Inspection on 07/09/06 for Norbury Crescent (30)

This inspection was carried out on 7th September 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 8 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) 20/12/05

Norbury Crescent (30) 31/08/05

Norbury Crescent (30) 02/03/05

Norbury Crescent (30) 20/12/04

Similar services:

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Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

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 Diane Thackrah Key Unannounced Inspection 7th September 2006 10:50a Norbury Crescent (30) DS0000025820.V309325.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 (30) DS0000025820.V309325.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 (30) DS0000025820.V309325.R01.S.doc Version 5.2 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.V309325.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20th December 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. 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. A copy of the service’s Statement of Purpose and Service User Guide can be obtained on request from the Registered Manager. Fees for the home at the time of writing are £980.00 per week and there are no additional charges. Norbury Crescent (30) DS0000025820.V309325.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on 7th September 2006 between 10.50 and 16.15. Care records were examined and a partial tour of the premises took place. Eight of the eleven service users currently residing at Norbury Crescent were at home throughout this inspection. Three service users were out at day centres. Five service users were spoken with. The Registered Manager and three staff members were also spoken with. There were no visitors in the home at the time of this inspection. The views of seven relatives and two social care practitioners have been received via comment cards. The views of these people will be reflected in this report. What the service does well: This is, in general, a well run home were service users have their needs well met. All feedback received about the home was very positive. One social care professional said that the organisation was an “excellent provider who worked well in partnership with them” A visitor said that they were satisfied with the care provided and found the staff members to be “helpful”. Another visitor said that the staff were “excellent” One service user spoken with said “I like it here” Another service user said that they had enjoyed a recent holiday with the home. There are good arrangements for ensuring that service user’s needs are assessed prior to them moving into the home and service users and their representatives are consulted with about the care to be provided on an ongoing basis. Service users have their health needs met well and are protected by good practice in handling medication. There are good arrangements for handling complaints and allegations of abuse. There are very good arrangements for ensuring that service users live a fulfilling lifestyle, in accordance with their wishes. Structured activities are provided daily and there are opportunities for service users to relax and spend time with their family members and friends. The home is generally comfortable, and there is a pleasant garden. Staff members are supplied in sufficient numbers and there is good staff training. All staff members are thoroughly vetted, offering a good level of protection to service users. There is good management of the home and a quality assurance system that takes into account the views of those using the service. Health and safety is taken seriously. Norbury Crescent (30) DS0000025820.V309325.R01.S.doc Version 5.2 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) DS0000025820.V309325.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Norbury Crescent (30) DS0000025820.V309325.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. There continue to be effective procedures for gathering information about the needs of prospective service users, which ensure that the needs of service users are met. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The Registered Manager said that the home’s Service User Guide and Statement of Purpose have recently been updated to reflect the environmental improvements in the home. There are good arrangements for reviewing these documents in order to ensure that service users and their representatives are provided with the information they need before moving into the home. Needs assessment documentation was not examined during this inspection, as there have been no new admissions. Norbury Crescent (30) DS0000025820.V309325.R01.S.doc Version 5.2 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): 6, 7 and 9. The home develops and agrees with each service user an individual Service User Plan that ensures that care and support is delivered in accordance with individual’s needs. There are, in general, appropriate arrangements for supporting service users to take risks as part of an independent lifestyle. There must, however, be better arrangements for reviewing risk assessments in order to ensure that changing needs are fully met. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The Service User Plans of two service users were examined. These were generally, in good order. All aspects of the service user’s unique personal, social and health care needs were recorded. There were risk assessments available for each service user. However, these had been completed some time ago, and there were no records detailing that these had been reviewed. There were records detailing that there had been reviews of care for each service user. These reviews had involved service users, their key relatives, Norbury Crescent (30) DS0000025820.V309325.R01.S.doc Version 5.2 Page 10 Care Managers and Key Workers. One Key Worker spoken with confirmed that they were involved in Service User Plan reviews. Whilst it was evident that formal reviews of care had occurred, there were no clear records detailing that reviews had occurred at least six monthly. It is necessary to ensure that Service User Plans, including risk assessments, are