Inspection on 17/10/06 for Norbury Crescent (20)

This inspection was carried out on 17th October 2006.

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

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

Other inspections for this house

Norbury Crescent (20) 02/02/06

Norbury Crescent (20) 20/12/04

Norbury Crescent (20) 02/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Norbury Crescent (20) 20 Norbury Crescent Norbury London SW16 4LA Lead Inspector Michael Stapley Key Unannounced Inspection 17th October 2006 09:30 Norbury Crescent (20) DS0000025876.V315634.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 Norbury Crescent (20) DS0000025876.V315634.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. Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norbury Crescent (20) Address 20 Norbury Crescent Norbury London SW16 4LA 020 8679 6168 020 8679 6168 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) Mr Michael McDonagh Mrs Denise McDonagh Sohail Edwin Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd February 2006 Brief Description of the Service: 20 Norbury Crescent is a large three bed roomed house set in a quiet road near local shops and amenities. The home is close to buses and a train station. The home has three floors has three single rooms a large living room, kitchen diner and a large room for the use of the service users to do what they choose. There is a separate laundry room. The office and the staff sleeping-in facilities are located on the top floor of the building; the sleepover room has en-suite facilities. There is a large garden at the back of the house. Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. • The home - is a small family home setting and staff endeavour to maintain this atmosphere of ordinary living, on an ordinary street within the local community. Service users - are very much the centre of attention in the home; all of them have a programme of day care, save for one who does not which to access such services. The home seeks to promote the independence of service users and ensure equality of service. Service users are encouraged wherever possible to become involved in the running of the home. Care Plans - Individual care plans are very comprehensive and headings include a pen portrait of the service user, weekly activities, health needs and communication skills to mention a few. The arrangements for health care needs of the service users is good, all service users are registered with a local General Practitioner, the home has the support of the local pharmacist for advice on medication. Training - Staff members have access to a range of training courses, including NVQ’s to build on their skills to ensure that they are able to meet the service users assessed needs. • • • What the service does well: • The staff team - The staff team at the home are very positive about the work they undertake with the service users. Staff commented on the range of opportunities that are available for service users, this was reflected in discussions with service users at the home. Staff Meetings - The home has staff meetings every month and these meetings are used to improve communication amongst the team and DS0000025876.V315634.R01.S.doc Version 5.2 Page 6 • Norbury Crescent (20) discuss basic care values. Staff members continue to improve their skills and knowledge by attending a number of different training courses. • Care plans - These are reviewed and monitored in consultation with service users, their families and representatives and are reviewed every six months in line with standard 6.10. In addition Person Centred care plans have been introduced for all service users. Most of the staff has received appropriate training in order to facilitate such plans although in discussion with the manager it was evident this needed to be updated. The home has a complaints procedure both in written and pictorial form. Environment - There have been some improvements in the environment with refurbishment and redecoration completed. • What has improved since the last inspection? Service user guides / guides / statement of purpose – these have been reviewed and improved in a more accessible format. The home has invested a great deal of time and money in making the environment a much more pleasant and welcoming place to be. PCP targets and goals – the home have achieved a number of goals and aspirations identified by service users within their own PCP meetings these are continuously reviewed and personal goals and targets are reset. Medication – the home has an excellent pharmacy provider with effective systems in place. NVQ trained staff – Since the last inspection a number of staff have completed their NVQ and a further number have commenced their NVQ training. Shift cover – The home now has a full team and therefore rely less on agency staff to cover shifts at the service. This means greater continuity of care and service delivery for the service users. Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 7 Communication – Because the home now has a full team there is better communication and consistency of approach and a greater commitment to communication. What they could do better: • • • Training - The home needs to ensure that all staff has received equal opportunities, race equality and anti-racism training. Ageing and Death – The home needs to ensure it has discussed and recorded the wishes of service users as outlined in Standard 21. Networking and share knowledge – Now that the home has a full team they need to expand their networks and share there knowledge with other local providers as well as gain from their experience. ICT service users – The home could support service users in gaining and developing an interest in computers by using software that has been designed to be easily useable and understandable. The home could focus on the development of service user’s independence through simplistic tools to enable individuals to gain greater opportunities in a self-directive lifestyle. • • 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. Norbury Crescent (20) DS0000025876.V315634.