Inspection on 31/08/05 for Norbury Crescent (30)

This inspection was carried out on 31st August 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Norbury Crescent (30) 15/01/08

Norbury Crescent (30) 07/09/06

Norbury Crescent (30) 20/12/05

Norbury Crescent (30) 02/03/05

Norbury Crescent (30) 20/12/04

Similar services:

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Edenvale

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Chatsworth Care - Dawson House

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Chatsworth Care - Tudor Lodge

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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 Lee Willis Unannounced 31August 2005 11:30 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 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 Stationary 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) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Norbury Crescent (30) Address 30 Norbury Crescent, Norbury, London, SW16 4LA Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8765 0431 020 8765 0431 Norcrest 2000 Home Limited Mr John Samuel Care Home 11 Category(ies) of LD Learning Disability (11) registration, with number of places Norbury Crescent (30) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2 March 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 behaviours that challenge the service. The home is registered with the CSCI to provide personal support and accommadation for up to eleven younger adults. There have been no new admissions since the homes last inspection and it remains fully occupied. 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, nearing completion. Built over three storeys the main house still 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 dinning 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 actvities building in the rear garden. Norbury Crescent (30) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and began at 11.30am on the morning of Wednesday 31st August 2005. It took three and three quarter hours to complete. Four service users were met during this inspection, albeit briefly, and were therefore not spoken to for any great length of time. Since April 2005 the Commission has received eighteen comment cards in respect of this service, of which, eleven had been completed by service users, five by their relatives, one by a Care Manager representing a funding authority, and one by a Community Nurse, who is a regular visitor to the home. The majority of this inspection was spent talking with the manager and a new member of staff. A considerable amount of time was also spent examining the homes records and touring the premises. No additional visits or complaints investigations have been carried out by the CSCI in respect of this service in the past twelve months. What the service does well: The overwhelming majority of comment cards received from service users, their relatives, a Care Manager and Community Nurse were extremely positive about the standard of care being provided by the home, and especially about the staff team. The Care Manager wrote ”I have been extremely impressed by the work and commitment of staff at the home”, while the Community Nurse added “I have always found the staff team to be professional in their attitude and wiling to take advice”. Information displayed on notice boards, in the form of photographs and pictures, ensures service users are always made aware who is on duty at any given time; what activities have been planned; and what meals they can choose from. The home also has a relatively stable staff team, the majority of whom have worked together for some time, ensuring the service users receive continuity of care from suitably qualified and experienced individuals who are familiar with their wishes, needs and daily routines. Furthermore, the approach of the registered manager is a very open and inclusive one, ensuring all the relevant professional agencies are notified without delay about any significant events that may occur in the home and action to be taken to minimise the likelihood of similar incidents reoccurring. Norbury Crescent (30) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 Page 6 What has improved since the last inspection? 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) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Norbury Crescent (30) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 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 standard(s) 1 The home ensures prospective service users and their representatives are provided with all the information they need to make an informed decision about whether or not to move in. EVIDENCE: The home has produced a comprehensive Statement of purpose that contains all the information required by the Care Homes Regulations (2001) and associated National Minimum Standards. This document was last reviewed in July 2005 and updated to reflect recent changes to staff qualifications and the homes physical environment. There have been no new admissions since the homes last inspection in March 2005. Norbury Crescent (30) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 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 standard(s) 6, 8, 9 & 10 Care plans accurately reflect service users personal, social and health care needs, ensuring staff can plan for and met them. Service users are also supported to take ‘responsible’ risks and precautionary measures are in place to, so far as reasonable practicable, minimise any identified risks and/or hazards. Suitable arrangements are have been set up to ensure the service users can participate in all aspects of life in the home. EVIDENCE: Care plans sampled at random were clearly generated from each service users individual needs assessments and contained detailed information about every aspect of their personal, social and health care needs. There have been no changes made to the existing care plan format in the past twelve months, although documentary evidence was available on request to show that plans are updated on a regular basis to reflect service users changing needs. As a result of several significant incidents involving one service user in recent months it was positively noted that two emergency Case Conference reviews had been set by the manager, involving the service user, their family, Care Manager, and other relevant healthcare professionals, to discuss these events and agree/record changes to their care