Inspection on 20/12/05 for Norbury Crescent (30)

This inspection was carried out on 20th December 2005.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Norbury Crescent (30) 15/01/08

Norbury Crescent (30) 07/09/06

Norbury Crescent (30) 31/08/05

Norbury Crescent (30) 02/03/05

Norbury Crescent (30) 20/12/04

Similar services:

Ashlong House

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Whitworth Lodge

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

CARE HOME ADULTS 18-65 Norbury Crescent (30) 30 Norbury Crescent Norbury London SW16 4LA Lead Inspector Diane Thackrah Unannounced Inspection 20th December 2005 09:00 Norbury Crescent (30) DS0000025820.V274095.R01.S.doc Version 5.1 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 (30) DS0000025820.V274095.R01.S.doc Version 5.1 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 (30) DS0000025820.V274095.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Norbury Crescent (30) Address 30 Norbury Crescent Norbury London SW16 4LA 020 8765 0431 020 8765 0431 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) Norcrest 2000 home Limited Mr John Samuel Care Home 11 Category(ies) of Learning disability (11) registration, with number of places Norbury Crescent (30) DS0000025820.V274095.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st August 2005 Brief Description of the Service: 30 Norbury Crescent is owned and staffed by Norcrest 2000 homes Ltd, a specialist provider of residential care homes for adults with learning disabilities and challenging behaviours. The home is registered with the Commission for Social Care Inspection to provide personal support and accommodation for up to eleven younger adults. The Registered Manager, John Samuel, remains in operational day-to-day control of the home. Situated in a residential area of Norbury, close to the centre of town, the home is well placed for accessing a wide variety of local shops, eating establishments and public transport links, including good bus and rail links to central London, Croydon and the surrounding areas. Significant changes have been made to the physical environment of the home in recent months with the building work on the lounge extension, staff sleep-in room, and new day services/activity rooms, now completed. Built over three storeys the main house comprises of eleven single occupancy bedrooms, of which three are located on the ground floor, a main lounge (recently extended), a large open plan kitchen and dining area, two ground floor offices, and a laundry room. There are sufficient numbers of toilet and bathing facilities located throughout the home near service users bedrooms and communal areas. The amount of outdoor space the service users, their guests and staff have to access remains adequate, despite the erection of a new two-roomed activities building in the rear garden. Norbury Crescent (30) DS0000025820.V274095.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 20th December 2005 between 09.00 and 12.00. Care records were examined and a partial tour of the premises took place. All eleven of the service users currently residing at Norbury Crescent were at home at the beginning of this inspection, however, six of these went out to day centres. Five service users were present during this inspection. Three service users were spoken with. The Registered Manager and four staff members were also spoken with. What the service does well: What has improved since the last inspection? Norbury Crescent (30) DS0000025820.V274095.R01.S.doc Version 5.1 Page 6 There have been a number of environmental improvements since the last inspection of the home. Building work on a new ‘day centre’ in the garden has been completed and service users now have access to this facility which will offer extra space for them to undertake structured daily living programmes. A good quality bath and wet room have been fitted and all communal areas have been repainted. Additionally, flooring in the kitchen has been replaced. Requirements made regarding the need for the review of fire risk assessments in relation to the environment, and the need for emergency evacuation procedures to be reviewed and displayed adjacent to fire alarm points have been met. There has been a safety check on the gas system in the home. Two staff members have been enrolled to undertake NVQ Level 2 in Care and the Registered Manager has enrolled to undertake the Registered Manager Award. He anticipates completing this Award by February 2007. 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 (30) DS0000025820.V274095.R01.S.doc Version 5.1 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 (30) DS0000025820.V274095.R01.S.doc Version 5.1 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): 2 and 5. There are effective procedures in place for gathering information about the needs of prospective service users, which ensure that the needs of service users are met. EVIDENCE: There are good arrangements for ensuring that the needs of prospective service users are assessed prior to moving in. Referrals to the home from Care Managers are followed by a visit to the prospective service user by the Registered Manager, and a senior staff member who carry out an assessment of needs. Assessment documentation for the most recent service user to be admitted to the home was examined. This contained comprehensive information about the service user’s health, personal and social care needs. Records highlight that the service user and their family members are consulted with throughout the assessment process. Consultation also occurs with health and social care professionals. Following assessment, the home complies a detailed proposal outlining how the holistic needs of the service user could be met by the home. Service users undergo a twelve week trial period in the home. Care is reviewed after a six week period, then yearly thereafter. There was a contract in place for the most recent service user. The contract contained all information required by Regulation and had been signed by the service user. Norbury Crescent (30) DS0000025820.V274095.R01.S.doc Version 5.1 Page 9 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): 7. There are good arrangements for consultation with service users, which ensures that they are involved in making decisions about their lives. EVIDENCE: Staff members were noted to consult with, and to engage in respectful interactions with service users throughout this inspection. Feedback from one service user was that they liked the staff members and that they were able to make decisions about things that were important to them. There were minutes detailing that there are regular service user’s meetings held in the home. These highlighted