Inspection on 12/09/05 for Nortonbrook

This inspection was carried out on 12th September 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Nortonbrook 11/12/07

Nortonbrook 27/07/06

Nortonbrook 07/03/06

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 TA2 6QP Lead Inspector David Kidner Announced 12 September 2005 th 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 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 Stationary 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 D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Nortonbrook Address 6 Kingdom Lane Norton Fitzwarren Taunton Somerset TA2 6QP 01823 336687 Telephone number Fax number Email 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 Ms Suzanne Low Care Home 3 Category(ies) of 1. People aged 16 - 65 years with learning registration, with number disabilities. of places Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home provides permanent residential use, for clients aged 16 years to 65 years. Date of last inspection 1st December 2004 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 Inspector was advised that the home will now only accommodate 2 service users. Both service users will be over the age of eighteen by 30.09.05. The accommodation comprises, a communal lounge, conservatory, kitchen and dining room. Both 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. Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Registered Manager and Proprietor are aware that the home must meet the Supplementary Standards for Care Homes accommodating Young People Aged 16 and 17. The Commission for Social Care Inspection (CSCI) has been advised that a new Manager has been appointed to the home following internal promotion of the current Registered Manager. An application for the new Registered Manager will be forwarded to the CSCI in the very near future. The Registered Manager and new Manager (Designate) were both present for the Inspection. The Announced Inspection was conducted over one day (7.5 hrs). The Inspector met both service users’; spoke to three care staff in private, viewed records in relation to care plans, staff recruitment and health and safety. The Inspector has received one comment card from one service user that had been completed by their parent. The overall comments were very positive. The Inspector viewed all parts of the home with the exception of one service user’s bedroom. The Inspector would like to thank the service users and the care team for making the Inspector feel welcome at the home and for their contribution towards the Inspection. As a result of the Inspection the home had one requirement and seven recommendations. What the service does well: What has improved since the last inspection? The Inspector noted that the number of accidents and incidents at the home has decreased. This appears to be due to the change of the service users living at the home. The service has made significant steps in providing service users with meaningful activities and for the first time, holidays for both service users. Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 Page 6 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. Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 2 4 The home has a detailed Statement of Purpose and Service User Guide. The home conducts a detailed pre-admission assessment prior to admitting a new service user to the home. EVIDENCE: Prospective service users and interested stakeholders are provided with the home’s Statement of Purpose and Service User Guide. The Inspector was advised that the home would in future be accommodating 2 service users as the third bedroom has now been converted into a larger office area. It is recommended that the home’s registration be amended to accommodate 2 service users. The Inspector viewed the pre-admission assessment that was conducted prior to the most recent service user being admitted to the home. An agreed transition plan was implemented involving all appropriate persons. The Registered Manager stated that the Directors of the company visited the person to complete the assessment and that care staff also visited the service user at their previous address and places of education. The pre-admission assessment had been re-visited to ensure that any changes in the previous assessment had been identified and further consideration given if needed. Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 Page 9 Three trial visits were arranged that also involved the parent of the service user. Overnight stays were not appropriate. Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 7 8 9 10 The home has detailed care plans that are reviewed on a regular basis. The home is very pro-active in implementing and reviewing risk assessments. Service users are encouraged to make decisions and participate in all aspects in the home as much as possible. EVIDENCE: The Inspector viewed both service users’ care plans. Both care plans had recently been reviewed and contained detailed documentation including likes, dislikes, activities, records of family contact, medical overviews and visits to other health care professionals, risk assessments, behavioural management guidelines and support guidelines. One service users file contained information relating to Looked after Children’s reviews (LAC) and an Individual Educational Plan. Service users are supported and encouraged to make decisions. Somerset Total Communication (STC) is used throughout the home. The home also uses Picture Exchange Communication System (PECS). It was noted that a communication strategy is to be implemented for one service user. Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 Page 11 Due to the complex needs of the service users the home does not hold service user meetings. Staff seek the views and the opinions of the service users on an individual basis and through observation of behaviours. The service users have a daily activities planner that identifies household tasks and other activities. There is also a STC board identifying staff members that are on duty. The Complaints Policy is also written in STC. The Inspector viewed some of the risk assessments that have been developed for individual service users. They had recently been updated. The Registered Manager stated that all risk assessments are reviewed on a regular basis and amendments made where needed. The service users and all interested stakeholders have access to the homes policies and procedures. There are policies for Confidentiality and the Disclosure of Information. All service user records are kept safe and secure. Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11 12 13 14 15 16 17 Service users access the local community and partake in a variety of leisure, recreational and social activities. There has been a major improvement in the accessing of leisure facilities out of the home. Staff have worked very hard in supporting service users to experience new opportunities, with very good results. The home encourages family and friends to visit as much as possible. The home offers a very flexible approach to mealtimes. EVIDENCE: Service users have access to specialist health care professionals if needed. This will support the care team in developing appropriate packages of care. Service users are able to access a church of their choice with support if so wished. Wherever possible service user’s are encouraged and supported to access a variety of activities. Such activities include swimming, walking, bowling, meals Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 Page 13 out, TV, garden games, video, DVD, cooking and music. All activities are recorded individually. Risk assessments are conducted for high-risk activities, including activities for service users under the age of 18yrs. It is noted that the activities for one service user has increased considerably over the last twelve months. The service users access facilities in the local community. There are positive relationships with the local community. The Inspector was advised that both service users have had a holiday. One service user had a four-day holiday to Disneyland, Paris. This was the service user’s first holiday and was very successful. The other service user went on a four-day holiday in Cornwall. There are plans for visits to Centre Parks later in the year. This is a major achievement. The Inspector was advised that there is very good contact with the parents of the service users. All relatives and friends are welcome to visit. All contact with parents, relatives and friends is recorded in individual personal files. The home has a small room that will be turned into a small light room. The parents are funding this. This demonstrates the good relationship that the home has with families. The Inspector spoke to a number of care staff at the time of the inspection and observed staff carrying out their duties. It was noted that care staff were interacting with service users in a professional manner and in the way that service users wished to be addressed. Somerset Total Communication was being used where needed. Service users have access to all areas of the home with the exception of private bedroom areas. Through discussions with the care team it was evident that staff promote privacy and confidentiality. Both service users have en-suite facilities that further promote privacy as all personal care is conducted in these areas. The home does not have a set menu. Menus are based on individual needs and choices. Service users will choose what they wish to eat on a daily basis and meal times are very flexible. A ‘ healthy diet ’ is promoted and healthy snacks are available between meals. However, service users also enjoy a trip to fast food outlets. This is acceptable but is closely monitored to ensure a healthy balance is maintained. Records of all meals are recorded individually. This ensures that the Registered Manager can monitor nutritional intake. Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 19 20 Service users receive support in the manner they prefer and the home ensures that service users have access to all appropriate health care professionals. The home should improve on the recording of medicines at the home. EVIDENCE: The care plans that the Inspector viewed indicated the manner in which service users preferred to receive their personal care. Both service users have an allocated key worker. Records viewed indicated that advice and support is obtained from a variety of healthcare professionals, including appointments with GPs, Speech and Language Therapists in addition to Consultant specialists. Records are kept of all visits and consultations. One service user has recently had a speech and language therapy assessment and the care team are implementing the recommendations made following the assessment. The Inspector viewed the arrangements for the recording of medicines at the home. The service users need full support in the management of their medicines. The home uses MAR sheets. It was noted that two staff signatures did not support one hand transcribed medicine. The inspector recommended that this be addressed. The Registered Manager ensures that medication is Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 Page 15 kept under regular review. The home maintains records of medicines that are returned to the pharmacy as needed. Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 23 The home has a robust Complaints Policy. The home ensures that service users are protected from abuse. EVIDENCE: The Registered Manager confirmed that the home has not had any complaints since the last inspection. The Complaints Policy is also written in Somerset Total Communication. The home has a Whistle blowing Policy and Somerset County Council Safeguarding Vulnerable Adults Document. The home also has a Policy on the Protection of Children from Abuse and a copy of the local Area Child Protection Committee. All staff sign to state that they are familiar and are aware of such policies. All care staff working at the home have undertaken an Enhanced CRB clearance and records viewed included POVA first checks. Staff do not commence work at the home until a satisfactory Enhanced CRB is obtained. Staff that the Inspector spoke to stated that they were aware of the home’s Whistle blowing Policy and Complaints Policy. Through discussions with the