Inspection on 23/02/06 for Norlin House

This inspection was carried out on 23rd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Norlin House 20/01/09

Norlin House 13/02/07

Norlin House 28/04/05

Norlin House 22/09/04

Norlin House 02/06/04

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Dalewood Respite Care

Orchard,The

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Fairways

Treloar College

Kestrel House, St Anne`s Opportunity Centre,

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

CARE HOME ADULTS 18-65 Norlin House 31 Ewart Road Kingston Portsmouth Hampshire PO1 5RH Lead Inspector Janet Ktomi Unannounced Inspection 23rd February 2006 14.00 Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Norlin House Address 31 Ewart Road Kingston Portsmouth Hampshire PO1 5RH 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) Independent Care (Portsmouth) Limited Mrs Linda Janice Rosa Walsh Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users may only be accommodated between the age of 18 - 55 years 28th April 2005 Date of last inspection Brief Description of the Service: Norlin House provides accommodation and care for up to three adults with a learning disability. The home is a terraced property situated in a residential area of Portsmouth, and close to local amenities and bus services. The home has a small rear courtyard garden. All bedrooms are for single occupancy and the communal areas consist of a ground floor lounge and kitchen/diner. The home is not suitable for people with a physical disability. The property is leased from a landlord, by Independent Care (Portsmouth) Limited and managed by Mrs Linda Walsh. Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second inspection of this inspection year. Two day’s notice was given to the home of the inspection to ensure that the manager and residents would be available to enable the remaining core standards to be assessed. Core standards not assessed during the first inspection were assessed along with additional core and non-core standards. The inspection lasted four and a half hours during which a tour of the building was undertaken. Discussions were held with the care staff on duty. The people living within the home were met during the inspection and they stated they enjoyed living at the home. Care and other records and documentation identified in the report were viewed. What the service does well: What has improved since the last inspection? The home is working with the local council’s training department to identify suitable training courses for induction and specialised training for care staff. Staff records are now securely stored within a locked cabinet with the key accessible only to staff on duty. A placement contract for one service user was viewed, although this has not been updated since the placement approximately five years ago it would appear to contain all the required information. The records in respect of service Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 6 user’s personal finances were viewed and would indicate that the service user is receiving benefits and that these are spent appropriately. 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. Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 5. The service users’ guide should be amended as suggested to the manager. The home does not intend to admit new service users but has an appropriate procedure should this occur. The home has a contract for purchasing agencies. EVIDENCE: The home is registered for up to three people, at the time of the inspection two people were living at the home. The proprietor/manager stated that she does not intend to admit a third person to the home and the bedroom registered for the third person has been converted to an office. The home has a service users’ guide that was shown to the inspector. The manager explained that this required updating as some staff mentioned in the guide have since left the home. The inspector advised the manager that she does not need to name individual care staff in the guide but should include a statement about the staffing structure and qualifications/training that staff will be expected to have or undertake. This would resolve the need to rewrite the service users’ guide each time a staff member left or new person was recruited. There have been no new admissions to the home for approximately two years. The documentation and pre-admission assessment for the person most recently admitted to the home was viewed and found to contain all the required information necessary for the manager to determine if the home is able to meet the person’s needs. Discussions with the manager indicated that Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 9 the views and needs of existing service users were paramount in any decisions as to whether a new person would be admitted to the home. The home is registered for up to three adults with a learning disability. Discussions with the manager indicated that she was aware of the extent of needs the home could accommodate and the home’s registration categories. The home has a contract for each service user. One was seen and had been signed by the service user and an employee of the health trust who fund the placement. This was signed at the time of placement a number of years prior to the inspection. The contract seen contained all the relevant information one would expect to see within a contract. Due to cognitive limitations it is unlikely that the service user would fully understand the contract, however the contract is essentially between the contracting health trust and the provider and as such is considered appropriate. Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 and 10. The care planning process identifies service users’ individual care needs and includes risk assessments where necessary and specific details as to how care needs will be met. The home must ensure that care plans and risk assessments are reviewed, when possible, with the service user. Staff are aware of confidentiality and records are appropriately stored within the home. EVIDENCE: The care plans for both people who live at the home were seen during the inspection. These detail domestic and daily routines as well as support needs, social interests and activities. Specific assessments had been completed for activities where there is an element of risk such as use of kitchen equipment, remaining in the home on their own and going out. There was no evidence in the care plans that the service users had been involved in care plan and risk assessment formation. If possible service users should sign their risk assessments and care plans to confirm that they have been involved in their production. Care plans should be reviewed at least every six months or more frequently should the need arise. Discussions with the manager and care records viewed Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 11 indicated that the home had previously reviewed care plans every month but had not done so for over six months. The home must ensure that care plans are reviewed with the service user or their representative at least every six months. Discussions were held as to ways this could be achieved without the need to totally re-write the care plan assuming that needs remain the same. Care plans seen also contained risk assessments for service users. These were designed to promote not restrict service users’ daily lives. Risk assessments should also be reviewed at least every six months and where appropriate service users should be involved in the risk assessment process and reviews. Again signatures would indicate that the service user had been involved in the process. The home has appropriate policies and procedures in place for unexplained absences or should service users not return home at the expected time. The arrangements for one service user’s personal finances were viewed. The account the service user holds only sends a statement once per year. The manager is the appointee. Each week an appropriate amount of personal cash is held for the service user and given to her each day. The remainder of her benefits is placed into her bank account. The service user is capable of spending her money as she wishes, and gets receipts wherever possible. These were seen during the inspection along with the full records of the service users’ personal money. The service user confirmed that she is able to spend her money as she wishes and showed the inspector a new bag she had purchased on the day of the inspection. The home has a policy and procedure for confidentiality that is included in the service users’ guide and on the induction checklist. Care staff and the manager were clear about instances when information may need to be shared with other professionals. Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 12 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): 11, 13, 14 and 16. Service users enjoy a varied lifestyle with lots of opportunities for community and leisure activities. EVIDENCE: The inspector was able to meet both of the people who live at the home. They confirmed to the inspector that they are able to decide how they spend their time and what activities they participate in. Both residents are fairly independent although need some supervision with some domestic (catering) tasks. Each service user has an individual weekly programme of activities that includes a range of organised and leisure activities, intended to help develop and maintain life skills and provides opportunities for socialisation away from the home. Care staff, service users and care records confirmed that service users often enjoy ad hoc community activities as the weather permits. Service users stated they enjoy going out shopping, to the beach, social clubs and visiting friends. Service users are encouraged to participate in domestic activities as their cognitive and physical abilities allow. One service user attends college part of the week. Care staff were observed interacting appropriately with service users during the inspection. Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 13 During a tour of the home the lounge and service users’ bedrooms were seen and contained appropriate home entertainment options including televisions and music centres. Service users spoken with confirmed that they enjoyed a range of appropriate leisure activities and told the inspector activities they had recently enjoyed. During the inspection service users were observed coming home from planned and ad hoc activities. The home has a no smoking policy, with staff who do smoke noted to do so outside in the rear garden. Both of the people living at the home have a pet dog each. One service user has difficulties in forming relationships and friendships therefore her pet provides a valuable companion and friend. Both dogs get on well together. The manager confirmed that the home finances pet-plan insurance and supports routine vet bills. Service users spoken with during the inspection said that they liked the food available at the home and that plenty of choice was available. The menus and food records were fully assessed during the previous inspection. Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Medication is appropriately administered within the home. The medications storage cupboard must be attached to the wall. EVIDENCE: All medication is stored in a locked cupboard in the office and administered via a pre-dispensed system wherever possible. Medication administration records were checked and found to be accurate and fully completed. No service users are currently self-medicating. There are no controlled drugs within the home. All staff who administer medication have received appropriate training and are deemed competent by the manager. At the time of the unannounced inspection the lockable cupboard containing medication was not secured to the wall and the home must ensure that the medications cupboard is attached to the wall with appropriate fixings. The medication administration sheets are provided monthly with the medications by the pharmacist. These state the medication, dosage and time it should be taken. The pharmacist also states the quantity that has been supplied. The home should sign on the MAR sheets to confirm that they have checked the medication into the home and that medication received is as stated by the pharmacist. Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 15 The medications administration policy and procedure was reviewed with the manager during the inspection to reflect the changes in procedure resulting from the recent switch to pre-dispensed system. The remaining core standards within this section were all inspected during the previous inspection. Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 16 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 The home has an appropriate complaints procedure and service users are able to complain. Staff within the home are aware of adult protection issues and follow the locally agreed procedure in the event of adult protection concerns. EVIDENCE: The home has a complaints policy which is made available to service users or their representatives in the service users’ guide. The complaints policy should ensure that all complaints are appropriately investigated within twenty-eight days. The home maintains a complaints book. Staff spoken with were aware of what procedure they should follow should a service user or their representative make a complaint. Service users at the home are cognitively able to make a complaint and it is the inspector’s opinion that should they wish to do so service users are able to complain. The home has a copy of the locally agreed adult protection policy and procedure. The manager has been unable to identify specific adult protection training as required during the previous inspection. The manager has identified this with the local council training department as a training need for her staff. Three of the four staff within the home have NVQ level 3, with the fourth undertaking level 3 training. Staff spoken with confirmed that adult protection issues were central to many of the units within the NVQ level 3 training. Discussions with the manager and staff indicated that they have a good level of understanding about adult protection. Following the previous inspection a requirement was made that the manager must follow up a referral made to the POVA list approximately one year prior to this inspection. The manager had appropriately referred an ex-employee to the list as unsuitable to work with vulnerable people. The manager explained the Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 17 situation that led to the POVA list referral but had not followed up on the referral stating that she did not have the telephone or contact numbers for POVA. The inspector explained where these numbers could be located and the manager must provide the Commission with written information following discussion with POVA in respect of the ex-employee. Care plans detail how staff should respond to inappropriate behaviour that service users may present. Service users have been provided with personal alarms for use when out. Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 18 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, 25, 26, 27, 28, 29 and 30. The home is suitable for the existing service users providing all single bedrooms and appropriate and communal space. The home is well maintained and clean. The shower must be repaired and written notification that this has been completed provided to the Commission. EVIDENCE: Both service users showed the inspector their bedrooms and the communal areas of the home were seen during the inspection. In relation to its structure and layout the home is suitable for its stated purpose, in that it meets service users’ needs in a comfortable and homely way. The main lounge is comfortable and well presented, with domestic style furnishings, as is the open plan kitchen/dining room. The home has a rear patio garden that contains a fishpond. Service users confirmed that the patio garden is pleasant in the warmer months and that they have free use of the communal areas of the home. There are no wheelchair users amongst the current service user group and the home would be unsuitable for people with a physical disability. All bedrooms are for single occupancy and were pleasantly decorated, contained all the necessary fixtures and furniture and were individually Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 19 personalised. Personal home entertainment equipment such as televisions, music centres and sensory lights were seen in the bedrooms. The home has one bathroom, containing shower, WC and washbasin. The service users informed the inspector that the shower was not working and, although unclear on specific times, that it had not worked for a while. The manager stated that the shower had not worked for about two weeks but there had been problems agreeing with the landlord who was responsible for paying for the repairs that may be covered by a warranty. The manager stated that this had now been resolved and she hoped the shower would be fixed in the near future. The home must inform the Commission in writing when the shower is repaired and fully functioning. At the time of the unannounced inspection the home was found to be clean, tidy and free from offensive odours. The certificate for the servicing of the boiler was seen during the inspection. Prior to the inspection the manager had discussed with the inspector some concerns with the roof of the home. The home is leased from a landlord who is responsible for the upkeep of the external parts of the home. A number of roof tiles were seen near the front door. The manager informed the inspector that the loose tiles had been removed however she believed that the roof had not been fully repaired. The tiles near the front door present a risk and must be moved, as staff cannot manoeuvre the rubbish bins past them. The manager must clarify with the landlord what repairs have been completed and ensure that the home is maintained to a safe standard. The manager must inform the Commission in writing when this has been completed. Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 20 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, 33, 35 and 36. Service users are supported by competent, qualified and experienced care staff who are supervised on a regular basis. EVIDENCE: Services users stated that they liked the care staff, that they were helpful and they could ask staff for help with any problems. As previously stated three of the four care staff employed at the home have NVQ level 3 with the fourth having level 2 and undertaking level 3 NVQ. 100 of the care staff therefore have NVQ level 2 or above in care. Care staff continue to undertake training, with one informing the inspector that she is now undertaking a diploma in health and social care. During the inspection the manager discussed training opportunities for care staff to meet induction (for new staff), mandatory updates and service user specific training. There are four permanent care staff employed within the home. Staffing rotas are designed to ensure staff are available at times when service users are at home. Staff