plan. Norbury Crescent (30) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 Page 10 A number of new risk assessments, which had been jointly agreed by the service user, their psychiatrist, Care Manager, and the manager, had also been undertaken in this time and incorporated into the individuals care plan for staff to follow. This particular individuals keyworker was spoken to at length during this inspection and it was evident from comments made they were fully aware of the new guidelines that were in place to minimise the risk of similar incidents involving her key service user reoccurring in the future. This same member of staff also felt the home was very good at encouraging service users to take ‘responsible’ risks as part of a structured programme of promoting independent living and choice. Having been on a brief tour of the premises it was positively noted that a lot of information was available in formats the service users could understand. An array of photographs and pictures with Velcro backing were pinned to notice boards in the kitchen/dinning area to ensure the service users were aware who was on duty, what activities had been planned, and what they could choose to have for lunch. The homes last staff meeting was held in July and the minutes revealed that a number of different topics were discussed, including any sufficient changes in service users needs, holidays, day trips, keyworker roles, and health issues relating to hot weather. Records revealed that staff meetings continue to be held on a monthly basis and are well attended. The manager said that as recommended in the homes previous inspection report the service providers had revised their confidentiality policy to include more detailed guidelines for staff with regard when and with whom they should share information of a confidential nature. The updated version is still in draft form and the manager has agreed to forward a copy of the finalised version to the CSCI on its completion. Norbury Crescent (30) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 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 standard(s) 12, 13 & 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. EVIDENCE: It was evident from comments made by staff met at the time of this inspection, as well as records examined, that the service users are encouraged to have active social lives. Just over half the service users currently residing at the home were out at the time of this visit, either attending various day centres or shopping with a member of staff. The building work on the new two roomed activity centre in the rear garden is almost complete and the manager hopes it will be open by October. The new building will provide the service users with far greater shared space and more opportunity to pursue their social/leisure interests. The home has its own transportation in the form of a minibus. Following a recent assessment by an Occupational Therapist it has been recommended that the home gives serious consideration to purchasing a vehicle with a Norbury Crescent (30) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 Page 12 tailgate lift to meet the mobility needs of those service users who require wheelchairs to access the wider community. It was positively noted that the home had taken this recommendation on board and was in the process of discussing the matter with the Directors of the service. Progress on this matter will be assessed at the homes next inspection. One service user spoken with said they had gone out to have fish and chips for lunch. Another service user who had stayed at home to have their lunch appeared to be enjoying a sweat and sour chicken and rice dish, which had been cooked by staff. The meal looked extremely appetising, hot, and in plentiful supply. During the course of this inspection a senior member of staff returned from a shopping trip laden with all manner of foodstuffs to replenish the homes dwindling food stocks. The published menus continue to be rotated on a four weekly basis, reviewed every four months or so and up dated accordingly to reflect the Seasons. The menus are extremely varied to cater for the specific religious and cultural needs of the service users. The service users are a very culturally diverse group and the menus accurately reflect this with foodstuffs, such as plantain, ackee, goat curry, Thai soup, as well as more traditional European style dishes, all included on the published menus. Norbury Crescent (30) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 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 standard(s) 18, 19 & 20 Suitable arrangements are in place to ensure that service users physical and emotional health care needs, and that they are protected by the homes procedures for dealing with medicines. EVIDENCE: Norbury Crescent (30) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 Page 14 As previously mentioned, following a referral made by the manager, a qualified Occupational Therapist undertook a thorough assessment of the premises in May 2005. It was positively noted that one suggestion has already been acted upon by the home and several others are still being considered by the providers, e.g. Protective side bars (not cot sides) have now been fitted to one service users bed to minimise the risk of them falling out at night and plans are being considered to enlarge a ground floor toilet/shower room to make it more accessible. No significant accidents have occurred in the home in the past six months, although as previously mentioned, several incidents involving the same service user have occurred during this period. Staff have appropriately maintained records of these incidents and notified the Commission without delay about their occurrence, in accordance with the Care Homes Regulations (2001). As required in the homes previous report it was positively noted that all those service users who are currently prescribed ‘as required’ (PRN) medication have detailed protocols in place that set out clearly when and how staff should give out this type of medication, and who is ultimately responsible for authorising its use. Norbury Crescent (30) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 Page 15 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 standard(s) 22 & 23 The homes vulnerable adult protection procedures are suitably robust and staff adequately trained to minimise the risk of service users, so far as reasonable practicable, being abused, neglected and/or