Inspection on 26/06/07 for Norbury Resource Centre

This inspection was carried out on 26th June 2007.

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

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

CARE HOMES FOR OLDER PEOPLE Norbury Resource Centre Norbury 2 Crabtree Road Sheffield S5 7BB Lead Inspector Karen Westhead Key Unannounced Inspection 10:30 26th June 2007 X10015.doc Version 1.40 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 DS0000067340.V331024.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 Older People. 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. DS0000067340.V331024.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norbury Resource Centre Address Norbury 2 Crabtree Road Sheffield S5 7BB 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) 0114 2425978 0114 2441969 None Sheffield Care Trust Miss Ann Procter Care Home 12 Category(ies) of Dementia - over 65 years of age (12) registration, with number of places DS0000067340.V331024.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Where additional services are provided e.g. day care, outreach, escort duty, staffing for this must be over and above that required by the care home. The service may admit persons between the ages of 60 and 65 years. Date of last inspection New Service due to new provider. Brief Description of the Service: Norbury Resource Centre (RC) is owned and run by Sheffield Care Trust. The Care Trust took over running the home in May 2006, taking over from Sheffield City Council. Norbury RC is a care home, which does not provide nursing care. It is purpose built and has room to care for up to twelve residents, male and female, who have a diagnosis of dementia. Two bedrooms are funded by the hospital for residents who require a period of recuperation following a hospital stay. The remaining ten bedrooms are for short term or respite residents some of who may live in the community but need to be looked after for short periods to give their carers a break or may not be able to stay at home during alterations or redecoration. Smoking is not allowed on the premises, but residents can smoke in a designated smoke room, which is well ventilated. Norbury RC is in a residential area called Norwood. There is a good bus route nearby which runs into Sheffield town centre. There are shops and pubs within a short distance. The home has twelve single bedrooms. All rooms are furnished but residents can bring their own equipment and personal belongings if they want to. This can help them feel at home and go some way to keeping their independence. There are also communal areas, which are spacious and comfortable and provide a venue for a wide range of social activities to take place and for residents to meet up in small groups. The building has three floors. The first floor and basement areas are offices, which are used by other care professionals, for example social workers. Norbury RC is on ground floor level. There is a passenger lift, which residents can use if they are going to the basement area to attend a meeting. Otherwise residents do not generally use these areas. DS0000067340.V331024.R01.S.doc Version 5.2 Page 5 There is a day centre attached to the home, but was not inspected as part of this visit. Norbury RC is well maintained throughout and there is a routine programme of refurbishment. There is a safe and accessible garden area for residents to use. There is ample car parking for staff and visitors and good access into the home for people with a disability. The fee charged is £356 per week. This information was provided during the inspection. Hairdressing, newspapers, private chiropody treatments and some toiletries are not included in the fee. DS0000067340.V331024.R01.S.doc Version 5.2 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This visit was done by one inspector and had not been prearranged with the manager or owner. The inspector arrived at 10.30am and left at 4.00pm. At the end of the visit the operations manager was told how well the home was being run and what was needed to make sure the home meets the standards. The reason for the visit was to make sure the home was being run for the benefit and well being of the residents and in line with requirements. Before the inspection information received about the home was reviewed. This included looking at the number of reported incidents and accidents, reports from other agencies such as the fire safety officer’s report and staff and resident questionnaires. In December 2006 the home was sent a comprehensive form to complete. All of this information was used to plan the inspection visit. During this visit a number of records were looked at which covered all aspects of the home and the care provided. All communal areas of the home were seen and some of the residents bedrooms. Most of the day was spent talking to residents, visitors, staff and the operations manager, to find out what it is like to live and work at Norbury RC. The manager was not on duty. What the service does well: Norbury RC is a friendly home with a relaxed atmosphere. Staff focus on resident wellbeing and the standards of the care they provide. The staff team work hard to keep the home up to the required standard and a nice place to live and work. All residents are assessed prior to coming to stay in the home and staff have a good insight into what care they can provide. The staff are proud of the care they deliver. They want residents to see the resource ‘as their home’ when they are staying and take their duty of care seriously. During the visit staff took an interest in the residents they were caring for and were knowledgeable, competent and professional in the way they did this. The inspection was done when the Sheffield area