spoken with felt that the staffing levels and arrangements were appropriate to the service users’ needs. The staff have worked at the home for several years and are familiar with the service users’ individual needs. Service users informed the inspector that they liked the staff who they described as helpful and nice. One staff member sleeps in the home overnight and remains on duty until the service users have gone out for their daytime activities. Another person comes on duty to coincide with the service users returning Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 21 from their activities. The manager confirmed that staff are provided for hospital appointments or should the service users be ill and not go to planned activities. The manager is available on call when not in the home. Service users have been risk assessed as being able to remain in the home on their own for short periods of time and stated they were happy with this. All care staff are aged over 21 years. The manager and staff confirmed that all staff have an annual appraisal and supervision approximately every two months. The records of annual appraisals and supervision for December 05 were seen. The grievance and disciplinary procedures are available in the office for staff. Staff have not received specific training in respect of dealing with physical aggression from service users, although will have covered aspects of challenging behaviour within their NVQ level 3. Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 22 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, 38, 39, 40, 41, 42 and 43. The management arrangements are appropriate for the size of the home. The home has the necessary policies and procedures in place with records stored and maintained appropriately. The insurance certificate was not available during the inspection, the home must obtain and display a copy of the insurance certificate. The home is generally a safe place for staff, visitors and service users however the manager must confirm with the landlord that the roof has been repaired. EVIDENCE: The manager informed the inspector that she has now completed the Registered Manager’s Award, having completed NVQ level 4 in care in 2005. The manager regularly covers shifts within the home so has a good knowledge of the service users and their needs. Service users stated that they would discuss any concerns with the manager or a member of staff and were observed interacting in a relaxed and friendly manner with the manager during the inspection. Staff stated that they could discuss any problems or suggestions with the manager. Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 23 The home has appropriate policies and procedures in place, some of which were seen during the inspection. As previously stated the medications policy was reviewed during the inspection to reflect the changes following the recent move to pre-dispensed medications. Staff were aware of the policies and procedures. During the unannounced inspection a variety of records was inspected. These included, Medication Administration Records, care plans and risk assessments, service users contract, personal finances, policies and procedures and duty rotas. There are appropriate secure storage facilities for records within the office. As previously stated the care plans and risk assessments must be reviewed, where possible with service users. The home is generally as safe place for staff and service users. As previously identified the manager must confirm with the landlord that the roof has been appropriately repaired and the tiles left by the front door removed to a safer position. Written confirmation of this must be provided to the Commission. Care staff are provided in appropriate numbers, at times required by the service users and have the necessary skills to meet their needs. The certificate for the servicing of the home’s boiler by an approved gas engineer was seen. The manager confirmed that the home is financially viable and there were no indications that this was not the case during the inspection. The insurance certificate was not available during the inspection. The manager telephoned the insurance company who confirmed that the home was insured with Ecclesiastical Insurance but that only one certificate for both homes owned by the manager/proprietor had been provided and was on display in the other home. The insurance company agreed to send a second certificate that must be displayed in Norlin House. The manager must provide a copy of the certificate to the Commission. Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 24 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 3 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 3 LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 3 3 X 3 2 2 3 Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 25 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6YA9 YA41 YA20 YA20YA41 Regulation 15 (1) 15 (2)(b) 13 (2) 13 (2) Requirement Care plans and risk assessments must be reviewed, where possible, with the service user, at least every six months. The medications storage cupboard must be secured to the wall. The medication administration records must be signed to confirm receipt of individual medications. The home must follow up the referral made to POVA. Written confirmation of the result of this must be sent to the Commission. The manager must consult with the landlord and ensure that the roof has been adequately repaired. The tiles by the front door must be moved to a safer location. The manager must inform the Commission in writing when the shower has been repaired. The home must display a current insurance certificate for the current provider. A copy must be sent to the Commission. Timescale for action 01/04/06 2. 3. 01/04/06 01/04/06 4. YA23 13 (6) 01/04/06 5. YA24YA42 23 (2)(b) 07/03/06 6. 7. YA27 YA437 23 (2)(b) 25 (2)(e) 07/03/06 07/03/06 Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 26 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 YA6 Good Practice Recommendations Service users should sign care plans to confirm that they have been involved in decisions about their care plans. Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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 Norlin House DS0000012002.V254564.R01.S.doc Version 5.1 Page 28 - 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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