CARE HOME ADULTS 18-65
Norbury Crescent (20) 20 Norbury Crescent Norbury London SW16 4LA Lead Inspector
James O`Hara Unannounced Inspection 2nd February 2006 09:30 Norbury Crescent (20) DS0000025876.V271647.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Norbury Crescent (20) DS0000025876.V271647.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Norbury Crescent (20) DS0000025876.V271647.R01.S.doc Version 5.0 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 Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Norbury Crescent (20) DS0000025876.V271647.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 18th July 2005 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.V271647.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second inspection at the home this inspection year the first took place in July 2005. The inspection began at 9.30 am and finished at noon on a Thursday morning. Methods of inspection included a tour of the premises, observation of contact between staff and service users and discussion with a service user and the home manager. Records examined included staff training, Criminal Records Bureau Checks, fire safety, service user activities, complaints, menus and medication systems. The home manager provided evidence regarding the requirements and recommendations set at the last inspection. What the service does well: What has improved since the last inspection?
There have been some improvements to the home since the last inspection and efforts have been made to ensure that service users live in a safe, homely and comfortable environment. The fire officer inspected the home in July 2005 and set a number of recommendations. The fire officer returned in January 2006 to review the recommendations, all recommendations had been met. The home is making good progress to train staff on the specific needs of the service users. The home manager is developing a staff appraisal system and staff supervision contracts. It was agreed that these would be examined in more detail at the next inspection after the home manager has had the opportunity to use them in the home. The home manager provided a certificate from Investors in People indicating that the home has made a commitment to the South London Learning and Skills Council to work towards investing effectively in all its employees.
Norbury Crescent (20) DS0000025876.V271647.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Norbury Crescent (20) DS0000025876.V271647.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Norbury Crescent (20) DS0000025876.V271647.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 5. Standards 1, 2 and 4 were assessed as met at the last inspection. By providing appropriate training for staff, prospective service users and current service users can be sure that the home will meet their needs. EVIDENCE: A requirement was set at the last inspection that the home manager ensure that all staff has training on Autism, Fire Safety, Moving and Handling, Food Hygiene and Health and Safety. Evidence was provided that most staff had attended training on fire safety and moving and handling on the 17/10/05 and medication 20/06/05. The home manager stated that most staff had also attended training on food hygiene and first aid on the 21/11/05 and were waiting for certificates to be sent to the home. The home manager had completed health and safety training and one member of staff has completed health and safety training as part of a health care assisstant and support worker training day however two staff stiil need training on health and safety. The home manager stated that autism training has been planned for March 2006 with the National Autistic Society. At the last inspection it was agreed that either the service users relative or advocate should sign the service users contract on their behalf.
Norbury Crescent (20) DS0000025876.V271647.R01.S.doc Version 5.0 Page 9 The home manager stated that two service users and their relatives had signed and agreed their contracts, one service user and their care manager/advocate are due to sign and agree a contract and the home manager had signed one service users contract at the request of a service users relative. It was noted that the fees had not been included in the service users contract. The home manager stated that this was because at that time fees were still being negotiated with the placing authorities. The home manager stated that he would update the contracts and consult with service users and their representatives for agreement. The updated contracts could then be signed and agreed. The service users contracts will be examined again at the next inspection. Norbury Crescent (20) DS0000025876.V271647.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 0. Standards 6, 7 and 9 assessed as met at the last inspection. EVIDENCE: Standards not inspected on this occasion. Norbury Crescent (20) DS0000025876.V271647.R01.S.doc Version 5.0 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17. Standards 12, 13, 14, 15 and 16 were assessed as met at the last inspection. The home has good systems in place that so that service users are able to choose what they want to eat however to ensure that the homes menus offer suitable nutrition and balance, advice should be sought from a dietician. EVIDENCE: On the day of the inspection one service user said that he is very happy living at the home. He said that he has learnt so many things since he came here and staff has been very helpful. He said staff helped him gain confidence to go shopping on his own for a small selection of goods. He also goes to Croydon with staff to buy comics, magazines and memorabilia for his hobbies Dr Who and Spider Man. He said that there are plenty of opportunties to get involved in activities inside and outside the home. He said that we go for meals out and have pizzas delivered to the home. The homes activities records indicate that he recently went on a shopping trip to Croydon, a day trip to London and tenpin bowling. Norbury Crescent (20) DS0000025876.V271647.R01.S.doc Version 5.0 Page 12 The home has created a pictorial selection of meals so that service users can choose what they wish to eat and details what ingredients are required to make up the meal. The homes menus were examined and indicated that service users have a choice of two different meals at lunchtime and evening meal, it was noted that potatoes, chips or mash was quite prevalent. It is recommended that the home manager seek the advice of a dietician as to the nutrition and balance of meals offered on the homes menus. Norbury Crescent (20) DS0000025876.V271647.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20. Standards 18 and 19 were assessed as met at the last inspection. The arrangements made for the health care needs of the service users are good. The home has the support of the local pharmacist for advice on medication. EVIDENCE: As required at the last inspection the registered manager has developed a system for a recording receipts and returns and checks and balances of medication. Medication returned to the pharmacist has been recorded, stamped and signed by the pharmacist as received. Norbury Crescent (20) DS0000025876.V271647.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22. Standards 22 and 23 were assessed as met at the last inspection. EVIDENCE: As recommended at the last inspection the home now employs a hardback book for the recording of complaints and compliments. Norbury Crescent (20) DS0000025876.V271647.R01.S.doc Version 5.0 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24. Standard 30 was assessed as met at the last inspection. There have been some improvements to the home since the last inspection and efforts have been made to ensure that service users live in a safe, homely and comfortable environment. EVIDENCE: A requirement was set at the last inspection that the home manager complete a fire risk assessment for the home and seek the advice of the fire brigade about the cupboard next to the cooker. The home manager provided evidence that a fire officer inspected the home on the 12/07/05 a number of recommendations were set. The home manager stated that the fire officer returned on the 17/01/06 to the home to review the recommendations, all recommendations had been met. As a result of the fire officers visit the home was fitted with 1 hour fire resistant doors and the issue of the cupboard next to the cooker was resolved. All staff had fire safety training and a fire risk assessment was completed for the home 15/09/05.
