Inspection on 25/04/08 for Norton House

This inspection was carried out on 25th April 2008.

CSCI found this care home to be providing an Adequate service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Norton House 15/01/08

Norton House 26/04/07

Norton House 26/04/05

Norton House 30/09/04

Norton House 07/06/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Norton House 10 Arneway Street London SW1P 2BG Lead Inspector Wynne Price-Rees Key Unannounced Inspection 25th April 2008 10:30 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 Norton House DS0000010862.V362122.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. Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norton House Address 10 Arneway Street London SW1P 2BG 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) 020 7976 7681 Anchor.org.uk Anchor Trust Manager post vacant Care Home 39 Category(ies) of Old age, not falling within any other category registration, with number (39) of places Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Old age, not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 39 15th January 2008 Date of last inspection Brief Description of the Service: Norton House is registered to provide care and accommodation for 39 older people. Currently there are 34 people using the service. The home is situated in a quiet cul de sac, off Horseferry Road, in Victoria and is close to local shops. The Anchor Trust operates the service, with all placements being made by Westminster Council. The current fees are £510 per week. Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. The inspection was unannounced and took ten and a half hours to complete over two days, starting on 25/04/08 and ending on 28/04/08. During the course of the inspection ten people who use the service were spoken with to get their views of the service they receive. The Care Manager and staff were also spoken with, care practices observed, records and procedures checked and a premises tour undertaken. All key standards were inspected and this information was triangulated with that gathered since the previous key inspection to give the new quality rating. The home was in the process of completing a self-assessment AQAA and the available information was compared to the inspection findings. Three residents’ files were case tracked, one from each floor. What the service does well: The people who use the service said they found the staff generally helpful, supportive and friendly in their approach to them, their needs and wishes. They felt the meals were of a high standard with plenty of choice and in portions that suited them. Diets and meals were provided that met the cultural and religious need of the people who use the service. The records kept were generally up to date, particularly those referring to health and safety although there were three specific exceptions. The required policies and procedures were in place and regularly reviewed. People who use the service said the liked their accommodation and were able to personalise it by bringing their possessions with them. The premises tour showed the home to be very clean, tidy and odour free. The care practices observed recognised the people who use the service’s rights to privacy, dignity and respect. They were also carried out in a caring, patient and supportive way. Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 6 The care plans case tracked showed people who use the service participate in them and those spoken with confirmed this. What has improved since the last inspection? What they could do better: During the early shift on the first inspection day floors one and two only had one care assistant on duty whilst the agreed rota level is two care assistants for each floor. The Team leader acted as the second care assistant, on one floor that meant they could not fulfil their floating role for the whole home. Agency or bank staff had not been contacted to meet the shortfall during this shift meaning that those on duty struggled to meet the needs of the residents’ on those floors. The rota also did not meet the staffing levels for other days during that week. An immediate requirement was made to meet the staffing levels and it was met during the second inspection day with a new rota drawn up. Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 7 The medication administration charts on one floor had gaps in them with no explanation recorded that meant staff coming on duty would not know if medication had been taken or not. The monthly care plan review records could not be located for two of the three people who use the service’s care plans. Although communal activities are provided and people who use the service said they enjoyed them it was felt more activities that stimulate the brain, exercise the body and take place on a one to one basis with staff could be introduced. Regulation 37 notifications have been forwarded to us as appropriate, and Regulation 26 provider visits taken place. A requirement made at the previous key inspection about confirmation that original recruitment documentation has been seen and by who is repeated at this inspection. 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. Norton House DS0000010862.V362122.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 Norton House DS0000010862.V362122.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): 3 and 6. People who use this service experience good quality outcomes in this area. They are fully assessed to establish that their needs and wishes can be met before being given the opportunity to visit so that they can decide if they want to move in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Whilst meeting with people who use the service during the inspection, the following comments were made about the assessment procedure and opportunity to visit the service before deciding if they wished to move in. “I visited before I moved in to see if I would like it”. “My relatives visited for me to see what it was like”. Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 10 “I stayed here a few times before I decided to move in permanently as I could not cope at home any longer”. “Someone came to see me to see if they could look after me”. Westminster City Council has a block contract with the home, all referrals come through them and they provide assessment information. The care plans for the last three people who use the service that have moved in were inspected and they contained assessment information from the placing authority and the assessment carried out by the home. Both types of assessments were comprehensive, met the criteria of the standards, were carried out prior to the resident moving in and enabled the home to identify if needs and wishes could be met. A Team leader who has been trained to do so carries out the home’s assessments. People who use the service receiving respite care were assessed using the same procedure as those who were staying permanently. The people who use the service confirmed that they had been given the opportunity to visit the home so that they could decide if they liked it, it met their needs and wishes and they wanted to move in. Needs identified in the assessments were included in the care plans. The assessments were signed off by the proposed person who would use the service. Norton House DS0000010862.V362122.