Inspection on 07/06/07 for Norwood Road 227

This is the latest available inspection report for this service, carried out on 7th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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

Norwood Road 227 29/09/05

Norwood Road 227 22/02/05

Norwood Road 227 09/11/04

Norwood Road 227 30/03/04

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

CARE HOME ADULTS 18-65 Norwood Road, 227 West Norwood London SE24 9AG Lead Inspector Ms Rehema Russell Unannounced Inspection 7th June 2007 8:00 Norwood Road, 227 DS0000022745.V342280.R02.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 Norwood Road, 227 DS0000022745.V342280.R02.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. Norwood Road, 227 DS0000022745.V342280.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norwood Road, 227 Address West Norwood London SE24 9AG 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) 0208 671 5469 www.southsidepartnership.org.uk Southside Partnership Ms Tawa Olaloko Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Norwood Road, 227 DS0000022745.V342280.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th January 2006 Brief Description of the Service: 227, Norwood Road is a large three storey house on a busy main road in a residential area. It is one of a number of homes where the care is provided by Southside Partnership and the building is owned and maintained by Hyde Housing Association. Car parking is not possible on the road outside the home, but is available in nearby side streets. The home is on a bus route and is walking distance from a rail station. There is a small parade of local shops opposite the home and a large park a few minutes walk away. The home has a front garden with steps to the front door and a rear garden with patio and steps leading to a larger lawned area. Communal sitting, dining and utility areas are on the ground floor. The first floor has three single bedrooms and a bathroom with toilet and there are two further single bedrooms, toilet, shower room and office/sleeping-in room on the second floor. The home would not admit service users with mobility problems/wheelchair needs as it is not suitable for people with physical disabilities. The home describes itself as a Teaching Project which service users should regard as their own home while developing their independence and potential and where appropriate, working towards more independent living. It is registered for five people. Prospective service users would be given the Statement of Purpose, Residents Handbook (Service User Guide), profile of the house and verbal information. A copy of the most recent inspection report is kept in the Service Users File in the conservatory and a copy is also available in the office. The weekly fee is £950.09 and there are no additional charges. Norwood Road, 227 DS0000022745.V342280.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 7th June 2007. The inspector met and spoke with two service users, the registered manager, the deputy manager and one support worker. The inspector also toured the communal areas and one bedroom and looked at documentation and records. The deputy manager had provided a pre-inspection questionnaire, which was completed well, and the manager provided further documentation on the day. At the time of the inspection there were four service users resident at the home, with one vacancy. What the service does well: What has improved since the last inspection? What they could do better: There are no requirements or recommendations arising from this inspection. Norwood Road, 227 DS0000022745.V342280.R02.S.doc Version 5.2 Page 6 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. Norwood Road, 227 DS0000022745.V342280.R02.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 Norwood Road, 227 DS0000022745.V342280.R02.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): 1, 2, 3, 4 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective service users are given comprehensive information about the home so that they are able to make an informed choice about where to live, and they are given several opportunities to visit and “test drive” the home. The home has a through assessment procedure which ensures that prospective service users’ individual aspirations and needs are thoroughly assessed. EVIDENCE: Prospective service users are given a full range of information in order to make a choice about living at the home. This includes a Statement of Purpose, Residents Handbook/Service User Guide and a profile of the house. These documents explain exactly how the house is organised, service users’ rights and responsibilities, and the facilities and support available at the home. Prospective service users are also given verbal information about the home, and are encouraged to make a series of trial visits, including an overnight stay, and to meet and speak with current service users and staff. The assessment procedure for the newest service user, who joined the home after the previous inspection of 5th January 2006, and an established service user was checked. The assessment procedure was found to be very thorough, covering all relevant areas needed to assess the suitability of the home for the needs and aspirations of the potential service users. There is an initial Norwood Road, 227 DS0000022745.V342280.R02.S.doc Version 5.2 Page 9 assessment, covering safe environment, communication, eating and drinking, sleeping, social interactions, personal hygiene, behaviour, mood, medication and sexuality. There is then a further assessment, outlining strengths and weaknesses, under the headings of physical, psychological, social and religious/cultural/spiritual. Risk assessments also form part of the assessment process and in addition other documentation is obtained from relevant specialists and professionals, such as Care Programme