that that there is consultation about daily living issues. Service users had made decisions about what they would like to eat and how they would like to spend their leisure time. The Registered Manager said that each service user has a key worker who accompanies them to go shopping and engage in other daily living activities. None of the current service users partake in independent advocacy, however the Registered Manager said that he is currently in the process of researching local advocacy programmes. Norbury Crescent (30) DS0000025820.V274095.R01.S.doc Version 5.1 Page 10 The Registered Manager has attended training in the ‘Picture Exchange Programme’ This has enabled staff members to support some service users to use a selection of photographs to express their wishes and to make decisions. Norbury Crescent (30) DS0000025820.V274095.R01.S.doc Version 5.1 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): 13, 15, 16 and 17. The number of opportunities the service users have to engage in social, leisure and recreational activities, both at home and in the wider community, appears to be varied and stimulating. Dietary needs are well catered for, nutritionally balanced, and clearly based on personal preferences and choice. However, one minor instance of poor practice was noted in relation to food hygiene, which does not ensure that the wellbeing of service users is fully promoted. EVIDENCE: Six service users were out at day centres during this inspection. Five service users do not attend day centres, but have structured daily living programmes. Building work on a new two roomed building in the rear garden has been completed since the last inspection of the home. The Registered Manager said that there are plans to use this room as a ‘day centre’ for service users involved in the daily living programmes. The new building will also provide service users with far greater shared space and more opportunity to pursue their social and leisure interests. One service user spoken with said that they had good opportunities for pursuing leisure activities out with the home. There Norbury Crescent (30) DS0000025820.V274095.R01.S.doc Version 5.1 Page 12 are two pleasant communal lounges were service users can relax and watch television. There is also a well kept garden. The home has its own transportation in the form of a minibus. A recommendation was made at the last inspection of the home, in line with a recommendation made by an Occupational Therapist, that the home gives serious consideration to purchasing a vehicle with a tailgate lift to meet the mobility needs of those service users who require wheelchairs to access the wider community. The Registered Manager has obtained a quotation in respect of purchasing such a vehicle. Service users were observed to enjoy freedom of movement within the home and restrictions about going outside are recorded in care plans. Staff members knock before entering service users bedrooms and bathroom doors have locks with an override device. There was feedback from one service users that they maintained regular contact with their family members. The Registered Manager said that service users are welcome to receive visitors in the home and that staff members support service users to visit their families. Some service users attended local social clubs. Service users have some responsibilities for household tasks, in line with their abilities. One service user was being supported to prepare their breakfast during this inspection. The menus are written in conjunction with service users, as evidenced in service user meeting minutes. Specific cultural diets are catered for. One service user said that they were happy with food in the home and that they were able to choose what was on the menu. Menus seen demonstrated a choice for each meal. There is a pleasant communal dining area and service users were noted to eat at a pace and time that suited them during this inspection. The kitchen was clean and well organised, however, there was an open tin of tomatoes stored in the fridge and it is recommended that staff members be reminded about their responsibilities in relation to food hygiene. Norbury Crescent (30) DS0000025820.V274095.R01.S.doc Version 5.1 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): None of these Standards were examined during this inspection. The key Standards were assessed as being met during the last inspection of the home. EVIDENCE: Norbury Crescent (30) DS0000025820.V274095.R01.S.doc Version 5.1 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 and 23. There is a system in place for the effective handling of complaints and service users and their relatives are encouraged to raise any concerns they have. Service users therefore know that their concerns will be acted upon. There are vulnerable adults policies and procedures and staff training in adult protection occurs which allows service users to be confident that they will be protected from abuse. EVIDENCE: Information is made available about how a compliant, concern or suggestion should be made, and how this will be handled. There is also information about how a complaint may be made to the Commission for Social Care Inspection. The Registered Manager said that service users and their relatives are encouraged to raise any concerns with staff members before they become problematic. He also said that no complaints have been made since the last inspection of the home. Staff members spoken with confirmed that they had undergone training in the protection of vulnerable adults and there were certificates to back this up. Croydon Council’s vulnerable adult protection procedures are available in the home. Norbury Crescent (30) DS0000025820.V274095.R01.S.doc Version 5.1 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 and 30. The size and layout of the home is furnished and decorated to a good standard which ensures that service users benefit from a comfortable, clean and homely living environment. EVIDENCE: Norbury Crescent (30) DS0000025820.V274095.R01.S.doc Version 5.1 Page 16 A number of environmental improvements have occurred recently including a lounge extension, new sleep-in room and since the last inspection, a building has been constructed in the garden which will be used as a ‘day service’ for service users in the home. There has also been a new bathroom fitted on the first floor and wet room fitted on the ground floor. Flooring in the kitchen has been replaced. The home was noted to be homely and generally well decorated and furnished. It was recommended at the last inspection of the home that the service providers should consider establishing a time specific rolling programme to redecorate the homes interior, especially the