harmed. EVIDENCE: In the past twelve months the home has not received any formal complaints about its operation. The homes complaints procedure is included in the service users guide and the manager said that all complaints/concerns would be recorded in the homes complaints log, in accordance with homes procedures, including any action taken as a result. In the past couple of months an allegation of financial abuse has been made within the home. A member of staff stole a service users cash card and misappropriated a large sum of money from their account. The member of staff, who has now resigned, later returned the money in full. The manager response was both appropriate and swift immediately suspending all those staff who were allegedly involved without prejudice pending an investigation into the matter. Furthermore, all the relevant professional agencies, including the police, the hoist Boroughs (Croydon Social Services) Vulnerable Adult Protection team (Learning Disabilities), the CSCI, and the victims relatives, and Care Manager representing the placing authority, were all notified about the theft as soon as it came to the managers attention. A second strategy meeting is to be convened by the Local Authority involving all the relevant professionals to share the findings of the homes investigation and to agree a plan of action. In the interim it was positively noted that a number of precautionary steps have already been taken by the manager to minimise the risk of a similar incidents reoccurring in the future. Firstly, a new digital safe has been Norbury Crescent (30) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 Page 16 purchased to store all the service users bank/building society books and valuables, which only the manager has, access too. This safe will be kept in a lockable cabinet in the office to minimise the risk of it being carried stolen. Secondly, a new pin number has been obtained to withdrawn money from ATM machines for this particular individual, which only the manager is privy too. Finally, the homes new deputy acting manager will begin auditing the service users finances on weekly basis from now on. This will be in addition to annual audits carried out by qualified accountants. Staff appropriately maintain service users financial records and balances recorded matched the amounts kept in the safe for each service user. Furthermore, receipts are kept for all items purchased by staff on service users behalves and these matched the homes records. Documentary evidence was available on request to show that sufficient numbers of the current staff team have received suitable training in recognising, preventing and reporting abuse. Furthermore, the vast majority of the staff team have attended courses in the appropriate use of physical intervention techniques. One new member of staff spoken to at length was aware that staff should only use these techniques as a very ‘last resort’ and in exceptional circumstances when all other attempts to diffuse an aggressive incident have failed. Specific guidance for staff to follow when dealing with aggression/challenging behaviour is included in each service users care plan. Norbury Crescent (30) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 Page 17 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 standard(s) 24, 27 & 28 The size and layout of the home, which is furnished and decorated to a reasonable standard, ensures the service users live in an extremely comfortable, clean and homely environment. Some of the homes fire safety arrangements are not sufficiently robust to protect the services users, their guests and staff from preventable harm. EVIDENCE: Norbury Crescent (30) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 Page 18 Since the homes last inspection work on the lounge extension, new staff sleepin room and activity rooms is almost complete. The manager is hoping these new facilities will be open by October 2005. The physical changes made to the homes environment will undoubtedly enhance the service users lives and provide them with more communal space to relax in and engage in shared activities. Having been on a tour of all the homes communal areas it was positively noted that following a major incident involving a service user, restrictors and double locks had been fitted to the top floor landing window. The manager said that because of the on going building work the interior décor of the home has been somewhat neglected. The manager concedes that some of the homes interior walls and carpets, especially in the hallways and stairwells, are beginning to look rather shabby and worn in places. It was agreed that the service providers should consider establishing a time specific rolling programme to redecorate the homes interior, especially the communal areas. A fire officer from the London Fire and Emergency Planning Authority (LFEPA) last visited the home in April 2005. Several requirements were made and the manager has agreed to review the homes fire risk assessments, ensure emergency evacuation procedures are conspicuously displayed adjacent fire alarm points, and reposition a sound activated fire door release mechanism attached to a fire resistant door in the hallway. Since the homes last inspection another keypad device, which is connected to the homes fire alarm system, has been fitted to a second door in the entrance porch to minimise the risk of service users absconding. None of the homes fire doors were wedged open at the time of this visit, in accordance with fire safety Regulations. A new kitchen floor was being put down at the time of this visit. The manager said that plans have been agreed and the money earmarked to refurbish the first floor bathroom and convert it into a wet room, as well as landscape the rear garden, now that the building work on the activity rooms was almost complete. Progress on these matters will be assessed at the homes next inspection. All the toilets and bathrooms viewed were found to be spotlessly clean, well maintained and stocked with ample supplies of toilet paper and soap. Norbury Crescent (30) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33 & 34 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: The staff members on duty at the time of this visit were all observed interacting with the service users in a very caring and respectful manner. One member of staff spoken with at length said that the homes policies and procedures are discussed at team meetings, along with staff’s