Approach, occupational therapist, South London & Maudsley (SLAM) and consultant psychologist. The home always assures potential service users that they can have someone of their choice with them at the assessment, which may be a friend, relative, community psychiatric nurse or keyworker from the previous placement. Prospective service users can be confident that the will meet their needs and aspirations based on the success that has been achieved by the home in enabling previous service users to move on to more independent living. In the last 17 months, two service users have had a planned move from the home to low supported accommodation. One was supported to self-medicate and obtain and sustain employment and is now sharing a flat in the community, and a second service user has moved to his own flat in an area outside London where his sister lives. Observation of staff interaction with service users, and service users’ opinions, indicated that staff have an open, friendly, respectful and supportive relationship with service users. If staff need specialist advice, it is available from the line manager of the home, from the psychiatrist, CPNs and specialist teams, from training provided by the parent organisation and from various publications and information received at the home. All service users are offered cultural assessments and as staff are from a variety of cultural backgrounds they are able to offer a range of skills, cultural knowledge and beliefs. One specialist team told the home that one service user’s communication skills had improved since he had been at the home and that a large factor in his improvement had been that there were staff in the team from his own ethnic background. Norwood Road, 227 DS0000022745.V342280.R02.S.doc Version 5.2 Page 10 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, 8, 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users assessed and changing needs and personal dreams and goals are reflected in their individual care plans. Service users are encouraged and supported to make decisions about all aspects of their lives and 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. EVIDENCE: Two of the four care files were examined. They were found to be well kept, thorough, clearly written and containing all necessary information for the care of service users. Care plans are in two parts. The first is a Person Centred Plan (PCP) which is written, signed and dated by the service user and incorporates their aspirations/dreams/wants, people they want involved in their care, support needs, action plan and timescale. The second part contains a minimum of three individual care plans, each of which identifies a particular need with short and long-term goals evaluated by the key worker and service user together, and signed and dated by the service user. Each care plan is Norwood Road, 227 DS0000022745.V342280.R02.S.doc Version 5.2 Page 11 reviewed monthly by the service user and key worker, and there was written evidence of the service user directly amending the care plan at the review meeting to better reflect their changing needs. Each care plan is also evaluated monthly, the evaluation also being signed and dated by the service user, and daily progress notes on each care plan are written twice daily by staff. Daily progress notes were found to be full and thorough. Case files also contained evidence of Community Care placement reviews, attended by the service user, relative, care co-ordinator and manager/deputy manager. One placement review, held after the first six months of the most recently placed service user, stated that “(the service user’s) independence has thrived since moving to (the home)”, and the service user’s relative stated that they were very pleased with “how much (the service user) has achieved in a short period of time living at the home”. As evidenced from care plans and other documentation and from speaking with service users, they are encouraged and supported to make as many decisions as possible about their own care and matters of daily living both inside and outside the home. Examples were given of staff supporting and implemented service users’ decisions about which family members they did or did not want to see, the choice of colours for décor, of activities and social functions, of what and when to eat and of how to spend their money and time. Staff give support in a tactful and sensitive way, and service users said that “staff are good at letting us choose and suggest things”, that they “have freedom” and that the home “ is not institutionalised”. Three of the four current service users managed their own finances, with the fourth having the local authority as appointee. Service users are given every opportunity to participate in the day to day running of the home. Staff emphasise that this is the service users’ home and that they therefore have full rights to choose and make decisions about daily life there, and also the responsibility to participate in the daily life and duties of the home. To encourage and support this, service users participate in staff recruitment, attend a joint staff and service user meeting annually, take their own minutes at monthly tenants (service user) meetings, decide by majority vote on any environmental issues at the home. Service users spoken with said that “staff are good at letting service users choose and suggest things”. One service user had suggested that an exercise bike be bought for the home, and this had been done. Risk assessments are undertaken at assessment and are also undertaken as situations arise during the service user’s stay at the home. These were seen and found to be detailed and thorough, undertaken with the participation and signature of the service user, and regularly reviewed. Individual risk assessments cover areas such as staying out overnight, substance misuse and sexual exploitation and general risk assessments cover areas such as cooking, and are also detailed, practical and regularly reviewed. A service user spoken with said that they felt safe and protected at the home but “also able to take Norwood Road, 227 DS0000022745.V342280.R02.S.doc Version 5.2 Page 12 reasonable risks”, for example not having to state where they are going when they leave the home unless they are attending a professional appointment. Norwood Road, 227 DS0000022745.V342280.R02.