communal areas. All communal areas have been repainted since the last inspection, however records were not available detailing plans for future arrangements for redecoration of the home. The Registered Manager, however, demonstrated a positive attitude towards addressing this issue. Following a visit from the London Fire and Emergency Planning Authority in April 2005 a number of Requirements were made. Since this visit the home’s fire risk assessments have been reviewed and emergency evacuation procedures have been displayed adjacent to fire alarm points. A Requirement was also made regarding the need to reposition a sound activated fire door release mechanism attached to a fire resistant door in the hallway. This Requirement has not been met. The Registered Manager said that after consultation with fire safety contractors he has been informed that repositioning the door release mechanism is not feasible and there are now plans to remove this door. The home was found to be clean, hygienic and free from offensive odours. Policies and procedures are in place in relation to infection control. Laundry facilities are appropriate. Training in food hygiene and inspection control occur, however, a recommendation has been made that staff members should be reminded about their responsibilities in relation to food hygiene. Refer to Standard 17 of this report. Norbury Crescent (30) DS0000025820.V274095.R01.S.doc Version 5.1 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): 32 and 35. In the main the home ensures that sufficient numbers of ‘suitably’ experienced staff are on duty at all times to meet the health and welfare needs of the service users. However, sufficient numbers of staff still need to be suitably trained in the use of moving and handling techniques to ensure the health and safety of both service users and staff are protected. EVIDENCE: Feedback from one service user was that they liked the staff members. All interactions observed between service users and staff members during this inspection were positive, relaxed, professional and respectful. A training and development plan was available and this detailed the desired and planned training for individual staff members. All new staff members undertake a comprehensive induction programme. Staff members spoken with confirmed that they received good opportunities for training and there were a number of certificates indicating that recent training has occurred for some staff members in food hygiene, safe handling of medication and the protection of vulnerable adults. A recommendation was made at the last inspection of the home regarding the need for 50 of the staff team to have achieved the NVQ Level 2 in Care Award, or above, by the end of 2005. The Registered Manager said that two staff members have recently been enrolled for this training, and when all staff members have completed training this 50 will have been achived. A Requirement made regarding the need for sufficient numbers of Norbury Crescent (30) DS0000025820.V274095.R01.S.doc Version 5.1 Page 18 staff members to be suitably trained in the use of moving and handling techniques has not yet been achieved, however, the Registered Manager said that training in moving and handling is planned for all staff members in January 2006. Norbury Crescent (30) DS0000025820.V274095.R01.S.doc Version 5.1 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, 39 and 42. There is good management and a programme of reviewing and development, which ensures that the home is run in the best interests of the service users. EVIDENCE: The Registered Manager, John Samuel has been in operational day-to-day control of the home for several years and is suitable experienced and qualified to undertake this role. Since the last inspection of the home Mr Samuel has enrolled to undertake the Registered Manager Award. He anticipates completing this Award by February 2007. There are regular quality assurance surveys. Service users, their relatives and Care Managers are invited to share their views about the service by filling in a questionnaire. A stakeholder report and service user report were available which detailed the outcomes of a quality assurance survey carried out in 2003/4. The Registered Manager said that policies and procedures are reviewed regularly. The home’s policy on confidentiality has been reviewed Norbury Crescent (30) DS0000025820.V274095.R01.S.doc Version 5.1 Page 20 since the last inspection. A detailed business plan has been produced; this had been revised in July 2005. There are good arrangements for ensuring the health and safety of service users and staff members. Records were available detailing that thorough health and safety checks of the premises are carried out on a monthly basis. There were certificates detailing that staff members receive training in safe working practices. However a Requirement has been made in relation to the need for moving and handling training to occur. Refer to Standard 35 of this report. An issue in relation to food hygiene has also been raised as a result of this inspection. Refer to Standard 17 of this report. There was a Landlords Gas Certificate, detailing that checks on the gas systems in the home had been made in September 2005. Records indicate that there are regular fire drills and weekly fire tests. Fridge and freezer temperatures are monitored daily and hot water temperatures are monitored. Norbury Crescent (30) DS0000025820.V274095.R01.S.doc Version 5.1 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 Standard No Score 1 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X 3 X 3 X X 3 X Norbury Crescent (30) DS0000025820.V274095.R01.S.doc Version 5.1 Page 22 Yes. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA24 Regulation 23 (4) Requirement The home must reposition the activated release mechanism attached to the hallway door, or remove this door, as planned. Repeat Requirement. Timescale of 01/11/05 unmet. Sufficient numbers of staff must be suitably trained in the use of moving and handling techniques. Documentary evidence of this training must be available for inspection on request. Timescale for action 01/02/06 2. YA35 13 (5)18 (1) 2.4 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA17 Good Practice Recommendations Staff members should be reminded about their responsibilities in relation to food hygiene DS0000025820.V274095.R01.S.doc Version 5.1 Page 23 Norbury Crescent (30) 2. YA24 The service providers should consider establishing a time specific rolling programme, to redecorate the homes interior. Norbury Crescent (30) DS0000025820.V274095.R01.S.doc Version 5.1 Page 24 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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