of money. The management of each individual’s money needs to be assessed and the outcome reflected in each person’s care plans and risk assessment plans. A number of Health and Safety records were checked, including the fire safety log. These records showed that health and safety matters are well managed and demonstrated that systems for monitoring when essential service and maintenance of equipment is due is sufficiently robust. Fire alarm systems are checked weekly; hot water outlet temperatures are recorded weekly and were noted to be within recommended limits and Annual Electrical Portable Appliance Testing is being completed. 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 26 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 3 2 X 3 X 4 X 5 3 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 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 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 3 X X 3 X 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 27 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. 1. Standard YA6 Regulation 15 Requirement The registered manager must ensure that all the care plans are regularly reviewed and updated to reflect changing needs and that these changes are accurately recorded. More robust management of finances must be put into place regarding residents’ money held for safekeeping. Peoples wishes related to spending need to be established. This will ensure that the financial interests of people using the service are protected. A robust quality assurance system must be put into place, and demonstrate how improvements are to be made. Timescale for action 30/09/08 2. YA23 17 30/09/08 3. YA39 24 30/10/08 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 28 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 YA30 YA36 Good Practice Recommendations The manger should ensure that there is an ongoing program of redecoration to maintain the home to a good standard. The registered manager should ensure staff receive the support and supervision they need to carry out their jobs. 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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 13 Norfolk Street DS0000004479.V369794.R01.S.doc Version 5.2 Page 30 - 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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