Inspection on 11/12/07 for Nortonbrook

This inspection was carried out on 11th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Nortonbrook 27/07/06

Nortonbrook 07/03/06

Nortonbrook 12/09/05

Nortonbrook 01/12/04

Nortonbrook 21/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Nortonbrook 6 Kingdom Lane Norton Fitzwarren Taunton Somerset TA2 6QP Lead Inspector Kathy McCluskey Unannounced Inspection 11th December 2007 11:00 Nortonbrook DS0000045740.V355605.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 Nortonbrook DS0000045740.V355605.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. Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Nortonbrook Address 6 Kingdom Lane Norton Fitzwarren Taunton Somerset TA2 6QP 01823 336687 NO FAX 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) Autism Solutions Limited Steven John Gibbs Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Nortonbrook DS0000045740.V355605.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 providing personal care only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following category: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is 3. Date of last inspection 27th July 2006 Brief Description of the Service: Nortonbrook is situated in village of Norton Fitzwarren approximately three miles from the county town of Taunton. The home is a large detached property situated in a small cul-de-sac in a residential area. The home was originally registered in July 2003 to provide short breaks, for younger adults. In November 2003 the registration was changed and it now provides long-term placements for up to 3 younger adults who have a learning disability. The accommodation comprises, of a large lounge, conservatory, kitchen and dining room. Bedrooms have en-suite facilities and are located on the first floor. There is a large enclosed garden to the rear of the property. The home also provides transport for service users. Given the layout of the home, it would not be suitable for service users with mobility difficulties. The Registered Provider is Autism Solutions Ltd and Mr Clothier is the responsible individual. The registered manager is Mr Steven Gibbs. Fees for current service users are between £1643 & £2762 per week. Additional charges include; toiletries, personal items, chiropody, holidays and day centre sessions. Fees are determined on an individual basis and are dependant on the assessed needs of the service user. Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection visit was to inspect relevant key standards under the Commission’s ‘Inspecting for Better Lives 2’ framework. This focuses on outcomes for service users and measures the quality of the service under four general headings. These are; - excellent, good, adequate and poor. This key inspection was conducted by regulation inspector Kathy McCluskey. At the time of this inspection, three service users were living at the home. Given the needs of service users, it was not appropriate for the inspector to spend time with them. The inspector was able to discreetly observe service users and staff interactions during the morning of the inspection. As part of this key inspection, the home was required to complete an Annual Quality Assurance Assessment for the Commission. This was received prior to the inspection and parts have been incorporated into this report. The Commission sent comment cards to service users, relatives and other stakeholders but none were returned to the Commission. The registered manager was not available for this inspection but the deputy manager was available throughout this visit. The inspector was able to speak with the responsible individual on the telephone during the inspection. The inspector was given unrestricted access to the home and all records required were made available. The inspector would like to thank service users, the deputy manager and staff for their time and cooperation with the inspection process. The following is a summary of the inspection findings and should be read in conjunction with the whole of the report. What the service does well: Nortonbrook provides a specialist service for adults with autism. The home ensures that service users are able to live a fulfilling life in the community. The home has a stable staff team who have been appropriately trained and an effective management team is in place. Staff stated that they felt well supported. There was evidence that staff were appropriately supervised. Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 6 Prospective service users are fully assessed by the home before a placement is offered and the home liaises closely with other healthcare professionals to ensure that the needs of service users can be fully met. The home ensures that each service user has a comprehensive plan of care which includes detailed risk assessments and clear guidelines around behaviour management. Care plans also include information about the preferences, likes and dislikes of the individual to enable staff to ensure a person centred approach to care. Service users are supported to access a wide range of leisure/social activities both within the home and out in the community. The home provides transport for service users at no extra cost. Each service user has a ‘life plan which is drawn up recognising the person with autism is also an individual with individual needs. Autism Solutions have developed a day centre, the ‘TRIAD centre’, which stands for ‘Training, Recreation & Individually Assessed Development Centre’ The centre can be accessed by service users at the home. The TRIAD centre has been ‘exclusively designed for people with complex needs and autism’ Each service user has their own bedroom, which has en-suite toilet/bathing facilities. As appropriate, service users can personalise their rooms. Service users have access to a comfortable environment, which is appropriate to their needs. The home has procedures in place to reduce the risk of harm or abuse to service users. Staff have been trained in the prevention of abuse and a range of policies are available. The home ensure that appropriate checks are obtained for prospective staff which include an enhanced criminal record check (CRB) and checks against the protection of vulnerable adults (POVA) and children’s (POCA) registers. What has improved since the last inspection? At the last key inspection, nine requirements were raised. A further inspection was conducted on 8th February 2007 and there was evidence that eight of the requirements had been addressed. At this key inspection, there were no outstanding requirements. Improvements included; increased staffing levels, enabling service users to access more community activities, staff training and cleanliness of the home. Since the last inspection, the Commission have approved an application for Mr Steven Gibbs to be registered manager. Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 7 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. Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 8 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 Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 9 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): 1, 2, 3 & 4 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need to enable them to make an informed decision about moving to the home. The home takes appropriate steps to ensure that the assessed needs of prospective service users can be fully met prior to a placement being offered. Staff have been appropriately trained to enable them to meet the needs of service users living at the home. EVIDENCE: The home has produced a statement of purpose and service user guide which is made available to service users, prospective service users and their representatives. As required at the last inspection, the statement of purpose has been updated and a copy forwarded to the Commission. One service user has moved to the home since the last inspection and the inspector was able to see evidence that the needs of the service user had been fully assessed prior to the service user being offered a placement at the home. Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 10 Detailed assessments had also bee obtained from other healthcare professionals. The inspector was informed that the service user visited the home prior to moving there. Staff at the home have received appropriate training to enable them to meet the needs of service users living there. Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 11 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, 9 & 10 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home’s care planning systems are good and take into account the preferences of service users. Any restrictions on a service user are clearly identified in their individual plan of care. The home ensures that all information regarding service users is handled appropriately. EVIDENCE: Each service user has an individual plan of care which sets out how an individual’s needs and aspirations will be met. The inspector examined the care plan for the most recent service user. Detailed information was available from other healthcare professionals. The Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 12 care plan contained information about how assessed needs should be met, including healthcare needs. A life history and the preferences of the individual had been recorded. Up to date behaviour management plans and risk assessments were also in place. Any restrictions imposed on service users are based on their individual risk assessments which were seen to be available in the care plan examined. Staff are able to communicate effectively with service users as all have received up to date training in Somerset Total Communication. Service users currently living at the home are unable to manage their own finances. The home does not act as appointee for service users but small amounts of monies are managed on behalf of service users. Records and receipts relating to transactions were examined at this inspection. The inspector was informed that service users were unable to sign to confirm transactions. Records are currently only signed by one staff member. To offer better protection, it has been recommended that all transactions are confirmed by two staff signatures (refer to standard 23). All records pertaining to service users were seen to be appropriately stored in accordance with the Data Protection Act 1998. All staff sign a confidentiality policy on commencement of employment. Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 13 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, 14, 15, 16 & 17 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. Service users are supported to take part in a range of leisure pursuits/activities. The home offers a healthy diet and the preferences of service users are respected. EVIDENCE: In line with their plan of care and risk assessments, service users are supported to access a variety of social activities both within the home and in the community. Staff spoken with confirmed that staffing levels had increased since the last inspection and this enabled them to spend more quality time with service users. Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 14 Activities that have taken place include, horse riding, swimming, walks, trips to the cinema and pubs, meals out and drives. Service users are supported to pursue their own interests/hobbies. This was apparent at the time of the inspection. The home also has a good sized garden with trampoline, a range of DVD’s, music and games. The registered provider Autism Solutions Ltd, have developed a ‘Triad Centre’. This is a day centre that service users can utilise where service users can benefit from bespoke activities. Service users are supported to plan annual holidays. The inspector was informed that two staff were due to support a service user to take a holiday in Devon. In line with the wishes of service users and individual plan of care, service users are supported to maintain links with their family. The inspector was informed of how one service user is supported to visit their relatives on a regular basis. During this inspection, service users were observed moving freely around the home. All service users have their own bedrooms with en-suite toilet and bathing facilities. Staff were observed knocking on bedroom doors prior to entering. The home does not have set menus. Meals offered are based on individual needs and choices. Care plans contained information regarding the individual’s likes and dislikes with regard to food and drink. A ‘ healthy diet ’ is promoted and healthy snacks are available between meals. Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 15 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 & 20 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. Service users are supported to meet their personal care needs in line with their preferences and plan of care. The home ensures that service users have access to a range of healthcare professionals. The home follows the correct procedures for the management and administration of service users medication. EVIDENCE: Staff support service users to meet their personal care needs in line with their plan of care. The care plan examined contained clear information regarding the needs and preferences of the individual. Each service user has their own en-suite bathing facilities so that any assistance with personal care can be carried out in a manner which respects the privacy and dignity of the individual. Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 16 The care plan examined provided evidence that service users are supported to access a range of healthcare professionals including psychologists and speech therapists. Records of the individual’s contact with healthcare professionals are maintained. Given the needs of service users living at the home, all prescribed medication is managed and administered by staff at the home. The inspector was able to see that staff had received appropriate training in the safe handling of medicines. Medication administration records were examined and were found to be well maintained. Clear protocols were in place for the use of ‘as required’ medication. Appropriate records are maintained for the receipt of medicines into the home and medicines returned to the pharmacy. The home does not currently hold any controlled drugs. Medicines were seen to be securely stored. Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 17 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 & 23 Quality in this outcome area is Good. This judgement has been made using available evidence including a visit to this service. The home has a satisfactory complaints procedure in place which is available in a format appropriate to the needs of service users. The home takes appropriate steps to reduce the risk of harm or abuse to service users. EVIDENCE: The home has a complaints procedure in place. Pre-inspection information supplied by the home stated that the complaints procedure is also available in symbol format for service users. The inspector was informed that the home have not received any complaints since the last inspection. No concerns have been raised directly with the Commission. Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 18 The home has a range of policies for staff relating to the protection of vulnerable adults and staff have received training in the prevention of abuse. Given the home’s registration, a Policy on the Protection of Children from Abuse and a copy of the local Area Child Protection Committee is available in the home. All staff sign to state that they are familiar and are aware of such policies. The home’s staff recruitment procedures are good and reduce the risk of harm or abuse to service users. Enhanced criminal record checks (CRB) and protection of vulnerable adult checks (POVA) have been obtained for all staff. Recruitment records for the two most recent staff members also contained protection of children checks (POCA). Staff have received appropriate and up to date training in the management of challenging behaviour and physical intervention. The inspector was informed that physical intervention would only be used in accordance with an individual’s agreed plan of care. As mentioned previously in this report under standard 7, it has been recommended that two staff sign records relating to service users’ financial transactions as this will offer better protection to service users and staff. Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 19 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, 26, 27, 28 & 30 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. Service users have access to comfortable environment which meets their individual needs. Service users have their own bedroom, which can be personalised subject to any risk assessments in place. All bedrooms have en-suite toilet and bathing facilities. Infection control procedures are generally good. EVIDENCE: Nortonbrook is a spacious four bedroom house which is situated in a quiet residential area. The home is registered with the Commission for a maximum of three service users. The fourth bedroom is a staff sleep-in room/office. Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 20 Communal areas are all situated on the ground floor and comprise of a spacious lounge, separate dining room and a conservatory. These areas are comfortably furnished but due to the needs of the service users, furnishings/fixtures are limited. There is a small domestic type kitchen which is suitable for the home’s stated purpose. The laundry area is located in the adjoining garage. Service users have their own bedroom with en-suite toilet and bathing facilities. As appropriate, service users are encouraged to personalise their rooms. Service users appeared comfortable in their surroundings. Due to the needs of service users, damage to the environment can be frequent. Staff confirmed that any issues are dealt with promptly by the company’s building and grounds maintenance team. At the time of this inspection, the standard of cleanliness was found to be satisfactory and there were no malodours. Staff took action at the time of the inspection to make liquid soap and paper towels available in the staff toilet. To reduce the risk of the spread of infection, it has been required that the seal around one en-suite bath is replaced. This was noted to be heavily cracked and stained. Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 21 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, 33, 34, 35 & 36 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. Staffing levels have improved and are now appropriate to the needs of service users living at the home. Staff have the skills necessary to meet the needs of service users at the home. The home follows the correct procedures for the recruitment of staff. Staff are appropriately supervised. EVIDENCE: Records relating to two staff were examined at this inspection. Both demonstrated that staff had received training appropriate to their role. Staff have received training in autism, managing challenging behaviour, abuse, Somerset Total Communication, moving and handling, first aid, person centred approach to care, health & safety, fire safety and safe handling of medication. Staff confirmed that the registered provider offered good training opportunities Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 22 and staff spoken with stated that they had received the training needed to enable them to meet the assessed needs of service users living at the home. The home provided the Commission with pre-inspection information which identified that of the eight care staff employed, three have achieved a minimum of an NVQ level 2 in care. This equates to 38 which is below the National Minimum Standard of 50 . Five care staff (62 ), are currently working towards this award. Staff spoken with informed the inspector that staffing levels had improved since the last inspection and that there were no concerns in meeting the assessed needs of service users currently living at the home. The inspector was informed that the staff team were ‘very flexible’ and that additional staff are on duty where required or where needed to assist service users access leisure/community events. Service users benefit from a stable staff team. Staff morale appeared good and staff spoken with stated that they had got to know the needs and preferences of service users very well and that service users benefited from continuity of care. The home does not use agency staff The inspector was advised that minimum staffing levels at the home are as follows: Three care staff during the day, two during the evening and one sleep-in at night. The inspector examined the procedures relating to staff recruitment. Two files were examined relating to the most recently appointed staff. Both contained all required information