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): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported to access all opportunities for personal development and to take part in age, peer and culturally appropriate activities at their choice. They are fully integrated into the local community and engage in appropriate leisure activities. Staff encourage and support service users to maintain appropriate personal, family and sexual relationships, respect service users’ rights and responsibilities and support them to enjoy a healthy and nutritious diet. EVIDENCE: The aim of the home is to prepare service users to move on to more independent living and so staff encourage and support service users to take all opportunities to develop social, emotional, communication and independent living skills. Service users prepare their own meals, budget their own money, select which activities to attend and the social life they wish to have, all with staff assistance if requested or needed. One service user said they appreciated Norwood Road, 227 DS0000022745.V342280.R02.S.doc Version 5.2 Page 14 that “staff have time for me”, that they “have the chance to cook” and to “do things with the others”. Service users also appreciate the day trips organised by staff and the once a week get togethers with other service users and staff for a take away and social evening. One service user currently chooses to attend a local Church. Service users are encouraged and supported by staff to continue their education or training, to find and keep appropriate employment and to take part in fulfilling activities, including culturally appropriate activities, according to their wishes and inclinations. One service user currently attends a local authority facility which provides paid skills teaching and future employment and a day centre which concentrates on furthering educational and employment skills. Another service user attend the parent organisation’s rehabilitation association. One service user regularly attends a day centre designed specifically for people of his cultural background and one service user chooses not to attend any regular day centres or prepare for paid work. Service users are fully integrated into the local community, participating in local colleges, public transport, cinemas, shopping facilities, museums, cafes, public houses and local events. Staff support service users to explore spiritual and religious interests of their choice and all service users are supported to understand their right to vote and staff have assisted them all to obtain postal voting rights. As service users do not wish to go away on holiday, staff provided day trips on a monthly basis, including recent trips to Brighton and Chessington Zoo. Staff also accompany service users to special meals on their birthdays, if this is how they wish to celebrate it. The majority of current service users have contact with either family or friends, although one service user has stated that they do not want contact with their family and staff have respected this. Staff demonstrated sensitivity and perception in their support of service users’ relationships. Appropriate sexual guidance is offered as necessary, including consultation with specialist teams in regard to specific issues. Risk assessments are undertaken if a service user’s behaviour may endanger their sexual health or put them at risk of sexual intimidation, and staff have provided leaflets on hepatitis. Verbal evidence from service users and staff confirmed that service users’ independence and individual choice is promoted in all aspects of life at the home. Service users choose when they wish to get up and go to bed, when and what they wish to eat, where they choose to spend their time both inside and outside the home, which activities and studies they wish to undertaken, and how they wish to spend their money. Staff do not enter service users’ bedrooms, except for the planned once a week health and safety checks or spot checks, and do not open their post. Staff sensitively monitor service users’ responsibilities whilst safeguarding their independence and choice, and this has been appreciated by service users’ placement authorities and next of Norwood Road, 227 DS0000022745.V342280.R02.S.doc Version 5.2 Page 15 kin, who have mentioned in reviews how pleased they are with the progress service users’ have made towards independence whilst at the home. All current service users are able to cook for themselves and there are risk assessments in place where necessary. One service user said she really appreciated being able to cook for herself and learn cooking skills, and some service users attend cookery classes at day centres. Staff provide assistance to service users if needed or requested, for example by providing recipes or suggestions. Staff keep records of service users’ meals that are observed or reported and encourage them to eat healthily by providing information and discussing healthy eating in key worker meetings. Menu records indicated that service users are eating regularly and healthily, including culturally appropriate foods if they choose. Staff provide a cooked meal on special occasions, such as Easter, and have purchased a smoothie-maker at service users’ request. Staff have also started cooling breakfast once a week for service users so that they can run a “day surgery” where service users