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 Norbury Crescent (20) DS0000025876.V315634.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 and 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good information and introduction opportunities for prospective service users to make an informed choice about moving to the home. Contracts between the home and the service users do not contain all the information required under standard five thus the rights of the residents of Norbury Crescent could be at risk. Staff at the home have access to a range of training programmes thus enabling them to offer a reasonably effective care programme for service users. EVIDENCE: The home has a preadmission procedure; prospective service users are able to visit the home on an individual basis. Service users are only admitted to the home once a full assessment of their needs; compiled by their care manager or Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 10 other relevant person has been received. All of the service users at Norbury Crescent had a clear process of introduction to the home according to their individual needs. The registered manager advised that assessment is on going and is seen as very much part of the care plan. Person centred care plans that are gradually being introduced are based on the home’s individual system which is an in depth assessment of all aspects of service users personal care, social, recreational and emotional needs. These are in an appropriate format for the service users currently at the home. They are user friendly easy to read and contain many photographs of service users, family, friends and significant events. The inspector suggests that In addition service users could have their own ‘Personal Planning Book’, which could be updated on a regular basis and would be unique to each service user. The home carries out internal six monthly reviews where information is up dated and care plans changed as appropriate. There are also yearly reviews carried out with the service users, their families and other professionals as appropriate. The home has a reasonable training programme including NVQ training. The training programme includes first aid, health and safety, medication, person centred care plans, fire awareness training and more recently makaton. The later training was also undertaken by one of the service users, which has enabled him to communicate more effectively with the other service users at the home. While this is to be commended the home could expand this training programme to include specific reference to Autism. The home has developed an in depth Statement of Purpose that is reviewed on a regular basis in the light of changes to legislation and the needs of the service users. The Statement of Purpose includes all elements of regulation 4 including the skills of the staff team and their experience and how these can meet the needs of service users. All of the service users at the home have a contract/statement of terms and conditions. However this does not contain all elements of Standard 5.2 namely the rooms to be occupied, rules in place at the home (in agreement with the purchasing authority), arrangements for the review of the Service Users Plan, and clearly states that there will be a ninety day trial period. Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 11 Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 12 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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user care plans contain all the information required as per standard six. Staff at the home have all the information they require to satisfactorily meet the needs of the service users. Service users have individual risk assessments and risk management strategies carried out thus enabling them to participate in activities in the home and in the community with appropriate support. EVIDENCE: Service user individual care plans are comprehensive and contain all the elements of standard six. Care plans contain a pen portrait of the service user, weekly activities, health needs and communication skills. Service users and their respective families are involved in drawing up such plans as outlined in standard 6.6. In addition service users have a key worker and evidence of key Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 13 working was duly noted where appropriate. The home has become far more service user focused. Service users are encouraged to become far more involved in the home. House meetings are service user led and support is given to establish opportunities for training at local colleges or day centres where appropriate. The registered manager explained that the home has moved towards Person Centred Plans where ownership of the plan is given to the individual service user. While this is to be commended it was noted that staff need to undertake Person Centred Planning training. Service users files sampled at random all had individual risk assessments and risk management strategies. Service users are encouraged to make their own decisions within the context of risk assessment. All service users have individual choice and the home provides an independent advocate for individual service users where desired, in addition it is evident that service users are empowered wherever possible through group meetings and key working. The home has a confidentiality policy that is available to service users and their respective families. Service users, their families and representatives are aware that all information about them is handled in a sensitive manner and that confidences are kept. Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 14 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 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The daily routines and house rules promote service users’ rights, and ensure equality and that all rights are enjoyed by service users. Service users are given opportunities to engage in age appropriate activities with an emphasis on using community-based facilities. Dietary needs are catered for and a balanced diet is provided, to ensure a nutritious diet based on personal preferences. EVIDENCE: During the inspection there were three service users at the home. One of the service users spent time showing the inspector some of his photographs and discussing a recent trip to America. The registered manager and staff were observed to interact with the service users in a positive manner. There was awareness from the staff that the service user’s privacy and individual choice Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 15 must be maintained. The service users were observed moving freely throughout the communal areas prior to going for a walk with one of the staff. The home supports service users to access appropriate activities such as swimming, sports and leisure activities and making use of the library. In addition service users have access to local parks, cafes, theatres and shops. None of the four service users is able to travel independently therefore the staff team support service users to access community resources. Service users spoken to stated that they enjoyed the activities on offer at the home. Service users at the home have an annual holiday; the inspector was advised that service users and staff went to the Lake District during the summer. In addition one of the service users has recently returned from a trip to America, while another service user went to Bulgaria. While this is to be commended it is was acknowledged that the cost of a minimum seven day holiday is not included in the contract as the expectation is that service user pay for the cost of the holiday. The registered manager agreed to write to the placing authorities to seek such funding. It is also suggested that this element of standard 14 be built into the contract of any new service user. Parents, relatives and friends are encouraged to visit the home whenever possible. Service users have access to a range of educational facilities and the manager advised that service users have access to the homes computer. It is suggested that the home consider having an Internet connection for service users. This would clearly be of benefit to service users as it would increase their range of leisure and educational opportunities. Weekly menus were constructed with the aid of the service user’s personal choice, advice from service user’s families and the experiences of the staff. One service user said that they enjoyed what they had to eat at the home. The home has access to its own vehicle and also uses community transport. A recommendation was made at the last inspection “that the home manager seek the advice of a dietician as to the nutrition and balance of meals offered on the homes menus” The registered manager advised the inspector that this recommendation applied to one service user in particular. The home had contacted the service users GP and a referral was made to a dietician. The later did an assessment and nutritional plans and guidelines were put in place for the service user who has since gained weight. On the evidence available at the time of the inspection this recommendation has been met. Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 16 Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 17 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 and 21. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care is carried out in a way that residents prefer so that dignity and choice are maintained. Residents’ medication is well managed to ensure good health. The home has yet to establish an up to date record of the service user’s wishes at death thus appropriate arrangements may not be made. EVIDENCE: Health records are maintained for each service user. Service users record examined during the inspection demonstrate that the service user had access to routine health checks and specialist health care. Significant events and accidents are recorded and monitored. The staff team at the home keep a Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 18 central record of incidents as well as an individual record on service user’s files. Staff members monitor service user’s health and maintain up to date records. Two of the four service users are not prescribed any regular medication. The registered manager advised the inspector that none of the service users self medicate. If any service user were to self medicate this could only be done after completion of a risk assessment for self-medication. In addition medication would need to be supplied by the pharmacist in a monitored dose system and appropriately stored. The home has appropriate medication policies and procedures. All service users have a ‘Medication Profile’ All of the staff team have now completed accredited medication training. The pharmacist visits the home on a regular basis. All requirements and recommendations from the inspection of 10th July 2006 have been complied within laid down timescales. In addition the pharmacist has a pharmacy inspection meeting with the registered manager every six months. All other medication records, including MAR sheets and service user profiles were correct at the time of the inspection. In addition the home keeps a list of specimen signatures for those staff that administer medication. The wishes of service users regarding death and dying have as yet not been clearly identified and recorded. The manager advised that he is in the process of drawing up a template for this to be recorded. It is suggested that some of this should be in a pictorial format. This will help support service users and their families to record their wishes at the time of their death. Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 19 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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a complaints policy and procedure, which facilitates good access to the complaints system for the residents, their family or their representatives. The home has the appropriate policies in place to ensure the protection of vulnerable service users. EVIDENCE: The home has a detailed complaints procedure, which has been updated to include all the necessary information that service users, relatives and other parties may need to make a complaint. However it does not state that any complaint can be directed to the commission at any time. In addition details of any investigation, action taken and outcomes must be duly record. The procedure is formatted with pictures and photographs so that it is more accessible to those who cannot read. Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 20 Service users spoken to were clear about whom they would go to if they were unhappy and felt comfortable to raise any concerns. The Registered Manager said that no complaints have been made to the home since the last inspection. There are also policies and procedures in place regarding the protection of vulnerable adults. The registered manager advised the inspector that arrangements have been made for all staff to undertake POVA training on 30th November 2006. The London Borough of Croydon’s Suspected Abuse of Vulnerable Adults Joint Policy is in place and the home also has its own policies on adult protection, whistle blowing and management of service users’ finances. In addition recruitment practices are generally secure to ensure that people are protected from unsuitable staff. Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 21 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, 25, 26, 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user’s bedrooms provide privacy and reflect individual interests and preferences. The home is homely, bright and clean with the necessary adaptations in place, thus providing the service users with safe, comfortable surroundings that meet their needs. EVIDENCE: There are adequate toilet and bathing facilities in the home. There is a bathroom and a toilet on the ground floor. In addition to a further bathroom and toilet on the first floor. One of the service users bedrooms is en-suite. Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 22 The communal space in the home consists of kitchen, a large sitting room and a dining room that are well maintained and comfortable. There is a rear garden that can be accessed by the service users via the conservatory. Norbury Crescent gives the impression of a family household and is decorated and furnished to reasonable standard. Service users have been consulted and involved with arranging the décor in the home wherever possible. For example, throughout the home there are photographs of occasions such as holidays, birthday parties and service users’ family and friends. Presently there are four service users living in the home. No aids or adaptations have been deemed as necessary at this time for either of the service users. There have been some improvements in the décor of the home since the last inspection although some areas including the bathroom are looking shabby and are in need of decoration. The registered manager stated that the home had a programme of redecoration and maintenance. The home has applied for planning permission to the local authority to develop the rear of the house and increase its numbers to accommodate five service users. Any programme of refurbishment would be incorporated into such development. The inspector was concerned to note that the stair carpets appeared to be warn out and are in need of replacing. In addition furnishing, fixtures and fittings are to be purchased as required. Bedrooms viewed provided sufficient with suitable furniture. All areas of the premises viewed were clean and free from offensive odours. Systems are in place for controlling the spread of infection. The home has thermostatic valves fitted to the bath to avoid any scalding accidents. The temperature of the water is taken and duly recorded. A recommendation was made at the last inspection “that the home manager send a copy of the fire officers last report to the Commission” This report was duly sent to the commission and all requirements/recommendations from that report have now been met. This recommendation has therefore now been met. Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 23 Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 24 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 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff team at the home have a range of skills and ability, which appear to meet the needs of the service users. The staff team have all had Criminal Records Check, as a safeguard to offer protection to the homes service users. EVIDENCE: The home offers reasonable training opportunities to staff at all levels within the home, although staff would benefit by taking specialist-training courses such as that offered by BILD or NAS for staff that work with service users who have a disability including autism. The inspector noted that none of the staff had undertaken disability equality training, race equality training or anti-racism training. A requirement has therefore been made that this training is made available to all staff within the home. Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 25 New members of staff complete an induction programme covering various subjects including health and safety, fire drills, and introductions to service users and other staff. The induction programmes are signed, dated and kept on staff files. Criminal Records Checks are completed before a new member of staff can begin work in a home. The home has a small but experienced staff team consisting of registered manager and support workers in addition to regular care bank staff. The registered manager offers professional to the support workers through regular supervision, which is in line with the standard. There are always two members of staff on duty who also undertakes sleepingin duties. There are suitable on call arrangements in place in case of an emergency. The inspector evidenced that a training plan was in place for Norbury Crescent. In addition the registered manager has introduced an annual appraisal