Norbury Crescent (20) DS0000025876.V271647.R01.S.doc Version 5.0 Page 16 The home manager stated that the registered provider plans to apply to the Commission for Social Care Inspection for a variation to the homes current registration. This variation is to increase the numbers of service users at the home from three to five. The home manager stated that the fire officer said that when this happens then the homes fire alarm system would need to be changed/upgraded. It is recommended that the home manager send a copy of the fire officers last report to the Commission. Vanity units and sinks have been fitted in all service users bedrooms since the last inspection. Norbury Crescent (20) DS0000025876.V271647.R01.S.doc Version 5.0 Page 17 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34 and 35. The home is making good progress in training staff on the specific needs of the service users. Criminal Records Bureau Checks are now held at the home. This will allow the Commission to check that staff vetting is occurring properly and facilitate the protection of the residents. EVIDENCE: A requirement was set at the last inspection that the home manager inform the Commission for Social Care Inspection when all staff Criminal Records Bureau Checks have been returned to the home and arrange a date for these to be inspected. Criminal Records Bureau Checks were seen for three regular members of staff. The home manager stated that the home aslo use regular agency staff who have completed a Criminal Records Bureau Check with the agency. 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. Norbury Crescent (20) DS0000025876.V271647.R01.S.doc Version 5.0 Page 18 The home manager is full-time however the home depends mainly on part time staff to cover the shifts. It was recommended at the last inspection that the registered provider employ full-time staff to cover the majority of the shifts in the home. The home manager stated that he plans to start full time staff. The recommendation will be reviewed at the next inspection. The home manager stated that he is developing a staff appraisal system and staff supervision contracts. It was agreed that these would be examined in more detail at the next inspection after the home manager has had the opportunity to use them in the home. The home manager provided a certificate from Investors in People. The certificate read The Chestnuts Residential Care Home has made a commitment to the South London Learning and Skills Council to work towards investing effectively in all its employees. The home manager said that he hoped the home would be accredited by Investors in People. Evidence was provided that staff had attended training on fire safety17/10/05, moving and handling 17/10/05 and medication 20/06/05. The home manager stated that staff had also attended training on food hygiene and first aid on the 21/11/05 and were waiting for certificates to be sent to the home. the home manager had completed health and safety training and one member of staff has completed health and safety training as part of a health care assisstant and support worker training day however two staff stiil need training on health and safety. Norbury Crescent (20) DS0000025876.V271647.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 39. Standard 42 was assessed as met at the last inspection. The home is well run and the home manager continues to work towards improving the home for the service users and staff. EVIDENCE: The home manager has five years experience working with people with learning disabilities and autism as a senior carer and as a deputy manager. He has completed NVQ level 2 and 3 and is currently completing the Registered Managers Award NVQ level 4. The registered providers carry out regulation 26 visits at the home. The home manager said that he plans to carry out three monthly Quality Assurance Surveys at the home and the registered providers other care home just round the corner. He said that he and the new manager at the other home would monitor each other’s service. He also provided service user and relatives questionnaires that he plans to employ as part of the Quality Assurance system.
Norbury Crescent (20) DS0000025876.V271647.R01.S.doc Version 5.0 Page 20 It was agreed that these systems would be examined in more detail at the next inspection after the home managers has had the opportunity to use them in the homes. Norbury Crescent (20) DS0000025876.V271647.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X 3 X 3 Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Norbury Crescent (20) Score X X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X X X DS0000025876.V271647.R01.S.doc Version 5.0 Page 22 No. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard YA17 YA24 YA33 YA34 Good Practice Recommendations It is recommended that the home manager seek the advice of a dietician as to the nutrition and balance of meals offered on the homes menus. It is recommended that the home manager send a copy of the fire officers last report to the Commission. It is recommended that the registered provider employ full-time staff to cover the majority of the shifts in the home. 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. Norbury Crescent (20) DS0000025876.V271647.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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