can get together to express their views and opinions together informally. The home also provides takeaways for service users for one evening each week, where they can choose whatever they like and enjoy the company of eating it together. Norwood Road, 227 DS0000022745.V342280.R02.S.doc Version 5.2 Page 16 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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users receive personal support in a sensitive and appropriate way, and their physical and emotional health needs are met. Service users are assisted to self-medicate and are well protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Service users do not require personal physical care but all require verbal prompting by staff for personal healthcare/hygiene issues. Evidence from service users and staff indicated that this is given sensitively and in a way that upholds service users’ privacy and dignity. Staff only discuss personal or potentially embarrassing subjects with service users in private and confidentially during keyworker meetings. No current service users require any aids or equipment but some do require psychiatric support from time to time, which is provided by community psychiatric nurses, psychiatrists or other specialists as needed. Evidence of this is documented in care plans and reviews. Files also evidenced best interests meetings held when appropriate, Norwood Road, 227 DS0000022745.V342280.R02.S.doc Version 5.2 Page 17 with attendees including the service user and next-of-kin, care co-ordinator, psychiatrist, registered manger and keyworker. Staff support and facilitate service users to take control of and manage their own healthcare as appropriate. Each service user has a health action plan which documents the health issues, name and date of practitioner seen and the date of the next planned visit. Health action plans evidence that service users are facilitated to see the GP, CPN and/or Consultant Psychiatrist regularly or as needed, and are supported to make optician/dental/chiropody appointments as they choose. One service user confirmed that she visits the GP on her own but knows that she could ask staff to accompany her if she wished. Recording, storage and administration of medication was found to be in very good order. Recording systems are strictly adhered to by staff and regular and random checks are conducted and recorded by the manager and deputy. The medication file, which is kept on hand near the medication cabinet, has very clear and detailed guidelines for missing and refused medication, for medication monitoring, for overnight stays outside of the home and for “as needed” medication. There is also a list of bank and agency staff sample signatures, clear instructions for the filling of dossette boxes, and full guidelines for reviewing, handling and ordering medication. As very good practice, there is an individual central record of incoming drugs for each service user. There is also a homely remedies list, signed and dated by the GP. All service users are supported to self-medicate, starting on a daily basis then progressing incrementally to a full week. Full notes of how the selfmedication is progressing are kept on the daily progress notes for each service user. The Community Pharmacist inspected medication on 25th January 2007 and gave the home full marks for all areas – there were no requirements or recommendations, and only one minor suggestion, which the home has implemented. Norwood Road, 227 DS0000022745.V342280.R02.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. This judgement has been made using available evidence including a visit to this service. Service users views are listened to and acted on and service users are protected from abuse, neglect and self-harm. EVIDENCE: Staff are fully conversant with the home’s policy regarding abuse and with the many different forms abuse may take. Training is given both during induction and on subsequent training courses, and discussed in team meetings. The deputy manager was able to outline the very many different forms of abuse and to detail the procedures that should be followed in the event of allegations. He was fully aware of the current local authority adult protection procedures. The manager gave several examples during the course of the inspection of how to deal with verbal or physical aggression. The home has a clear and detailed complaints policy and procedure. Staff encourage service users to make complaints by keeping a copy of the procedure in a file in the lounge, where it is readily available, which has blank complaints sheets that service users can fill in. Any complaints that are personal or confidential are not kept in this file but in another that is kept locked up. Service users said that if they had a complaint they would tell staff, who are always willing to listen. They said that if it happened that there was no response to their complaint, they would put a note in the complaints book. The complaints book was seen and evidenced that there had been two complaints received since the previous inspection of 5th January 2006, both Norwood Road, 227 DS0000022745.V342280.R02.S.doc Version 5.2 Page 19 from a neighbour about noise nuisance. Both complaints had been responded to within 28 days and had been resolved. Norwood Road, 227 DS0000022745.V342280.R02.