keyworking responsibilities. This member of staff went onto say that they were receiving a comprehensive induction, which had begun on her first day and was still on going. As part of this induction the new member of staff also said they had been provided with the homes grievance and disciplinary procedures and the terms and conditions of their employment. The manager stated that only one member of his current staff team had achieved a National Vocational Qualification in care, although three others had started this training and were well on course to have achieved this award by the end of the year. Furthermore, arrangements had been made for two other Norbury Crescent (30) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 Page 20 members of staff, including the new member spoken with, to enrol on a suitable NVQ course in October. There have been no changes to staffing levels since the last inspection, which remain adequate to meet the assessed needs of the service users. Five members of staff, which included a senior in charge of the early shift and the homes manager, were all on duty at the time of this unannounced inspection. Since the homes previous inspection two members of staff have left the employment of Norcrest and three new members have been recruited. The files of all three new members were examined in some depth and found to contain all the relevant information required by the Care Homes Regulations (2001) and associated Standards; including completed job applications; up to date Enhanced Criminal Records (CRB) and Protection Of Vulnerable Adult (POVA) register checks; two written references; proof of identity, and Home Office approved work permits for non EEC Nationals. The vast majority of staff have attended a number of compulsory training courses that are relevant to the work they perform, including fire safety and prevention, first aid, basic food hygiene, and vulnerable adult protection. However, insufficient numbers of staff have yet to receive any training in the appropriate use of moving and handling techniques. This must be rectified as a matter of urgency. Furthermore, the manager has also identified other shortfalls in his current staff teams training and has made suitable arrangements to address these issues. Progress on these matters will be assessed at the homes next inspection. Norbury Crescent (30) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 42 & 43 In the main the homes health and safety arrangements are sufficiently robust to ensure potential risks to service users, their guests and staffs health are, so far as reasonably practicably, minimised. Nevertheless, the homes gas installations still need to be tested by a suitably qualified engineer on a more frequent basis. 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. Mr Samuel hopes to have enrolled on a suitable NVQ Level 4 course by the end of this year in order to achieve his Registered Manager Award. In the main the home is well maintained and ‘suitable’ arrangements are in place to promote and protect the health and safety of the service users, there guests and staff. Up to date Certificates of worthiness were in place as evidence that ‘suitably’ qualified professionals had checked the homes Norbury Crescent (30) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 Page 22 electrical wringing, fire extinguishers, call bell alarm system, and emergency lighting, in the past six months. The homes gas installations have not been tested since April 2004 and a suitably qualified engineer as a matter of urgency must carry out a ‘Landlords’ check. As required in the homes previous report its insurance cover for service users belongings and employer’s liability has been renewed and documentary evidence by way of a certificate was available on request. Furthermore, since the homes last inspection it was also positively noted that the manager, in conjunction with the service providers, has compiled an annual development and business plan for the home. Norbury Crescent (30) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 Page 23 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 3 x x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x 4 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x 3 3 x x Standard No 11 12 13 14 15 16 17 x 3 3 x x x 4 Standard No 31 32 33 34 35 36 Score 3 3 3 3 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Norbury Crescent (30) Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 2 3 G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 Page 24 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 24 Regulation 23(4) Requirement The home must ensure its fire risk assessments are kept under regular review, emergency fire evacuation procedures are conspiciously displayed adjacent fire alarm points, and a sound activated release mechanism attached to a hallyway door is repositioned. Sufficient numbers of staff must be suitably trained in the use of moving and handling techniques. Documentary evidence of this training must be avialable for inspection on request. The homes gas installations must be checked out by a suitably qualified engineer as a matter of urgency and a Certifcate of worthiness forwarded to the Commission. Timescale for action 1st November 2005 2. 35 13(5) & 18(1), Sch 2.4 1st January 2006 3. 42 13(4) 1st October 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 Page 25 Norbury Crescent (30) 1. 13 2. 3. 4. 24 32 37 The home should give serious consideration to acquiring a vechile with a tailgate lift to ensure the mobility needs of all the homes service users continue to be met and the health and safety of staff is not compromised. The service providers should consider establishing a time specific rolling programme to redecorate the homes interior, especially the communal areas. 50 of the homes staff team to have achieved their NVQ level 2 or above in care by the end of 2005. The manager should have at least enrolled on a NVQ 4 course by the end of the year (2005) in order to achieve his Registered Managers Award by the middle of 2006. Norbury Crescent (30) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 Page 26 Commission for Social Care Inspection Croydon, Kingston & Sutton 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. Extracts may not be used or reproduced without the express permission of CSCI Norbury Crescent (30) G53-G53 S25820 norburycrescent30 V215792 160805 stage0.doc Version 1.40 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!