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 and 10. People who use this service experience adequate quality outcomes in this area. The care plans are comprehensive with information in place that show how staff are supporting the people who use the service with their social, health, cultural, emotional, communication and independent living needs. Generally health care needs are met apart from some aspects of recording medication administered. People using the service are treated with respect and their dignity observed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Whilst meeting with people who use the service during the inspection, the following comments were made about their involvement in the planning of the care and support they receive. Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 12 “I have a care plan but don’t get too involved in it as I’m not that interested and do what I enjoy”. “ I have signed off parts of my care plan and sit down with the staff to discuss it”. “The staff are very nice and treat me the way I like”. The care plans for the last three people who use the service to move in were checked. These were situated on each floor. The care plans were initially based on information from the assessments carried out and information provided by the person using the service to identify needs, wishes, likes, dislikes and life history. The established goals were agreed with the person using the service and they signed them in some areas. Expected outcomes were also identified. On one file, three of five goals were signed off by staff; with two left blank. The care plan goals included health and personal care, social, cultural and religious needs that were underpinned by enabling risk assessments. The goals and risk assessments were regularly reviewed. Each file was case tracked by picking a particular goal and referencing with daily entries made over a period of time. One social activity was to visit the pub and this was evidenced by the record of visits made, confirmation by the person using the service and seeing the person sitting outside the local pub having a pint. Another person had a goal set of regularly visiting the shops. Regular trips were recorded, she confirmed she went out regularly and this included a trip during the inspection. Whilst the daily entries were in place the monthly reviews were missing on two of the three files tracked. The annual local authority placement reviews were available on a separate file. The health care needs of people who use the service are incorporated within the care plans with goals set and expected outcomes established to promote the health of the individual and contribute to best quality of life possible. People who use the service confirmed they have the option of being registered with the home’s GP or keeping their own and have full access to community based health care services. The GP visits weekly and people using the service can either visit the services within the community or the services will visit them depending on what they prefer. District nurses visited people who use the service during the inspection. The medication administration records were checked for all people who use the service and two floors recorded administration correctly whilst one floor had gaps in the recording with no explanation in most instances. There were a total of five gaps in the medication recording for four different people who use the service. The outcome for people using the service was that staff coming on shift were uncertain if medication has been given. Medication was appropriately stored securely in a locked room on each floor. People using the service spoken with confirmed their privacy and dignity were respected and this was confirmed by the care practices observed. Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 13 Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 14 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. People who use this service experience adequate quality outcomes in this area. A wider range of activities should be provided, throughout the waking day, that are more person centred and meet identified interests of residents individually as well as a group. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Whilst meeting with people who use the service during the inspection, the following comments were made about their daily lives and activities available to them. “I enjoy the activities provided”. “I feel more mental stimulation and physical activity is required”. “It’s a long time between the afternoon and bedtime”. Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 15 “More one to one activities with staff would be good”. “Activities are provided but I don’t join in”. “We have our meals together”. “I have my newspaper delivered every morning and am a crossword fiend”. The home has a designated Activities Co-ordinator who provides a range of inhouse group activities that mainly take place in the mornings and are posted in communal areas so that people who use the service know what is available. These include dominoes, bingo, quizzes, newspaper sessions, cards and drafts. Snooker, cake-making and painting are also available. The Co-ordinator finishes at 3pm and there did not seem a lot of activity taking place in the afternoon although this maybe because people were having an afternoon nap. One person using the service said that group activities were fine but did little to stimulate the brain, particularly in the afternoon. Outings have also taken place to museums and local parks with an Easter trip to the seaside available for those who wish to go. The home has been encouraging people who use the service to have breakfast and lunch together in the downstairs dining area to promote interaction and participation in what is going on. People who use the service felt this has been a success, but it has been recognised that having two large meals for lunch and breakfast has meant people tend to be a bit tired in the afternoon and activities are focused between these meals. To give a wider spread of activities it is proposed to try having a lighter lunch and encourage people who use the service to eat the evening meal together as well encouraging activities throughout the day and into the evening. There was not much one to one interaction