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, 26, 27, 28, 29, 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users live in a homely, comfortable, attractive, well maintained and safe environment. Toilet and bathrooms provide sufficient privacy and shared spaces complement and supplement service users’ individual rooms. No current service users require specialist equipment. The home is clean and hygienic throughout. EVIDENCE: The home is suitable for its stated purpose. The premises are accessible, safe and well maintained throughout. The décor, furniture, fixtures and fittings are of good quality and the whole home is attractive, non-institutional and homely. Service users have chosen the decoration colours, and have a full choice in how the furniture and fittings are arranged. The lounge, kitchen and conservatory walls have been redecorated and it is planned to recarpet the hall and conservatory this year. The premises are in keeping with the local community and the home blends in with the other residential premises alongside it. It has local shops and a café just over the road, a large park Norwood Road, 227 DS0000022745.V342280.R02.S.doc Version 5.2 Page 21 within a few minutes walk, and a bus stop outside with links to larger community facilities and rail stations. All bedrooms were not seen at this inspection because at the time the inspector was ready to tour the building three of the four service users were out of the home and permission to enter their rooms had not been sought in advance. However, earlier in the day one service user had told the inspector that she was very happy with her room, that it was decorated as she liked, that she had brought her own chair with her, that she was always warm enough in it and that the room was “lovely”. The inspector was also able to see the bedroom of the one service user who remained in the home that day, and to note that staff had managed to make improvements to the way the service user used the bedding and furniture despite the service users’ very strong autistic traits. The home has a suitable number of bathrooms and toilets and offers service users the choice of bath or shower. There is an additional toilet on the ground floor which is conveniently located for the communal areas. The shared spaces in the home are of particularly high quality. The living room has leather sofas, video, television, DVD player, freeview box, library, plants, mirrors, framed photos of service users, fruit bowl, clock, framed prints, and good quality carpet and curtains. Staff have also created an area where relevant information is kept which gives service users easy access to the complaints file, Statement of Purpose, Service Users Handbook/Guide, draft mental Health Bill, Data Protection Act, Cornwall report, Information on Autism and Drugs, Adult Protection Procedures, National Minimum Standards and others. One set of information about the Mental Health Act was used by a previous tenant to help get himself off his section. There is also a file with information about restaurants and take-aways in the local area. The lounge is very comfortable, homely and pleasant area to sit in. There is also a separate conservatory where residents may smoke and access the garden. This is also an attractive room, with television and a music system, an exercise bike, a view of the back garden and ceiling blinds in order to control the temperature on sunny days. It also has a service users’ memo book which has notification of the next breakfast to be cooked by staff and space for service users to put in their choice of food. This book also evidenced service users being given choices about paint colours and other environmental items, with the majority vote prevailing. The home does not admit service users with physical disabilities as it is not suitable, having stairs to the front door, stairs to the back garden and two flights of stairs inside. Current service users do not require any specialist equipment or aids. On the day of the inspection the home all communal areas were found to be in an excellent state of cleanliness and hygiene. The kitchen, which is used by all service users for drinks and food preparation, was clean, hygienic and well Norwood Road, 227 DS0000022745.V342280.R02.S.doc Version 5.2 Page 22 maintained. Laundry facilities are situated in the room adjoining the conservatory, completely separate and away from the kitchen. Norwood Road, 227 DS0000022745.V342280.R02.S.doc Version 5.2 Page 23 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, 33, 34, 35 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported by a competent, qualified and effective staff team that are appropriately trained. The Registered Provider’s recruitment policy and practices support and protect service users, and there is a good staff development programme at the home. EVIDENCE: Of the four support workers (including the deputy manager) at the home, the deputy and one support worker have NVQ Level 3 and the third support worker is in the process of obtaining NVQ Level 3. Therefore the home has exceeded the 2005 NVQ Level 2 recommended training target. It was evident from observation and discussions with staff that they have the skills, experience and understanding necessary to meet service users’ needs, including an understanding of and commitment to equal opportunities and supporting any cultural needs. Similarly, there was evidence of good relationships with other professionals and a willingness to use outside advice and expertise as required. Rotas showed that there is sufficient staff cover to meet the needs of service users and that a management member of staff, either the registered manager Norwood Road, 227 DS0000022745.V342280.R02.S.doc Version 5.2 Page 24 or deputy manager, is on duty each day. The deputy manager works shifts, including weekends. There is very low staff turnover, with only one member of staff leaving the team since the previous inspection of 5th January 2006. Agency cover is used to cover certain shifts and allow flexibility, but this is almost always bank or agency staff who are familiar with the home and service users and can therefore provide continuity of care. The staff team reflects the cultural and gender composition of service users, regular, monthly, minuted team meetings take place, and staff use specialist services from relevant professions whenever appropriate. The Registered