was flooded due to recent rainfall and therefore the day centre was closed. This meant that staff, who would have normally been working in the day centre, were deployed to the care home. Therefore it was difficult to access what the normal routine would be. DS0000067340.V331024.R01.S.doc Version 5.2 Page 7 Residents, who were able to share their experiences, talked positively about the surroundings and the staff looking after them. Residents said they could keep their independence and a feeling of usefulness. Staff were seen to give assistance without denying the resident the right to try for themselves. The food in the home is good. The menu provided includes traditional home cooking. Residents have a good relationship with the staff and feel able to talk about things, which worry them and know they will be listened to by staff they can trust. The building and facilities provided are of a good standard. The home is clean and smells fresh. Requirements have been made about the premises and the need to record risk assessments. It is recommended that staff consider using signs around the home to allow residents to find their way around independently. However, this should not overshadow what is a pleasant and comfortable place for residents to live. 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. The summary of this inspection report can be made available in other formats on request. DS0000067340.V331024.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000067340.V331024.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are assessed prior to moving in and there is enough information available about the home to help residents and relatives decide if Norbury RC will meet their needs. EVIDENCE: The Statement of Purpose provides enough information for residents and their relatives to make an informed choice about whether they think Norbury RC might be a suitable place to stay for short periods of time. Two of the bedrooms are funded by the local hospital for residents who need a period of recuperation following a hospital stay; the remaining ten bedrooms are used on a regular basis by residents who need a short stay due to other reasons. Such as a carer taking a break or if their own home needs work doing in it and DS0000067340.V331024.R01.S.doc Version 5.2 Page 10 it is not appropriate for them to stay during this time. One relative, who had completed a questionnaire prior to the visit, said they had been given a booklet and it was very informative. Five residents plans of care were looked at in detail. These were selected after the inspector had had a chance to speak to residents, had an opportunity to observe the level of interaction by staff and asking staff about the care needs of the residents to identify which residents might need a greater level of care. Before a short stay is booked, residents have an assessment by a senior member of staff and the social worker to make sure the home can meet their needs. In many cases the resident may already know the service and staff because they have attended the day centre. Staff work with the family and friends of residents to gain as much information as they can to make sure the resident settles. This practice is used particularly where residents were unable to give their history depending on their level of cognitive impairment. Admissions only take place if the manager is confident that staff have the skills, ability and qualifications to meet the needs of the resident. Prospective residents are given the opportunity to spend time at the home, before admission. This allows them to ask questions of the staff and other residents and gain an insight into life in the home. All residents are provided with a contract, which sets out the terms and conditions of their stay. Examples were seen where representatives had signed the contract on behalf of the resident. The contract is written using plain language and is therefore clear. DS0000067340.V331024.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents care needs are met. Individual care plans give staff the information they need to provide the care required. Some development work is needed to enhance the use of risk assessments. EVIDENCE: Five plans of care were looked at in detail. The information gives an insight into the needs of the resident but more work is needed to make sure risk assessments are properly applied and give enough detail. For example where residents habits and behaviour may pose a risk to others, details of what the behaviour is, why the risk is present and what staff should do to minimise this should be recorded. DS0000067340.V331024.R01.S.doc Version 5.2 Page 12 Plans of care are being reviewed; therefore any changes in care delivery are recorded and kept up to date. Staff record what has happened on each shift, morning, afternoon and night, for every resident. This daily record was checked against other documents, for example, accident forms and care plans and this showed that staff were being consistent and recording events accurately. The staff group talked about the care provided at Norbury RC and there are clear boundaries within which the home operates. For example, when they are no longer able to give the level of care needed they know when to consult other professionals and if necessary assist the resident and their family to find an alternative home which can provide long term care. If resident’s needs can be met in the home using other resources, for example the district nurses or specialist nursing teams this is tried. The staff team understand the importance of residents being supported to take control of their own lives. Those residents spoken to, and were able to express their views, said they made decisions about such things as when