regarding activities between staff and people using the service past caring for people’s immediate needs and providing tea when required, although some people who use the service said they preferred it that way. People who use the service participating in person centred activities were generally those that were capable of carrying them out themselves or with minimal support. One person who uses the service went to the pub by themselves, another went shopping and someone else was doing the crossword. One person using the service sat quietly until we sat down and had a chat, when they became animated particularly whilst discussing travel as they have previously travelled a lot. This information was contained in their life history and is an example of how to provide more person centred care using information available providing staff have the time to implement it. The Care manager said that the home is looking to recruit volunteers to boost the person centred activities available. More person centred care would also promote the diversity of people who use the service. Arrangements are in place for people who use the service to visit appropriate places’ of worship if they wish. Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 16 Everyone spoken with who uses the service said the meals provided and choice were very good and if they wanted something different it was provided. The home provides meals that meet the cultural and religious needs and preferences of people who use the service. Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 17 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 and 18. People who use this service experience good quality outcomes in this area. People who use the service are listened to, complaints investigated with outcomes and they are protected from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Whilst meeting with people who use the service during the inspection, the following comments were made about if they had any complaints, who they would complain to, how these were dealt with and if they felt safe and protected. “No complaints about the home”. “I feel safe here”. “Staff looks after me”. “I don’t have any complaints”. “If I had a complaint I would tell the staff on my floor or the Manager”. Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 18 “I don’t have a problem with complaining”. “Any complaints I have made have been listened to and acted on”. “An advocate comes from Westminster if I have any complaints”. “Lucky to get in here”. There have been two complaints recorded since the last key inspection both of which were logged and fully investigated with outcomes recorded. People who use the service said they were aware of how to complain, who to and were comfortable making complaints. There are complaints forms located on each floor. The people who use the service have access to the Westminster City Council complaints procedure, as the placing authority as well as the home’s complaint procedure. People who use the service said they felt safe living at the home. There is an adult protection procedure in place and training records showed that staff have received adult protection training as part of their induction. There are no current adult protection issues. Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 19 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 and 26. People who use this service experience good quality outcomes in this area. A homely, clean and safe environment is provided for people who use the service to live in. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Whilst meeting with people who use the service during the inspection, the following comments were made about where they live and if they felt safe, comfortable and happy there. “I like my room”. “I was able to bring things in with me to make it feel more like home”. Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 20 “I like it here”. “I didn’t know there were places like this”. “It’s not the same as my home that I lived in for 40 years but it is nice”. “I like having my own en-suite”. “The home is very clean”. “There is a nice relaxed atmosphere”. The accommodation provided matched the home’s statement of purpose. A tour of the premises showed the home to be clean, tidy and odour free. It was also well lit. We were invited into a number people who use the service’s rooms that had been personalised by them to make them more homely. Everyone spoken with said they were very happy with their rooms. All required control of infection documentation was in place and regular checks carried out by the home’s health and safety representative or outside contractors. There was ample communal space for people who use the service and an outside sitting area. Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 21 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. People who use this service experience adequate quality outcomes in this area. There are suitably trained, competent and diverse staff employed to meet the needs and wishes of people who use the service that have been properly vetted. There were not adequate numbers of staff on duty to meet the needs of people who use the service, during the first inspection day and steps were not taken to address this until we pointed it out. The rota was unclear regarding who was on duty. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Whilst meeting with people who use the service and staff during the inspection, the following comments were made about the staff and staffing at the home. “Generally staff are good”. “Staff always help and look after me”. “They always let me know what is going on”. “Sometimes it doesn’t feel as if there are enough staff around”. Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 22 “They are very good but always in a rush”. “Night staff are very good”. “I don’t like staff changing from floor to floor”. “I prefer to have someone I know and who knows me”. “In the main the staff were very good but as with everything in life you don’t get on with everyone all the time and have personality clashes”. “We could do with more training”. “Sometimes we feel stretched and we don’t have time to talk with the people”. The people who use the service were generally very complementary about the staff team and way they carry out their duties and responsibilities. The care practices observed indicated that the home has a professional and skilled staff team who genuinely care for the people who use the service and put their interests first. Having said this staff did seem to be stretched and had little opportunity to sit down and spend quality one to one time with individual residents’. On the early shift there was only one care assistant on duty on floors one and four when the rota showed there should be two on each floor. A team leader helped out on