reviewed, at least six monthly, with clear records detailing when these reviews took place, and any changes made. A Requirement is made regarding this issue. There was feedback from one service user regarding them being able to make decisions about the things that were important to them. One staff member confirmed that part of their duties were to support service users to make choices about their lives. Information in care records highlighted that service users have been supported to make decisions about things such as leisure activities and food. One care staff member said that there are monthly service users meetings were service users are supported to make decisions about daily living issues. This is good practice. However, it was disappointing to note that there were only two sets of meeting minutes available for 2006. A recommendation is made regarding this issue. Norbury Crescent (30) DS0000025820.V309325.R01.S.doc Version 5.2 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): 12, 13, 15, 16 and 17. There are good arrangements for ensuring that service users take part in appropriate activities, are involved in the community, have opportunities for engaging in appropriate relationships and have access to leisure and social activities. Wholesome and enjoyable meals are provided. This ensures that differing expectations and lifestyles are well catered for. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There was information in the Service User Plans examined detailing the arrangements for the service users to attend local day centres. One service user attends computer and communication training in the community. Staff members support this service user to continue the training in the home. There is a day centre service attached to the home. Two service users were using the day centre at the time of this inspection, with one to one staff support. Records were available detailing that service users follow a structured educational programme during day centre sessions. Norbury Crescent (30) DS0000025820.V309325.R01.S.doc Version 5.2 Page 12 Service users have opportunities for taking part in a variety of activities within the home and in the wider community. One service user had a Service User Plan that detailed that they would make their own breakfast and lunch with the assistance of a support worker. This activity occurred during this inspection. There was documentation detailing that service users attend a variety of local day centres and an evening social club. One service user was being supported to attend a health care appointment during this inspection, and then planned to spend an evening with their family. A tour of the building highlighted that most service users have television and music equipment in their bedrooms. There is a pleasant lounge, were three service users were relaxing during this inspection. One service user was listening to the radio. A new extension has recently been added to the lounge, offering service users an extra space in which to spend time. All service users have recently been on a week’s holiday to Centre Parks. One service user said that they had enjoyed swimming and visiting restaurants during this holiday. The home has it’s own transport which is often used to facilitate outings to the seaside or places of interest. A number of service users recently spent a day at Leeds Castle. The home works to open visiting arrangements and care records seen detailed that family contact is supported. During the course of this inspection, staff members were observed to interact in a positive, relaxed and respectful manor with service users. Service users were noted to be at liberty to spend time were, and with whom they wanted. Two service users spoken with said that they liked the meals in the home. A staff member said that the service users have an opportunity to assist with the food shopping. There was a menu that detailed that food served is healthy and varied, and that a choice is available. Service users who do not communicate verbally have been provided with pictorial boxes to allow them to indicate what they would like to eat. There were minutes of service users meetings detailing that service users had been consulted with about food. Norbury Crescent (30) DS0000025820.V309325.R01.S.doc Version 5.2 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): 18, 19 and 20. There are good arrangements for ensuring that service users receive personal support in a way that they prefer, and health care that ensures that there emotional and health care needs are met. There are good arrangements for ensuring that medication is handled safely, which ensures that the well being of service users is protected. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: One staff member spoken to said that they supported service users to go clothes shopping, and to buy other personal items and a service user confirmed that they were able to choose the clothing that they purchased and wore. Service User Plans seen provided clear information about how the service user liked, and needed to be supported with their health and personal care needs. There was also information about the arrangements for getting up and going to bed. Care records seen detailed that service users have access to a range of health care professionals and that the home is proactive in arranging health care appointments. There were records detailing that service users are Norbury Crescent (30) DS0000025820.V309325.R01.S.doc Version 5.2 Page 14 registered with a general practitioner, have their weight monitored regularly and see opticians and dentists as necessary. Records also highlighted that service users have received support to see health care professional regarding their emotional health care needs, and to have their medication reviewed. The home’s accident book revealed that there have been no accidents involving service users since the last inspection of the home. The Registered Manager confirmed this to be the case. Records are kept of all medicines received, administered and returned to the dispensing pharmacist by the home. Medication Administration Records were examined for two service users and these were in good order. These records accurately reflected the current medication stocks held by the home. Medication was stored securely and safely in a locked cabinet in the home’s office. Staff members spoken with confirmed that only those staff members who have received training, could handle medication. Norbury Crescent (30) DS0000025820.V309325.R01.S.doc Version 5.2 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 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. Arrangements are in place for handling allegations and instances of abuse. This ensures that service users will be protected from harm. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There are policies and procedures in place for dealing with complaints. Information is made available in the Service User Guide about how a compliant, concern or suggestion should be made, and how this will be handled. This information also includes details about how a concern may be raised with the Commission for Social Care Inspection. Feedback from seven relatives indicated that they had been made aware of the home’s complaints policies and procedures. The Registered Manager said that three complaints have been made about the home since the last inspection. Examination of the home’s complaints log highlighted that these complaints had been handled appropriately. The home has a copy of Croydon Council’s vulnerable adult protection procedures and all staff members are required to read the home’s policy and procedures on adult abuse as part of their induction programme. Norbury Crescent (30) DS0000025820.V309325.R01.S.doc Version 5.2 Page 16 There is a safe for service users to keep their money in. Records were available detailing service user’s income and expenditure. Receipts for purchases were available. Norbury Crescent (30) DS0000025820.V309325.R01.S.doc Version 5.2 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 the following standard(s): 24, 26, 27 and 30. There have been improvements to the environment; however, there is a need for improvements in relation to the décor, furnishings and cleanliness in the home in order to ensure that service users live in a comfortable and homely environment. Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: A Requirement was made at the last two inspections of the home regarding the need to reposition the activated release mechanism attached to the hallway door, or remove this door, as planned. The Registered Manager has consulted with the local fire officer regarding this issue, and has now made suitable changes. This Requirement is now considered met. Communal areas of the home were noted to be homely and generally, clean. It was positive to note that the kitchen has been refurbished and new appliances have been purchased since the last inspection. There is a garden to the rear of the home that is well maintained and two service users were noted to enjoy spending time in the garden during this inspection. There was new, good quality furniture in the communal lounge. This room was generally comfortable and homely in appearance, however, the paintwork on one wall was stained and in Norbury Crescent (30) DS0000025820.V309325.R01.S.doc Version 5.2 Page 18 need of cleaning. The skirting boards on the first and second floor corridors were very dusty, as were the curtain rails and lampshades, and two windows were cracked. The Registered Manager said that plans were in place to repair these windows, however, there is a need for further efforts to make one of these windows safe. The bedrooms of four service user’s were viewed, these had been personalised and had homely touches. Two service users spoken with said that they liked their bedrooms. Keys to bedrooms are provided and one bedroom was noted to have a safe. Bedrooms were generally, adequately furnished, however, there was some old and worn furniture and stained paintwork. Bedrooms did not appear well cleaned, one had a dirty sink and another two had very dusty skirting boards and stained paintwork. One bedroom wall on the ground floor had been re-plastered in one area, but had not been repainted. There is a sufficient number of toilet, shower and bathing facilities. Most bathrooms and toilets seen were clean and well decorated. However, the shower room on the first floor of the home was not homely in appearance, or well cleaned. There were no hand drying facilities in this room and there was an unlocked cupboard, which provided access to exposed pipes. It is of concern that a significant number of concerns about hygiene and maintenance have been raised as a result of this inspection. It is also disappointing that there was no annual development plan detailing the arrangements for the routine maintenance and renewal of the fabric and decoration of the home. Refer to Standard 39 of this report. A number of Requirements are made regarding the issues discussed above. It is strongly recommended that the organisation review the arrangements for maintaining cleanliness in the home. There are suitable arrangements for the control of infection and for laundry. Norbury Crescent (30) DS0000025820.V309325.R01.S.doc Version 5.2 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 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, 34 and 35. Staff members are provided in sufficient numbers and the procedures for the recruitment of staff are robust and provide the safeguards to offer protection to people living in the home. There is a staff training and development programme that provides staff members with skills necessary for meeting the needs of service users. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Staffing levels appeared to be appropriate, and in line with the needs of current service users at the time of this inspection. There were four care staff members on duty at the time of this inspection and the Registered Manager later came on duty. There was feedback from visitors that staffing levels are sufficient and that staff members provide good support. One social care professional said that staff worked in partnership with them. A visitor said that their relative, who lives in the home, was very happy at Norbury Crescent and that the staff members were “good and helpful” One service user spoken with said that they thought that the staff members were helpful. Norbury Crescent (30) DS0000025820.V309325.R01.S.doc Version 5.2 Page 20 The Registered Manager said that no new staff members have been employed to work in the home since the last inspection. Pre-recruitment checks and induction records have therefore not been examined during this inspection. Previous inspections of the home have found these Standards to be met. Records were available detailing that there has been refresher training for some staff members. Certificates were available that detailed that the whole staff team have received training in moving and handling in March 2006, in line with a Requirement made at the last inspection of the home. Two staff members spoken to confirmed that they had attended this training, and found it to use useful. A senior staff member said that they had very recently completed training at NVQ Level 2 in Care, and were scheduled to commence training at NVQ Level 3 in Care. It was positive to note that this staff member saw training as being important to the work that they carried out. A Certificate was available detailing that a second staff member had recently successfully completed NVQ Level 2 in Care training. The Registered Manager said that a further three staff members are currently undertaking this training, and another two are scheduled to do so. Norbury Crescent (30) DS0000025820.V309325.R01.S.doc Version 5.2 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 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 continues to be good management and a good quality assurance system, however, this must be improved to ensure that the home is run in the best interests of service users. Health and safety is taken seriously. This ensures that the health and well being of service users is protected. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service EVIDENCE: There continues to be a qualified an experienced Registered Manager in post. Staff members spoken with said that they received good support and guidance from the Registered Manager. There was feedback from visitors detailing that the Registered Manager consulted with them, and kept them informed about things that were important. Norbury Crescent (30) DS0000025820.V309325.R01.S.doc Version 5.2 Page 22 There are a number of tools for self- monitoring in the home; however, an annual development plan was not available. The Registered Manager said that this document was currently being worked on. A high number of Requirements have been made regarding maintenance issues in the home. It is necessary that an annual development plan be developed detailing the arrangements for the routine maintenance and renewal of the fabric and decoration of the home. Service users and their family members and staff members are surveyed on a regular basis about their views on the home. The organisation then collates the results of surveys and compiles an annual report. The Registered Manager said that the organisation is scheduled to undertake a satisfaction survey. There were records detailing that staff members are trained in safe working practices such as moving and handling, food hygiene, infection control and first aid. Records also indicated that there are regular safety checks on water temperatures, fridge and freezer temperatures, the fire alarm, emergency lighting, fire fighting equipment, and door guards. There are regular fire drills, gas and electricity safety checks and portable electrical appliance safety checks. There are risk assessments in place for chemicals and all accidents and incidents are recorded. Norbury Crescent (30) DS0000025820.V309325.R01.S.doc Version 5.2 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 Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 2 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 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 X 3 X 2 X X 3 X Norbury Crescent (30) DS0000025820.V309325.R01.S.doc Version 5.2 Page 24 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 YA6 Regulation 15 (2)(b) Requirement The Registered Provider must ensure that the Service User Plan, including risk assessments are reviewed at least six monthly, with records kept. The Registered Provider must ensure that stained walls in the lounge and in service user’s bedrooms are cleaned or repainted. The Registered Provider must ensure that the broken windows in the corridors on the first and second floor of the home are repaired, as planned. Timescale for action 01/11/06 2. YA24 23 (2)(d) 01/11/06 3. YA24 22 (1)(a) 13 (4)(a) 01/10/06 4. YA26 23 (2)(d) 5. YA26 23 (2)(d) The first floor window must be made safe until it is repaired. The Registered Provider must 01/11/06 ensure that all areas of the home are kept dust and stain free (specifically skirting boards in corridors and service user’s bedrooms, lampshades and curtain rails in corridors, and paintwork in service user’s bedrooms) The Registered Provider must 01/11/06 ensure that the bedroom near the office on the ground floor is DS0000025820.V309325.R01.S.doc Version 5.2 Page 25 Norbury Crescent (30) redecorated. 6. YA27 23 (2)(d) The Registered Provider must ensure that the shower room on the home first floor: Is kept clean. Has a hand-drying facility. The Registered Provider must ensure that there are no accessible, exposed pipes in the shower room on the home first floor. The Registered Providers must produce an annual development plan and make this available for inspection. 1. 2. 01/10/06 7. YA27 13 (4)(a) 01/10/06 8. YA39 24 (1)(a)(b) 01/11/06 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. 2. Refer to Standard YA7 YA30 Good Practice Recommendations It is strongly recommended that service users meetings be facilitated on a more regular basis. It is strongly recommended that the organisation review the arrangements for maintaining cleanliness in the home. Norbury Crescent (30) DS0000025820.V309325.R01.S.doc Version 5.2 Page 26 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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