and included an enhanced criminal record check (CRB), protection of vulnerable adults and children’s checks POVA & POCA. It has been recommended that full dates rather than just the year, are provided by the applicant on the employment history section of the application form. This will allow the employer to identify and explore any gaps in employment. It has also been recommended that a risk assessment, which identifies any restrictions imposed on a staff member, is completed for any member of staff who commences employment on a POVAfirst, pending a full CRB. This should be signed by the employer and staff member. All staff undergo a two week period of induction on commencement of employment and during this time the staff member is based at the registered provider’s office. The inspector was able to see evidence that staff are appropriately supervised. Detailed and up to date records were available in the two staff files seen at this Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 23 inspection. Supervision records clearly identified any training needs or requests. Staff had signed records confirming that they had received a copy of their supervision record. Both staff spoken with during the inspection informed the inspector that they felt well supported. Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 24 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, 40 & 42 Quality in this outcome area is Good This judgement has been made using available evidence including a visit to this service. The home has effective management systems in place. The home’s arrangements for ensuring the health & safety of persons at the home are generally good. EVIDENCE: Since the home’s last key inspection, the Commission have approved an application for Mr Steven Gibbs to be registered manager. Mr Gibbs has over 10 years experience in caring for people with learning disabilities and autism and had worked at the home for 3 years. He has achieved a NVQ level 3 in care and is currently working towards an NVQ level 4 in management. Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 25 Mr Gibbs was not present for this inspection though the deputy manager was available throughout the inspection. The Commission was provided with pre-inspection information which stated that the home has ‘an effective quality assurance programme which seeks the views of parents and other stakeholders’. As part of the quality assurance process, the responsible individual conducts monthly visits to the home and copies of reports are maintained at the home. Regular meetings are held for staff and staff spoken with during the inspection confirmed that they felt well supported. Given the complex needs of service users living at the home, the inspector was informed that formal meetings for service users are not appropriate. Pre-inspection information provided by the home stated that the home has a range of up to date policies and procedures in place for staff. A tour of the premises was conducted and a selection of records examined in relation to the home’s procedures for ensuring the health and safety of persons at the home. The findings were as follows: FIRE SAFETY – Information provided by the home stated that the home’s fire systems were last serviced in September 2007. The home currently conducts in-house checks on fire detection systems on a monthly basis. It has been recommended that this is carried out on a weekly basis. The home does not have emergency lighting. Staff confirmed that they received regular training in fire safety. GAS SAFETY – The home provided the Commission with information confirming that the home has an up to date annual Landlords Gas Safety Certificate date August 2007. ELECTRICAL SAFETY – Annual testing for portable electrical equipment was last carried out in March 2007. HOT WATER OUTLETS – The home maintains records of regular testing of all hot water outlets. It was concerning that the temperatures of en-suite bath/shower outlets were well in excess of the safe upper limits stated by the Health & Safety Executive of 44c for baths and 42c for showers. Given the needs of service users, taps to baths are currently disabled and can only be used by a member of staff. Whilst this can reduce the risk of scalding, it has been required that action is taken to ensure that thermostatic controls are adjusted to ensure that hot water outlets do not exceed the safe upper limits. The responsible individual was made aware of this on the day of the inspection and he gave his assurances that action would be taken to address. Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 26 ACCIDENTS – The inspector was able to view the home’s accident/incident reports. These are audited monthly by the registered manager. The number of accidents/incidents were unremarkable and none required RIDDOR or the Commission to be notified. Records indicated that staff have received training in first aid. To ensure the safety of service users, upstairs windows are fitted with restrictors and wardrobes are secured to the wall. As previously mentioned in this report, staff have received appropriate mandatory training such as safe moving and handling, food hygiene, fire safety and health & safety. The home does not have a passenger lift or any lifting equipment as the home does not accommodate people with physical/mobility difficulties. Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 3 4 3 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 3 25 3 26 3 27 3 28 3 29 x 30 2 STAFFING Standard No Score 31 x 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 3 x 2 x Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 28 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA30 Regulation 13(3) Requirement To reduce the risk of the spread of infection, the registered person must ensure that the seal around the identified ensuite bath is replaced. The registered person must take appropriate action to ensure that bath and shower hot water outlets do not exceed HSE safe upper limits. Timescale for action 23/12/07 2. YA42 13(4) 20/12/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA23 YA34 Good Practice Recommendations To offer better protection, the registered person should ensure that two staff sign to confirm all financial transactions made on behalf of service users. The registered person should ensure that full dates of employment are provided by applicants on the staff application form, as this will allow the home to identify and explore any gaps in employment. The registered person should ensure that risk assessments DS0000045740.V355605.R01.S.doc Version 5.2 Page 29 3. YA34 Nortonbrook are signed and completed for any staff member commencing employment on a POVA First, pending a full CRB. Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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 Nortonbrook DS0000045740.V355605.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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