to get up, go to bed and what they wished to eat. Medication is correctly administered and storage is satisfactory. Only staff trained to give out medication do so. Practices around medication have been reviewed recently and staff are undergoing retraining following an incident in the home, which highlighted areas where systems could be improved. The drugs held were checked alongside the record sheets and were found to be accurate. Residents are normally admitted from the local area and as such are able to keep their own doctor whilst staying at Norbury RC. Residents are seen in private when the doctor visits and staff accompany them to make sure the doctor is given up to date information and to discuss any changes in medication or treatment. Comments from residents and relatives showed they were very satisfied and content with the care provided. District nurses, who had completed a questionnaire, said that staff communicated well with them and that the home provided ‘excellent support’ for people staying in the home. One relative said they had ‘visited a few homes before choosing Norbury’. It was clear during conversations with staff that they take an interest in the well being of each resident and try to provide them with a good quality of life during their stay. Some areas of good practice were seen, for example the way in which staff approached residents who were in need of attention and the manner in which they answered resident’s questions, which were on occasion repeated many times due to short term memory loss. DS0000067340.V331024.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s lifestyle in the home matches their expectations and they are helped to exercise choice and control over their lives. EVIDENCE: Residents, who were able to express a view, said staff were very good at keeping them entertained, and that they were not made to join in with games and other activities if they didn’t want to. Residents can also attend the day centre during their stay. Staff said the home is part of the community and well known for the service it provides for local people. Questionnaires completed by residents and relatives referred to staff in a positive way. They also said the home was a ‘busy place’ and that they (the staff) ‘do their best to keep everyone happy and content’. Residents told the inspector they enjoyed activities in the home, such as the games of dominoes and arts and crafts. The inspector gained the view that family and friends are DS0000067340.V331024.R01.S.doc Version 5.2 Page 14 seen as an important part of residents lives and that they were encouraged to be involved in the care of the resident if this was appropriate. One family member described their relative as ‘a private person’ and that it was important to him that he could ‘chose to be alone’. This is respected by staff who are sensitive to the wishes of residents who may prefer to have private time and this is checked out on admission. The inspector sat with residents in the dining room whilst the main meal of the day was being served. Residents said the meal served was typical of the standard at every mealtime. It was sampled by the inspector and was found to be hot, tasty and well cooked. The menus for the week are displayed on the notice board in the hallway. The cook said she knows what residents like to eat and tends to keep to traditional menu choices. Different ‘modern dishes’ like pasta and curry are tried periodically but not popular. If residents coming to stay prefer less traditional dishes, there are members of staff who have skills in this area and are happy to advise on recipes. There are choices available at meal times and alternatives are offered if residents do not want what is on the menu. There are a variety of choices for the teatime meal, which is either a choice of hot or cold snack. Residents are also offered a full cook breakfast every morning. The manner in which the meal was served showed that staff were sensitive to resident’s wishes and gave them ample time to finish each course and make sure they had enough to drink. On the day of the visit the day centre had been closed due to flooding in the local area. Therefore there were a lot of staff on duty over the course of the visit and difficult to access how busy staff are over this peak period. Staff said they were usually all right during peak periods if there were no admissions or discharges at the same time. The kitchen was clean, tidy and well organised. Records of cleaning schedules, food delivery, serving temperatures and fridge temperatures are kept. The cook prepares the main meal of the day and prepares the teatime meal as far as possible to ease the burden on staff. Some residents, relatives and health care professionals shared their views about the home. Here is a sample of positive comments. • Carry on the good work. • Treatment is 1st class. • They provide a kind, caring and friendly environment. • Staff can’t do enough. • There are no prejudices. • My personal care is seen to. • They look after my medication. • Meals are OK. DS0000067340.V331024.R01.S.doc Version 5.2 Page 15 • • The home is kept spotlessly clean. The staff are very caring and nothing is too much trouble. Other comments included: • If a person is bewildered and upset, staff may not respond to them with the dignity a more highly trained staff might expect. This was balanced by the same person saying, residents privacy and dignity was respected in the usual and obvious ways. • • • • • Physical care is good. Care is needed to make sure psychological needs are also met. Food would be better if it was softer and easier to chew. Small groups of staff work with residents, but there are few opportunities for residents to go out unless with a visitor. There