for all staff. The training needs for staff are identified during the annual appraisal and duly recorded following which arrangements are made for staff to attend such training. In addition all staff that is employed at Norbury Crescent has an identified training plan. The inspector noted that all staff at Norbury Crescent is now receiving supervision at least six times each year. The supervision format is comprehensive and contains all elements of standard 36.4 Records seen during the course of this inspection were signed and dated by the registered manager and member of staff. There were two recommendations for good practise made at this last inspection • It is recommended that the registered provider employ full-time staff to cover the majority of the shifts in the home. This recommendation has been met given that the home have now appointed to full time staff. It is recommended that the home manager seeks confirmation in writing from the agency that all staff sent to the home has had Criminal Records Bureau clearence. The inspector evidenced a letter from the agency that CRB checks are carried out on all staff sent to the home. This recommendation has therefore now been met. • Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 26 Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 27 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 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home appears to be open and transparent with clear lines of accountability, which is aimed at ensuring the well being of the service users. EVIDENCE: The registered manager offer support and supervision to the support workers at the home. There were good support mechanisms in place and the manager meets with one of the directors on a regular basis to discuss any issues concerning the home, efforts are made to meet any concerns or improve the Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 28 service. The home has an annual development plan and business plan for 2006-07, which was available for inspection. The managing company ensure all records are in place by completing monthly regulation 26 reports although these reports are not sent to the commission as per regulation. A requirement has therefore been made that the next three reports are sent to the commission. Records required for the safety and well being of service users are in place including accidents, water temperatures, complaints, incidents, food records, fire records, staff and service user’s case files, medication records. Fire drills are up to date and a fire risk assessment had been completed. The residents are beginning to benefit from a stable staff team and a continuity of approach this generates. However for residents and their stakeholders these developments need to be consolidated and built on in order for them to be confident that their best interests are safeguarded, their views are taken into account and the home is well managed. The system for consultation with service users, families, stakeholders and other interested parties is reasonable. The quality assurance system includes relatives, staff and outside professional questionnaires. The home will need to evidence that the results of the surveys are published and acted on for the benefit and wellbeing of the service users at the home. In addition the registered person must ensure that the home as an internal audit at least once a year. All policies and procedures that are relevant to service users are now in a suitable format including complaints and service user guide. All certificates in respect of health and safety were evidenced during the course of this inspection; save for the gas certificate that the manager advised was sent to the directors. Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 29 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 3 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 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 3 3 X 3 X 2 2 X Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 30 Are there any outstanding requirements from the last inspection? NO. 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 YA35 Regulation 18.1 Requirement Timescale for action 2. YA41 26 3. YA42 13 23 The registered person must ensure that all staff receive 31/01/07 equal opportunities training, race equality and anti-racism training. The registered person must send 31/10/06 a copy of the next three monthly regulation 26 reports to the commission. The registered person must send 30/11/06 a copy of the current gas certificate to the CSCI, local office RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA4 YA5 YA14 Good Practice Recommendations It is strongly recommended that all prospective service users be offered a minimum three-month ‘settling in’ period. It is strongly recommended that all service user’s contracts are amended to include all elements of standard 5.2 It is strongly recommended that all service users in longterm placements have as part of the basic contract price DS0000025876.V315634.R01.S.doc Version 5.2 Page 31 Norbury Crescent (20) 4. 5. YA21 YA22 6. 7. 7. YA35 YA35 YA39 the option of a seven-day holiday outside the home. It is strongly recommended that service users wishes concerning terminal care and death are discussed and duly recorded. It is strongly recommended that the homes complaints procedure be amended to include a statement that any complainant may complain to the commission at anytime of an investigation. It is strongly recommended that all staff receive specialist training such as that offered by BILD or NAS as part of their individual training and development plan. It is strongly recommended that all staff undertake PCP training as part of their individual training and development plan. It is strongly recommended that the registered person undertake a financial audit of the home at least annually. Norbury Crescent (20) DS0000025876.V315634.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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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