one of the floors as a second care assistant but this still left one floor short and meant they could not perform their duties of going between each floor. The rota itself was not clearly written and it was difficult to work out who should and should not be on duty. No effort was made to cover the staff shortage, during this shift until we pointed it out. An immediate requirement was made that the agreed number of staff must be on duty and this was met on the second inspection day by using bank and agency staff. A new clearer rota had also been put in place. The home has a robust recruitment policy and procedure that makes sure staff are appropriately qualified and vetted including CRB clearance prior to starting work. There was evidence that recruitment references had been checked for validity although the staff front sheet had not been completed in some instances to confirm that all original documentation had been seen. Staff confirmed that they had received six days of induction including food hygiene, health and safety, manual handling, basic first aid and adult protection. There were three days of theory and three shadowing. This was verified by a sample of staff records inspected. Of thirty-six staff employed, thirty had achieved NVQ level 2 or above and the other six were newly recruited and had been enrolled on NVQ courses. In addition staff have access to a rolling training programme and refresher courses. Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 23 Staff did mention that some record keeping was easier to understand than others due to the level of writing skills of some staff who do not have English as their first language. This was born out in some of the entries inspected. The home is attempting to promote equality and diversity by recruiting staff with similar backgrounds to people who use the service. There are two Polish people who use the service and the home has identified a number of Polish candidates as part of the recruitment drive who also have the required skill levels, experience and qualifications to fill vacant posts. Staff confirmed that regular supervision is taking place. Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 24 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, 33, 35 and 38. People who use this service experience adequate quality outcomes in this area. The home is generally well managed in the interests of those who use the service. Regulation 26 visits need review to capture any shortfalls in meeting standards. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 25 Whilst meeting with people who use the service and staff during the inspection, the following comments were made about the home’s management. “I have no problem with the management”. “Sometimes we do not have enough time to complete all our tasks”. “I feel supported by the management”. The Care Manager has been in post for six months, has seventeen years experience as a Day Centre Manager and Deputy Care Manager of a care home and is currently doing the NVQ level 4 managerial qualification. They are also undertaking the CSCI registration process. The home and organisation have quality assurance monitoring systems in place that incorporate a self-assessment AQAA, questionnaires sent to people who use the service and their relatives, people who use the service resident meetings and annual reviews of policies and procedures. Six monthly reviews with Care Package Managers from Westminster City Council also take place and the home’s GP feeds back weekly. Regulation 26 provider visits are also regularly carried out. However the Regulation 26 visits focus may need review to make sure that areas such as unclear rotas, medication administration recording omissions, care plan goals not being signed off and incomplete recruitment front sheets are picked up. The home has a designated health and safety representative who has responsibility for carrying out various checks. Records demonstrated that these had been efficiently carried out. Infection control checks are carried out weekly, COSHH assessments with new products and staff training three monthly, fire drills quarterly, alarms weekly, call alarms quarterly, asbestos checks bi-annually and the lift annually. The risk assessments were updated on 01/01/08, VDU tested 23/02/08,water system and plant checked 22/02/08, pest control on 27/03/08, fire extinguishers serviced in September 07 and fridge and freezer temperatures twice daily. The accident and incident books are checked monthly during the regulation 26 visits. Cleaning materials were also suitably stored. There is a central bank account that is used for all residents’ savings and all residents have their own account number linked to the account. At the last inspection we were not able to ascertain why none of the resident’s accounts had any interest payments. Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 26 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 X X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X X 3 Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES 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 15 (2) (b) Requirement Staff must sign off all agreed care plan goals and monthly reviews kept on file. The medication administration records must be correctly filled in and if there are any gaps there must be a written explanation. The home must develop more person centred activities. Timescale for action 28/04/08 2. OP9 13 (2) 28/04/08 3. OP12 12 (1) (a) 01/08/08 4. OP27 18 (1) (a) The agreed staffing levels must 28/04/08 be maintained at all times to make sure the needs and wishes of people who use the service are met and a clear rota in place. The Manager must make sure that all original documentation copied as part of the recruitment procedure has confirmation that the originals were seen when and by whom. This is a repeat requirement DS0000010862.V362122.R01.S.doc 5. OP29 19 15/06/08 Norton House Version 5.2 Page 28 from the last key inspection. 6. OP33 24 (1) (a) & (b) The organisation must review the areas that the regulation 26 visits check to make sure that areas not meeting the standards are picked up and the quality assurance system works affectively. Regulation 26 visit reports must be sent to the CSCI for 6 months for monitoring. 01/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP30 OP35 Good Practice Recommendations The organisation should consider introducing English language and literacy training to support staff whose first language is not English. The organisational procedures for saving residents finances should be changed so that all residents having their own separate bank accounts and also receive the relevant amount of interest. Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Norton House DS0000010862.V362122.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!