are little meaningful activities. Staff strive to occupy residents, but this is not always achieved. All of these comments were shared with the operations manager who was able to understand the context of both positive and negative comments and said he would take them to the staff meeting to see if there were any areas they could improve on. He was satisfied that on the whole comments were positive and that the less positive comments gave staff an indication of where work may be needed. Some residents, who were not able to talk about their experiences, showed they recognised the staff in their responses to them and felt safe in their presence. There was an atmosphere of calmness throughout the day. Staff said they are not under pressure to meet routines by a specified time. There was an emphasis on making sure residents were comfortable. Staff did not walk past residents without acknowledging them and if residents were looking ‘lost’ or unsure staff picked up on this straight away. Residents were spoken to in a calm and professional manner and given time to make their views known. The layout of the building allows residents to walk around freely and select different areas to sit. Relatives/carers meetings are held monthly. This means residents and relatives are able to give their views and ideas. It was clear from the views of residents and relatives that they felt they had a voice in the home and were able to engage with staff if they thought things needed to be changed or had a suggestion. All accidents and incidents in the home are being recorded. DS0000067340.V331024.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The level of staff training and knowledge means that complaints will be taken seriously and residents will be protected from abuse. EVIDENCE: Residents and relatives who completed a questionnaire said they knew who to complain to if they were unhappy. The complaints procedure is available to residents and relatives in the information given to them on admission. Those residents spoken to who were able to express a view said they had not had reason to make a complaint. Copies of the adult protection procedures are available for staff to read and refer to. Staff showed a good awareness of what they should do if they thought residents might have been subject to any form of abuse and were able to identify the different types of abuse possible. Training had also been given. DS0000067340.V331024.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of decoration and maintenance of the home is good. Some work is needed to make sure the home is safe and fit for purpose. EVIDENCE: The home is well furnished and attention to detail makes the home feel comfortable to residents. Staff take a pride in the home and what they offer to residents coming to stay. There are five toilets and three bathrooms, which are used by residents. Residents and staff said there is plenty of hot water and that the temperature in the home can be altered if they need it to be. However, there is a problem DS0000067340.V331024.R01.S.doc Version 5.2 Page 18 with some areas, where the water exceeds a safe temperature. This had been reported to the maintenance department and as yet the problem had not been dealt with. The operations manager said safeguards were in place to protect residents from scalding and that all baths were done on a supervised basis. Resident’s bedrooms are decorated and furnished in a basic way, so as to allow residents to bring their own belongings if they wish to. The home was clean and tidy throughout. Bedroom doors have locks fitted, which allow staff to gain entry in the case of an emergency but which can allow residents privacy when using the room or be able to lock it when they leave it. Residents are not routinely given a key to the room they are using. But the operations manager explained that they have access to their bedrooms at all times. During the visit, all staff did knock on bedroom doors before entering. The nurse call system was heard being used on two occasions. Responses by staff were good on each occasion. No comments received during the visit suggested that there were problems with the call system working effectively during the night. The home was clean, tidy and smelt fresh. There is a good infection control policy and staff work within this. The kitchen area is well organised. The cook said all the equipment was working, apart from the chest freezer, which was under repair. In the meantime food was being delivered daily. Work is needed: • To make sure the electrical hardwiring is checked by a certified electrician who can confirm that the system is safe and fit for purpose. • To make sure the area leading from the external fire door is free of moss. • To make sure residents can use the bathrooms in private by them being fitted with suitable locks. • To make sure that all hazardous equipment, including razors are stored safely and not available to residents. • To make sure the grounds surrounding the home are kept tidy and weed free. It is recommended that better signage, suitable for residents with limited understanding and poor sight, be placed in selected areas of the home to allow residents to remain as independent as possible. Apart from this, information provided by the manager confirms that equipment and services are being maintained according to health and safety laws. DS0000067340.V331024.