Inspection on 24/01/08 for Norton Place

This inspection was carried out on 24th January 2008.

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

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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Norton Place 13/02/07

Norton Place 11/01/06

Norton Place 03/09/05

Norton Place 08/02/05

Norton Place 21/09/04

Norton Place 09/03/04

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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 Norton Place 162 Ness Road Shoeburyness Essex SS3 9DL Lead Inspector Sarah Hannington Unannounced Inspection 24th January 2008 10:00 Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norton Place Address 162 Ness Road Shoeburyness Essex SS3 9DL 01702 291221 01702 291221 judith.hounsell@estuary.co.uk 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) Estuary Housing Association Limited Ms Judith Anne Hounsell Care Home 11 Category(ies) of Dementia (2), Learning disability (11) registration, with number of places Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. To provide care to two named residents with learning disabilities and who have dementia, aged under 65 years, and whose names are known to the Commission. No more than eleven Younger Adults with a learning disability to be accommodated and provided with care with nursing. Excluding any person who is liable to be detained under the provision of the Mental Health Act 1983. 13th February 2007 Date of last inspection Brief Description of the Service: Norton Place is a care home with nursing for 11 residents with learning disabilities. It is situated in the grounds of the NHS Health Care Services in Shoeburyness. It is close to local shops, facilities and the seafront. The home has in 11 single bedrooms, a lounge/dining room, sensory room and a conservatory at the entrance to the premises. All the rooms are situated on the ground floor. There is a very large garden at the rear of the home. There is parking at the front of the premises and the home has a minibus with access for wheelchair users. The pre-inspection questionnaire identifies the weekly fees as being £1,548.78. Additional charges/costs identified as incurred by residents relate to chiropody (£10), hairdressing, personal toiletries, magazines, activities, massage/reflexology or sensory therapy. Norton Place DS0000015552.V357687.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 2 Star. This means the people who use this service experience good quality outcomes. The site visit inspection focused on all of the key standards and any requirements and recommendations from the last key inspection. The inspection took 8 hours to complete. The manager was present throughout the inspection. Due to the communication needs of the residents living at the home the CSCI (Commission for Social Care Inspection) felt that it was not possible to use surveys for feedback. However it was possible during the site visit to speak to many of the staff and some of the people living at the home. Additionally the manager was sent a Annual Quality Assurance Assessment (AQAA) form by CSCI, prior to the inspection that asked how well the home is meeting the needs of the people who live at Pinetree Place. We also looked at what else we already know about the home and compared it with what the manager had said in the information provided on the AQAA. Information collated from the AQAA and discussions during the site inspection are reflected within this report. What the service does well: What has improved since the last inspection? Many of the requirements and recommendations from the last inspection have been achieved. The recruitment records now show that proper checks have been done for all staff, including agency. Training for staff in the safeguarding and protecting of vulnerable adults has now been completed. Medication records are up to date and accurate. The manager has updated the Statement of Purpose and Service Users Guide. Activities for individuals are better Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 Page 6 recorded. Healthy fresh nutritious food is now in place and pictorial menus are provided. A new experienced chef has been recruited and is in post. Selfclosing fire doors are now fitted and working. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A robust assessment process reassures residents that their needs will be met before they move to the home. EVIDENCE: Documentation around the areas of pre-assessments, risk assessments, care plans and consultation with individuals were inspected. Documentation evidenced that it gave sufficient detail to the person and about their individual needs. The manager states on the AQAA that, ‘If the service is confident that Norton Place is able to meet the needs of a prospective resident, the person is invited by the Manager to visit the home on an introductory basis. These visits offer the chance to meet with other Service Users, staff, view the room in which they may live in and the common areas of the home, have a meal, discuss how the home can meet their needs and see the kind of records held in the home about Service Users During each visit a designated member of staff would be allocated to have time to attend 1:1 with the prospective resident. Records will be made of the outcome of each visit. The manager or deputy of the home will be available for at least one of the visits’ Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 Page 9 The majority of relatives expressed an opinion that they had a number of visits to the home prior to any placement being offered. They also confirmed that consultation regarding pre-admission assessments and the care plan went ahead, as well as receiving a letter confirming that the home could meet the resident individual needs. Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents assessed needs are followed through in care plans that give staff the necessary information to provide good care outcomes. EVIDENCE: Case tracking took place in respect of four residents, other personal care records were also looked at as a part of this process to assess how involved and how well the services offered match the needs of the individual. Evidence from documentation showed that, good clear instructions were available for staff to follow when working with individuals and that daily log sheets are completed well and showed good interaction between staff and resident. Within the assessments all areas of health care for individuals had been identified, such as weight monitoring, nutrition, medication. Care plans evidenced that pre-assessments, initial assessment and Com 5(information from the referring social worker), were reflective of each other. The manager states on the AQAA that, ‘All care plans aim to provide as much information about the individual as possible. This information enables the Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 Page 11 service user to be heard in the way that they are able to communicate. All the care plans are based on the specific needs, likes and dislikes of the service users. Service user consultation involving different people within the circle of support for them underpins all aspects of care.’ Care Plans evidenced that the staff ensure that residents are consulted with, as much as possible and includes their views. Advocates, families and other professionals are used within this process usually at the six monthly review meeting. The manager states on the AQAA that, ‘The home believes that service users should always be aware of any information held and written about them and have the right to read any documents. A key working system is active in the home to encourage and support the service users with communicating, achieving their needs and aspirations. Bi-Monthly staff supervisions and house meetings and daily hand-over reports record discussions on service user need.’ Risk assessments are to a good standard and reviewed regularly in most care plans, however in some care files risk assessments need to be updated to ensure that the individual’s safety is still maintained to a good standard. The risk assessments looked at, do lower the risk to an acceptable level, but also allow residents to take reasonable risks to support them in living a full and purposeful life. Additionally Including infringements of rights documentation to evidence why it is necessary to restrict individual’s rights could be implemented and evidence that risks have been discussed with individuals. The manager states on the AQAA that, ‘Risk assessments are in place to evidence where we provide support and supervision, issue and review dates for all risk assessments are written clearly on the plans’ The majority of residents expressed an opinion that they are happy with the care they received and felt that the staff had respect for them and that their privacy was protected. Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Opportunities for residents to receive activities, which are suited to their needs and wishes, are available. EVIDENCE: The manager states on the AQAA that, ‘The service users who presently live at Norton Place are mostly of retirement age. However some people are still able to access day centre activities and are supported 1:1 to do this when required. Service users who spend much of the day at home are supported to occupy there day as they are able. One of the service users attends a community Jewish day centre.’ Observation on the day of inspection and talking to staff and residents, it is clear that staff on duty are making the use of the time they have to engage residents in activities within the home Residents spoken with felt that they had plenty of activities if they chose to do so, some residents said that they had 1-1 sessions of their choice. A sensory Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 Page 13 room is available and a person comes in once a week to provide massages to individuals. Some residents still attend a day centre from Monday until Friday. Plenty of contact with relatives and friends was recorded within personal notes, care plans and generally within documentation. All residents’ preferences are recorded within the care plans. The manager states on the AQAA that, ‘The home has an appointed chaplain who visits the home. Although he is C/E minister, he visits all the people who live here and wish to speak with him and often spends a long time with a person of the Jewish faith. He is the minister for a local church, which backs on to the homes garden’ The majority of relatives expressed that they felt the staff welcomed them into the home when ever they visited and that they were kept well infromed about any issues. The manager states on the AQAA that, ‘Visitors to the home are welcome at any time, and for those who are unable to visit regularly, contact is maintained by letters and the telephone. Each service user has their own room and there are other areas in the home that could provide privacy.’ Looking through documenation nutrition and food planning had been taken into account when planning menus. For one indivdual who had lost their appetite, additional records were set up to track this and could see that staff had been vigilant in recording this information and demonstrated good outcomes for the individual. Pictorial aids are used to enable indivduals to have a choice of meals, snacks and drinks. There were plenty of provision of foods within the stock cupboard to ensure indivduals had access to food and drinks other than at meal times. Fresh foods are used and liquidised meals are prepared with care, such as , keeping the different vegetables and meat separate so it keeps the taste of the meal as much as possible. The majority of residents expressed an opinion that they are happy with the food provided and that it reflects their tastes. The manager states on the AQAA that, ‘Food and mealtimes are treated as an occasion and something to look forward to. Residents enjoy the flexibility of meal arrangements: This is evidenced by the attitude of the new chef, who is able to provide a varied diet, using fresh ingredients and also offer alternatives at all times. This is evidenced by the current records, but will be enhanced with the introduction of formal menu plans.’ Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents generally received the support necessary to ensure their physical and emotional health needs were met. EVIDENCE: The manager states on the AQAA that, ‘The personal and health care support, which a resident receives, is based on their individual needs. The principles of respect, dignity and privacy are put into practice.’ Four Care plans were inspected and overall documentation looked at gave some good examples of how staff were addressing specific areas of need, such as, epilepsy, diet, mobility and behavioural. Documentation evidenced a good picture of how staff interacted with individuals and supported them. Good recording and monitoring consisted of how staff recorded the practical support they gave to individuals and how they were following protocols set by management. The manager states on the AQAA that, ‘Each resident has a plan that has been agreed with them. This is written in plain language, is easy to understand and considers all areas of the individual’s life including health, personal and social care needs. When health needs change the relevant training is booked so that Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 Page 15 staff can meet the changing needs of the service user. Training is regularly discussed in house meetings and staff supervisions.’ There is a monitored dosage system in place and lockable storage for medication. Medication profiles are present with photographs of individuals attached. No omissions were present on MAR sheets and medication in general was kept in accordance with required legislation. Staff who administer medication have received training. Staff discussion around medication and individual need showed that they knew individual needs well, were competent around the medication policy and procedures. The manager states on the AQAA that, ‘Audit stock checks are done on a monthly basis either by the home manager or a designated member of staff, and there is a system in place to carry out and record random audits.’ The majority of residents expressed an opinion that they are happy with the health care support that they receive from staff. Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents benefit from a pictorial complaints procedure. Residents are protected by staff knowledge and training. EVIDENCE: There have been no complaints made to the home or reported to the CSCI office since the last inspection. The manager has a good complaints procedure in place. All complaints are recorded, maintained and outcomes recorded. A service user complaints procedure is available in a format of their communication choice. The manager states on the AQAA that, ‘Any complaint is treated seriously and response is prompt with an accepted outcome.’ A Resident spoken with was aware of their rights and had some idea of what may constitute abuse. They did have a clear idea of what they would do if they wanted to make a complaint. All staff have attended safe guarding (protection of vulnerable adults) training. Speaking with staff they showed that awareness around these issues was to a good standard of both understanding and knowledge. The manager states on the AQAA that, ‘All staff at Norton Place receive annual POVA from abuse training.’ Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,28,29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident at Norton Place live in a homely and comfortable environment. Attention is needed to communal areas to provide residents with a wellmaintained environment that reflect there assessed needs and choices. EVIDENCE: The home is clean, tidy and all areas are odour free. Overall the home environment presents no health and safety issues. However in some of the bedrooms, flooring and general redecoration of walls and furnishings is much needed. The manager states on the AQAA that, ‘Projected budget planning for 2008 to address choice of flooring in bedrooms. When the service user is able to choose, this will be honoured, but if this is not possible flooring considered to be the best possible kind for each circumstance and within the constraints of budget will be used.’ Overall communal areas, such as, walls, flooring, either needed renewing, Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 Page 18 (where it is worn) deep cleaning and woodwork and walls where they are scuffed need repainting. Specifically in one corridor where a rail had been removed needed completion by being re-painted. The conservatory needed to have high cleaning carried out and of the structure overall, some blinds need replacement and the structure risk assessed in terms of wear, tear and safety in respect of some parts of the joints looking worn and eroded. A sluice for soiled clothing needs to be provided and put into place as soon as possible to maintain safety of infection control for individuals’. The manager states on the AQAA that, ‘Externally there is a large garden for the private use of residents. The garden is very tranquil and attracts birds and squirrels which provide pleasure for the service users living at Norton Place. 8 of the bedrooms have a window that opens up and affords an opportunity to look into the garden even when someone is confined to bed.’ On the back of the property is a large garden. Presently none of the residents can access this due to their assessed mobility needs. Speaking with staff, they voiced on the residents behalf, that if they could they would use this area frequently, particularly in the summer months. Therefore it is in the best interests of the group and of indivduals that this area is made accesseble. Particularly as so many of the indivduals who live at Norton place, consider themselves to be either retired or choose to spend large parts of the day at home. Access issues are largly to do with an unlevel lawn and no paths available to use wheelchairs on. Additionally stimulation for residents who have demnetia maybe greatly benefited from this additional space to use as a different sort of stimulation and awareness of surroundings. Therefore the organisation needs to think about residents being able to access this by providing suitable paving and to redesign the layout of the lawn, so that it can be used and would evidence that equality and diversity is implemented. This would not only be beneficial to individuals, but would reflect the managers statement of purpose, where it states, ‘externally there is a large garden for the private use of residents.’ And later states in the aims and objectives within the service user guide, ‘ we aim to promote residents’ choice and independence in all repects of their daily living and providing specialist equipment if required.’ Equipment provided for individuals and the overall group is well maintained and is reviewed on a regular basis. The manager states on the AQAA that, ‘Personal and home aids are serviced 6 monthly, yearly or as required when there is an obvious problem in between routine service visits. Record is kept of these visits with the work undertaken and any action required. The bathrooms have special equipment to meet the needs of individual service users. These needs are assessed by Occupational Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 Page 19 Therapists. The equipment available includes, Parker Bath with reclining action and overhead tracking in one bathroom. Shower unit with overhead tracking in the second bathroom with specialist shower chairs. Grab rails. Beds are provided with the facility of height adjustment and tilt. There are handrails along the corridor and an alarm call system in each bedroom, bathroom, toilet and communal areas. A leased vehicle is available for the use of Norton Place service users only and this is wheelchair accessible. Other specialist equipment currently in use at Norton Place meets the assessed needs of the current service users includes, Two mobile hoists and overhead tracking in one bedroom, a range specialist lifting equipment and matresses’. Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered positive relationships by well-supported and caring staff. Residents are protected by staff recruitment, induction and training. EVIDENCE: The manager states on the AQAA that, ‘Norton Place is a nursing home and service users have access to a qualified nurse at all times.’ There is a good experienced staff team in place, however a number of agency staff are used to cover frequents sickness levels and two posts which have recently become vacant. The organisiation manage this by using regular agency staff who are well qualified, experienced and know the residents well. These staff are treated the same as the permennant staff by having support and supervision from the manager. The manager is in the process of addressing these vacancies and regular levels of sickness that occur, with senior management. Staff files were reviewed and recruitment records evidenced that application forms were completed, interviews were held, two references obtained, criminal records bureau checks undertaken and proof of ID and photograph kept. Contracts of conditions of service and job descriptions were issued to new Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 Page 21 staff. All agency staff used had all the required documentation in place needed to maintain the safety of the residents at Norton Place. Training opportunities for all staff are good and include manual handling, health and safety, first aid, dementia awareness, fire awareness, safeguarding and infection control. Staff spoken with reflected that courses undertaken had developed a better understanding of the residents that they worked with. The Manager is being proactive in booking numerous courses and then identifying who is to attend through the supervision process. Six out of fourteen staff have completed NVQ training. A further three staff are put forward for NVQ training and additionally 6 staff also hold a RGN or Learning Disability Nurse qualification. Staff receive good support through induction, handover’s, staff meetings, supervision and training. Induction for new staff is also is to a good standard which protects the residents’ health, welfare and safety. The manager states on the AQAA that, ‘The team is made up of people with wide skill mix and together with support staff are additionally trained to the specific health needs of the service users at Norton Place, i.e. training in diabetes, epilepsy, dementia etc. Staff undertaking NVQ awards have heightened awareness of DOH publications ‘Our health. Staff have had training on the Mental Capacity Act this year and are adapting to the thinking around this, which is beginning to be reflected in the plans. All staff are trained in the mandatory areas.’ The majority of residents expressed an opinion that they are well looked after by staff and feel that staff knew their needs well. This was also evidenced through observation of staff interaction with individuals. Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager protects and promotes the health, safety and welfare of the residents at Norton Place. EVIDENCE: The manager states on the AQAA that, ‘The management of the home is based on openness and respect and has effective quality assurance systems to run the home and meet the aims and objectives.’ The manager is knowledgeable, has good experience of the resident group she works with and is highly organised and efficient in her role. There is clear accountability of roles amongst the team and has provided a strong shift leader support system. The policy, procedures, support for both residents and staff which maintains that their health, safety and welfare. The manager leads by example and encourages the staff team to practice in terms of a residents rights and empowerment. Practice is continually changing and adapting Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 Page 23 according to individual and group need which in turn moulds the service provided. Policy, procedures and documentation evidence that resident finances are protected. All health and safety checks that were inspected are up to date. Within the fire records looked at were found to be to a good standard. The manager states on the AQAA that, ‘All the service users living at Norton Place currently require help to manage their money and are supported by the staff to do this. If they wish and are able to, the residents are helped to take responsibility for managing their own money.’ Quality Assurance is still being further developed and information needs to be collated and made available to CSCI and all other interested parties. At present the organisiation is not carrying out regulation 26 monthly quality control visits. This needs to be implemented and for copies of these visits to be kept within the home. The manager states on the AQAA that, we are planning to introduce a formal proactive system to look at compliance, quality and improvement. Looking at introducing a new system to ensure that compliance is met each month as per Reg 26 visits, and at a level that exceeds minimum standards. We plan to extend our current monitoring systems to reflect each month what we think we could do better. This will help to keep these plans active and current.’ The majority of residents expressed an opinion that they are happy with the staff, service provided and management support. Overall the home provides a very person centred based service which promotes and encouarges independence of the individual. Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 2 26 X 27 X 28 2 29 2 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation Sch 3 (p)(q) Requirement Any restrictions on choice, freedom or being able to be included in health care decisions, (consultation) is clearly recorded onto a format (infringements of rights) to evidence that this is clearly thought out and why it is necessary. Communal and bedroom areas in need of repair and redecoration to be kept in a good state of regular repair. Residents must be provided with a well decorated and a homely environment, and the vinyl floors in residents’ bedrooms reviewed unless there is a clearly evidenced reason for them. This is a repeat requirement from the last inspection 13/02/07 The garden to be adapted and planned out so that the individual and group assessed need is met and that they have safe access. Timescale for action 28/03/08 2. YA24 Reg23 (1) (2)(a)(b) (c)(d) 23(1)& 2(d) 31/07/08 3. YA25 31/07/08 4. YA28 YA29 23 (2)(o) 31/12/08 Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 Page 26 5. YA30 23 (2)(k) Sluicing facilities to be provided for the protection of residents regarding infection control. Regular review of the quality of care provided at the home to be collated and kept on the premises and made available to CSCI and all other interested parties. This is a repeat requirement from the last inspection 13/02/07 The registered person must ensure that the monthly Reg 26 monitoring visits are undertaken and that the reports are kept within the home and available for inspection. This is a repeat requirement from the last inspection 13/02/07 28/03/08 6. YA39 24 28/03/08 7. YA39 Reg 26 (1) 28/03/08 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 Refer to Standard YA39 Good Practice Recommendations Quality-monitoring information need to be collated and actions plan with outcomes to be kept on the premises and made available for inspection and to all other interested parties. Norton Place DS0000015552.V357687.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. 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