Provider has a thorough recruitment procedure but as it is a large organisation, recruitment is conducted from Head Office and records are maintained there. At previous inspections, discussions with new staff have demonstrated that the Registered Provider follows a thorough recruitment procedure, based on equal opportunities and including all of the checks that ensure the protection of service users. This was confirmed by another inspector who visited the Registered Provider’s offices and checked recruitment files at the beginning of 2007. All staff joining the home have an initial induction which covers all of the basic policies and procedures at the home, including medication and health and safety. Within their first six months of employment all staff then take the TOPPS training which includes manual handling, food hygiene, fire safety, medication, risk assessment, health and safety and equal opportunities. They also attend a one day external training course on mental health issues. From then on training and development needs are raised in supervision for individuals and in team meetings for the staff group as a whole. The Registered Provider runs a very well organised and comprehensive training programme, and provides individual training profiles for staff and regular reminders to homes when refresher courses are due. The manager also ensures that any information/training needs arising from the particular mental health problems of service users at the home are provided for and discussed in team meetings, so that staff have any specialist knowledge required to meet service users’ needs. Training attended by staff in the past 12 months has included: fire safety, how to manage depression, medication, assertiveness training, working with substance misuse, data protection, employment law, first aid, working with personality disorders, and health and safety. To further progress staff development, each member of staff now has a particular area of responsibility at the home, for example budget monitoring, activities, training, annual leave and professional development. In addition, each month staff are given a different responsibility for areas such as organising day trips, the duty rota, getting contractor quotes and service user meetings. Norwood Road, 227 DS0000022745.V342280.R02.S.doc Version 5.2 Page 25 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, 41, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home and their views underpin all selfmonitoring, review and development. Service users’ rights and best interests are safeguarded by the home’s record keeping and their health, safety and welfare is promoted and protected. EVIDENCE: The Registered Manager is fully competent, experienced and qualified to run the home. She has NVQ Level 4 in Care and Management and has the Registered Managers Award. In addition, she is an NVQ Assessor at Levels 3 and 4. She has managed the home for over 7 years and has a comprehensive understanding of mental health issues and staff management. She has also completed the Management Development training provided by the Registered Provider. Norwood Road, 227 DS0000022745.V342280.R02.S.doc Version 5.2 Page 26 The Registered Provider has completed the externally verifiable quality monitoring and assurance system for the home (PQASSO), under which it has achieved level 2 as an organisation. It runs a regular “Talk Up” for service users whereby service users get together and are provided with an outside presentation on areas of interest, such as an Employment Fair. In addition thorough registered provider visits are conducted monthly and financial audits are carried out annually. Internally, service users views and self-monitoring takes place via team meetings, monthly key worker meetings and monthly tenants (service users) meetings, all of which are minuted. Minutes of service user meetings are kept in the Service Users Memo file in the conservatory, and a complaints file with the complaints procedure and blank forms is kept in the lounge, so that they are easily accessible to service users. Staff have also introduced a monthly breakfast “surgery” and a suggestion box, and conduct an annual service users’ survey. At the time of the inspection a support worker was composing the survey for this year, the result of which should be summarised and printed up, as has been done in previous years. During the course of the inspection a range of records required by legislation to be kept were seen and were all found to be in good order. This included assessment papers, care files, medication charts, health and safety checks, health records, diary, complaints book, tenant’s meeting minutes, rotas and communication book. The following certificates and recorded checks were seen and were all found to be up to date and in good order: fire drills, call points, risk assessments, LFEPA visit, fire alarm certificate, health & safety audit, gas safety certificate, and community pharmacist inspection. Hazardous substances are kept in a locked cupboard in the kitchen. Norwood Road, 227 DS0000022745.V342280.R02.S.doc Version 5.2 Page 27 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 4 2 4 3 3 4 3 5 X 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 4 25 X 26 3 27 4 28 4 29 3 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 4 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 4 3 X LIFESTYLES Standard No Score 11 3 12 4 13 3 14 3 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 4 X 4 X 3 X 3 3 X Norwood Road, 227 DS0000022745.V342280.R02.S.doc Version 5.2 Page 28 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. Refer to Standard Good Practice Recommendations Norwood Road, 227 DS0000022745.V342280.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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. 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