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are competent, experience and trained well enough to be able look after residents properly. EVIDENCE: The information provided at the inspection showed that two staff had left in the last twelve months, one following a period of leave and the other for health reasons. The recruitment files of four staff were seen. The necessary pre employment checks had been made to make sure they were suitable to work with the vulnerable people. Staff are responsible for reading policies and procedures. The senior members of staff make sure all staff are informed of any changes. Two staff members’ work a waking shift during the night. Staff hours are used creatively and this means there are staff available at busy times of the day, including mealtimes and when residents are getting up and going to bed. The home is carrying four vacancies for care staff totalling 116 hours per week. There is a freeze on recruitment so regular staff are being used from a local agency to cover the shortfall in hours. This means agency workers are kept to DS0000067340.V331024.R01.S.doc Version 5.2 Page 20 a minimum in the interests of continuity of care for residents. The manager is not included on the roster and works in addition to the staff delivering direct care to residents. There are suitable on call arrangements. It was mentioned during the visit that there are male staff available however, they were usually deployed to the day centre to drive minibuses and did not work many hours in the home. This was discussed with the operations manager who elected to monitor this situation to make sure residents in the home had access to male staff if this was their preference. This changes according to who is staying at the home at any one time. Residents are confident in the abilities of staff and said many times that they felt safe and well looked after. Staff training is provided and a programme of courses is planned in advance to make sure all staff have attended necessary training to keep their skills and abilities up to date. Staff said they had attended courses in the past, including principles of care, moving and handling, fire safety and medication administration. A large proportion of staff have completed a recognised care award, a national vocational qualification at level 2. Staff were spoken about in positive terms by all who talked with the inspector. The residents said they felt looked after and that staff were attentive and kind. DS0000067340.V331024.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 35, 36, 37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and run in the best interests of residents. EVIDENCE: The manager and operations manager are involved in the day-to-day running of the home and have the necessary skills to be able to run the home effectively. There is a clear understanding of the key principles of care and there is a strong ethos of openness and transparency in the way the home is run. DS0000067340.V331024.R01.S.doc Version 5.2 Page 22 Staff mentioned that the home could be very busy when there were a lot of admissions and discharges. Residents arrive and leave according to their individual circumstances and the numbers fluctuate daily. Therefore some days can be ‘hectic’. Staff said they sometimes felt the pressure of that. This was discussed with the operations manager who acknowledged this and said if necessary senior staff would help during busy times of the day. Equal opportunities are promoted and this is shown in the practices in the home and the way in which residents and staff are treated. Residents’ are well cared for and attention had been given to their appearance, including their hairstyles and clothing. The home only handles small amounts of cash on behalf of residents. This is accounted for when the resident arrives and if staff are given the responsibility of looking after this during their stay, a record is kept of all expenditure and receipts are obtained as necessary. All records regarding residents and staff are kept in a locked filing cabinet in the office when not being used. Where changes have been made the manager has updated all the policies and procedures relating to the home to make sure they are in line with current good practice and remain relevant to Norbury RC. DS0000067340.V331024.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 Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 2 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X 3 3 3 3 DS0000067340.V331024.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? N/A 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 OP7 Regulation 12 Requirement The registered person must make sure plans of care include risk assessments, which are specific to the needs of the resident. The registered person must make sure the electrical hard wiring in the home has been tested by a person who is qualified to carry out this work and obtain a certificate saying it is safe. The registered person must make sure the area leading from the final fire exit door is free from moss. The registered person must make sure the grounds are kept tidy and free from weeds. The registered person must make sure all equipment, including razors are stored safely. 3 OP21 16 The registered person must provide suitable locks to bathrooms so that residents can DS0000067340.V331024.R01.S.doc Timescale for action 12/08/07 2 OP19 23(4) 22/10/07 22/10/07 Version 5.2 Page 25 use facilities in private. 4 OP25 13 The registered person must make sure residents are not at risk of scalding by keeping hot water at a suitable temperature. 30/09/07 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 OP19 Good Practice Recommendations The registered person should look at ways of introducing signs in the home, which allow residents with limited understanding and sight to be able to move around the home independently. DS0000067340.V331024.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000067340.V331024.R01.S.doc Version 5.2 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. 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