Inspection on 16/12/04 for Normanby House

Care Home For Older PeopleNormanby House6 Belgrave Crescent Scarborough North Yorkshire YO11 1UBUnannounced Inspection16th December 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Normanby House Address 6 Belgrave Crescent, Scarborough, North Yorkshire, YO11 1UB Email address Name of registered provider(s)/company (if applicable) Anchor Trust Name of registered manager (if applicable) Mrs Penelope Jane Fletcher Type of registration Care Home No. of places registered (if applicable) 25 Tel No: 01723 501638 Fax No: 01723 369318Category(ies) of registration, with (number of places) Old age, not falling within any other category (25) Registration number B060000277 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 30th July 2002 YES NO 22/06/04 If Yes refer to Part CNormanby HousePage 1 Date of inspection visit Time of inspection visit Name of inspector 1 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspection16th December 2004 09:30 am David White N/A Marion ONeillID Code140799Normanby HousePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementNormanby HousePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Normanby House. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Normanby HousePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Normanby House is a semi-detached property approximately half a mile from Scarborough town. It consists in part of a converted dwelling house and purpose built accommodation. The upper floors are accessed by vertical passenger lift. The home is set in its own grounds with adequate parking spaces. It has easy access to the shops, amenities and local transport systems. The home provides residential care for 25 older people aged 65 years of age and over who do not have any specialist requirements. Anchor Trust is the registered Provider.Normanby HousePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This inspection took place on an unannounced basis on 16th December 2004. Most of the standards had been assessed at the previous inspection in June 2004. Service users and visitors spoken to gave an open and positive account of the home and were complimentary about the quality of care provided in the home. The general standard of documentation within the service user files is in need of improvement. Choice of Home (Standards 1 ­ 6) None of the 2 standards assessed were met. Each service user should be provided with a statement of terms and conditions or a contract at the point of admission that clearly states the responsibilities of the service user and the organisation. However one service user who has been living at the home for over two months has not as yet received any documentation in relation to this. Service users should be admitted into the home only following a pre-admission assessment carried out by a suitable qualified or trained person, however there was no evidence in the file of a newly admitted service user to show that this had happened prior to their admission. Health and Personal Care (Standards 7 ­ 11) 1 of the 2 standards assessed was met. Staff support service users to promote their health. Specialist advice is sought to meet specific identified healthcare needs. Each service user has a GP and access to other NHS healthcare facilities. All staff working at the home are to have medication training via a distance-learning course organised by York College. Daily Life and Social Activities (Standards 12 ­ 15) 3 of the 3 standards assessed were met. Service users spoken to feel they have opportunity to exercise their choice in relation to all aspects of their daily routine. Activities are on offer in the home if service users wish to participate. Staff provide care in a respectful and dignified manner and direct observation confirmed that service users and visitors to the home are treated in a courteous manner. Complaints and Protection (Standards 16 ­ 18) The only standard assessed was met The home has adult protection and procedures in place to safeguard service users from abuse. There was clear written evidence to show that policies and procedures had been followed in response to an incident of abuse that had recently occurred in the home. Environment (Standards 19 ­ 26) 3 of the 3 standards assessed were met. The physical layout of the home is suitable to meet the statement of purpose. There is a sufficient amount of space within personal and communal areas to meet the required standards. The home is clean and well maintained. Normanby House Page 6 Staffing (Standards 27 ­ 30) 2 of the 3 standards assessed were met. The home is carrying out robust recruitment procedures to ensure that service users are protected. Half of the care staff have now attained NVQ level 2 or equivalent and the remaining staff are all undergoing NVQ training. The manager must review the current staffing arrangements to ensure that all aspects of the health and welfare of service users are met. Management and Administration (Standards 31 ­ 38) 3 of the 3 standards assessed were met. The home has quality assurance systems in place to measure the success in meeting the aims and objectives of the service. All records in the home were in good order including systems for the recording of monies and valuables held by the home on behalf of service users. The home is carrying out safe working practices to ensure the health and safety of service users.Normanby HousePage 7 Requirements from last Inspection visit fully actioned?YESNormanby HousePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 5 OP2 Each service user is provided with a statement of terms and conditions at the point of moving into the home. New service users are admitted to the home only if their needs have been fully assessed by a suitably qualified or trained person. The registered person shall review staffing levels to ensure that persons are working at the home in such numbers as are appropriate for meeting all aspects of the health and welfare of service users. As from 16/12/04 As from 16/12/04214OP3318OP27As from 16/12/04RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * 1 OP9 All care staff who administer medication should receive training on all aspects of the homes policy on medicines handling and records.Normanby HousePage 9 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NO YES YES NO NO NO YES NO YES YES YES NO NO NO NO YES YES YES 4 3 8 YES YES YES YES 12 0 16/12/04 9.30 5.5Normanby HousePage 10 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Normanby HousePage 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) X To (£) XAny charges for extras If yes, please state what the extras are: Key findings/Evidence Standard not assessed.YES CHIROPODY, HAIRDRESSERS, TOILETRIES 0 Standard met?Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 1 Key findings/Evidence Standard met? All service users should be issued with contracts either before or on the day of their admission. However one service user who has lived at the home for over two months has not as yet received a statement of terms and conditions. The contracts seen clearly stated what the Anchor Housing Trust is responsible for and what the service users are responsible for. See requirement from this inspection number 1Normanby HousePage 12 Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 1 Key findings/Evidence Standard met? It is normal practice for the home that new service users are only admitted if an appropriately trained person prior to admission has carried out an assessment and the home is able to meet the identified needs of prospective service users. For those service users referred through care management arrangements the Care Management assessment and care plan are obtained prior to admission. However one of the service user files inspected, that of a new service user, did not show any evidence that a pre-admission assessment had been carried out before the service user was admitted into the home. See requirement from this inspection number 2 Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? Standard not assessed. Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? Standard not assessed. Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? Intermediate care not provided.Normanby HousePage 13 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 0 Key findings/Evidence Standard met? Standard not assessed. Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 5 03 Key findings/Evidence Standard met? Staff support service users to maintain their health. Specialist advice is sought for specific healthcare needs and two District Nurses were observed to be attending the home at the time of inspection. The service users have a GP who will visit the home if medical attention is required and this was confirmed at the inspection when a GP was visiting one of the service users who had developed some chest problems. Visits from healthcare specialists are recorded within the individual service user files.Normanby HousePage 14 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 2 Key findings/Evidence Standard Met? The home has policies and procedures for the control, administration, recording and safekeeping of medicines used in the home. The supplying pharmacist has recently carried out an inspection of the homes medication systems and there are no outstanding recommendations. One of the service users is prescribed Controlled Drugs and the Controlled Drugs register was inspected and no discrepancies were found. On the day of inspection some of the care staff were attending induction for a Managing medicine distance-learning course that is to be provided by York College. All the staff in the home are to be enrolled on the course. See recommendation from this inspection number 1 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 0 Key findings/Evidence Standard met? Standard not assessed. Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 0 Key findings/Evidence Standard met? Standard not assessed.Normanby HousePage 15 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 3 Key findings/Evidence Standard met? Day-to-day routines within the home are sufficiently flexible to allow service users opportunity to exercise choice. There is a notice board that provides information about a number of activities in the home. Residents participate as and when they wish. Service users spoken to feel that all staff respect their privacy and that they are able to live their life as they choose. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 3 Key findings/Evidence Standard met? Service users are encouraged to maintain links with their family and friends. Visitors spoken to at the inspection were complimentary about the care that was provided to their relative and the attitudes of staff towards them during their visits. Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? Staff encourage service users to maintain their independence. Direct observation showed that service users are able to bring personal possessions into the home with them. All the service users manage their own financial affairs in some cases with the assistance of family members or solicitors. It was noted through direct observation that service users mail was not opened at the point of them receiving it. Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? Standard not assessed.Normanby HousePage 16 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence Standard not assessed. X X X X X X X 0Standard met?Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? Standard not assessed.Normanby HousePage 17 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES 13 Key findings/Evidence Standard met? There has been an incident of abuse in the home since the previous inspection. Documentary evidence provided by the manager of the home to the Commission showed that all appropriate adult protection procedures had been followed to safeguard service users.Normanby HousePage 18 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? As the home is largely purpose built it is suitable for its stated purpose. All parts of the home are accessible. A full tour of the premises was not made on this occasion but those parts of the home that were seen were in good order. The grounds are small but are safe, attractive and accessible. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? Standard not assessed. Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 0 Key findings/Evidence Standard met? Standard not assessed.Normanby HousePage 19 Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met? Standard not assessed. Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite Key findings/Evidence All the bedrooms meet the required standards. YES NO NO X X X X Standard met? 3 X XX X X XNormanby HousePage 20 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 0 Key findings/Evidence Standard met? Standard not assessed. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 0 Key findings/Evidence Standard met? Standard not assessed. Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? The home is kept clean and odour free throughout. The laundry facilities are suitable for the home and there are three areas for sluicing. Service users are encouraged to do their own laundry if they are able and they wish to. The home has policies and procedures for the control of infection.Normanby HousePage 21 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X XX X X Standard met? 1Normanby HousePage 22 The home is meeting the requirements in relation to the number of staffing hours provided by care and ancillary staff. However inspection of the duty rotas showed that whilst there are sufficient numbers of care staff on duty for the morning shifts and the night shifts, there are generally only two members of care staff on duty for each afternoon shift. There was no evidence to suggest that this was having a detrimental effect on the care provided to service users. However it was felt that the general quality of documentation within the care plans was not of the required standard and that this was partly due to the staffing shortfall in terms of staffing numbers. Some of the service users also commented that they were aware of pressures on staffing time although they did not feel that their care had suffered because of this. All the staff work in a flexible manner to ensure that the needs of the service users are met and there are low levels of sickness in the home. The manager has attempted to use agency workers to cover vacant shifts but this has proved difficult due to the demand for agency workers from other care providers. The manager is aware of the need to recruit more care staff in order to increase the staffing numbers and has put out advertisements for the vacant posts. Ancillary staff are employed in sufficient numbers to ensure that standards relating to food and hygiene are met. See requirement from this inspection number 3 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 6 50 3 Key findings/Evidence Standard met? The registered manager has worked hard to ensure that this standard is met. Half of the staff have attained NVQ level 2 or equivalent and all of the other staff are undergoing either the NVQ level 2 or NVQ level 3. Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? Four staff files were inspected including those of the most recently recruited members of staff. All the files contained written evidence that robust pre-employment checks including POVA checks have been carried out to ensure the protection of service users. Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? Standard not assessed.Normanby HousePage 23 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 0 Key findings/Evidence Standard met? Standard not assessed. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? Standard not assessed. Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 3 Key findings/Evidence Standard met? The home is externally assessed through the Hospitality Assured scheme. Monthly visits are carried out as required. Service user surveys are carried out to seek the views of the service users. Policies and procedures are regularly reviewed and updated by the organisation to reflect good practice and legislative changes. Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? Standard not assessed.Normanby HousePage 24 Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence Standard not assessed. Standard met? 0 X X XStandard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? Standard not assessed. Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? All individual service user records and the homes records were in good order. All valuables and money held for safekeeping are secured in the homes safe and appropriate records are maintained. A check was made of 4 service users money held by the home against the records and they were found to tally. Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? The home has made proper provision to ensure that there are safe working practices in respect of fire safety, first aid and food hygiene. Individual and general risk assessments have been carried out to ensure safe working practices. Any recommendations from fire and environmental health inspections have been acted upon. An inspection of the kitchen was carried out and all matters relating to food hygiene were in good order. Hazardous products are stored appropriately and records and data sheets maintained as required. New staff receive health and safety training at the point of induction and refresher courses are provided to all staff.Normanby HousePage 25 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateDavid White Stephen SharpSignature Signature SignaturePublic reports It should be noted that all CSCI inspection reports are public documents.Normanby HousePage 26 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 16th December, 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleNormanby HousePage 27 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNOYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NONormanby HousePage 28 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Normanby HousePage 29 Normanby House / 16th December 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000007961.V195037.R01© This report may only be used in its entirety. 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