staff, they demonstrated the process they would undertake if they needed to raise any areas of concern. The home has developed behaviour management guidelines/protocols for all staff to follow. These are reviewed on a regular basis. Records are kept of all incidents and episodes of behaviours that challenge the service. On a monthly basis the home conducts a behaviour analysis of all such episodes. Records viewed by the Inspector indicated that there has been a marked decrease in the episodes of challenging behaviour. Physical Intervention is not used at the home. The Inspector recommends that all care staff should sign the behaviour Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 Page 17 guidelines/protocols to confirm their awareness and understanding of such documents. At the previous inspection it was recommended that the provider should review the current appointeship arrangement for one service user and an ‘independent’, source of support be arranged. This has been addressed. Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 25 26 27 28 29 30 Nortonbrook strives to promote a homely environment. The home is well maintained, however, will need constant reviewing of the home’s refurbishment and redecoration programme. EVIDENCE: Nortonbrook promotes a homely environment. It is acknowledged that the environment can be susceptible to extreme wear and tear. The care team make every effort to promote a homely environment. The Inspector viewed all areas of the home except one service user’s bedroom. The home has a lounge, conservatory, kitchen, dining room, and a large garden to the rear of the property. The home has a planned maintenance and renewal programme. The Inspector was advised that some areas of the home would be redecorated and refurbished, as there are some areas that are in need of minor redecoration and refurbishment. There is adequate shared space. The lounge had photographs on the walls depicting the holidays service users have enjoyed in recent times. The home has a large rear garden that has been made safe with an erection of a fence with risk assessments conducted. The Inspector was advised that due Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 Page 19 to the close proximity of the home to a small stream that the garden has flooded on one occasion. This is further highlighted in Standard 42. The Inspector viewed one service user’s bedroom. It reflected the needs and preferences of the service user. Both service users have en-suite facilities. The Inspector was advised that the flooring in on one service user’s bedroom and new flooring in another service user’s bathroom are to be replaced in the near future. There is also a toilet/washbasin on the ground floor. The home has a cleaning schedule. The laundry facilities are situated in the large garage area and are accessed via the conservatory. This area is kept locked at all times unless access is required. The home has domestic style washing machine and tumble dryer. The COSSH cupboard is also located in this area and is always kept locked. On the day of the inspection the home was clean and hygienic and free of unpleasant odours. Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 33 34 Staff spoken to at the time of the Inspection appeared to be aware of their roles and responsibilities. The home has robust recruitment practices. EVIDENCE: All staff have job descriptions. On induction staff are informed of the main aims and values of the home. The staff that the Inspector spoke to at the time of the inspection confirmed that they had an induction that included training in autism awareness, medication, breakaway techniques, POVA as well as mandatory training. The Inspector did not view the training records at the home for all staff members. Therefore, Standard 32 was not fully inspected. The staff that the Inspector spoke to confirmed that there is usually two to three staff on duty at the home during waking hours and that there is one sleep in person. It was also commented upon that there is excellent on-call support at all times of the day. The rota viewed indicated that there is adequate staff on duty to meet the needs of the service users. Staff spoken to confirmed this. The Registered Manager confirmed that there is always a minimum of two staff on duty during the daytime and that the staff rota is adjusted to meet the needs of the service users. The Inspector viewed the documentation in relation to the recruitment of staff. There was a minor shortfall in the required documentation. This was discussed Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 Page 21 with the Registered Manager at the time of the inspection. It was noted that one staff member has not received an Enhanced CRB disclosure but a POVA first check has been completed. The Inspector was advised that the staff member did not commence working at the home until the POVA first check was received and is not working unsupervised. The staff member confirmed this. Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 40 41 42 The majority of records at the home are stored safely and securely. The home has various Policies and Procedures that are produced by Autism Solutions and are accessible to all. The home could improve its quality assurance and quality monitoring processes. The home strives to promote a safe environment. EVIDENCE: The Inspector had some discussion in relation to quality assurance. The Inspector recommends that the Registered Manager conduct surveys to gain views from service users, family, friends and other interested stakeholders as part of the homes’ quality assurance and quality monitoring systems. Autism Solutions has developed comprehensive Policies and Procedures. The home has a vast number of policies and procedures including all the required policies and procedures as listed in Appendix 2 of the National Minimum Standards. Service users, staff and all interested stakeholders have access to these. This includes a policy in relation to Standard 14.9 of the Supplementary Standards in relation to service users under the age of eighteen not having Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 Page 23 access to or watch videos and DVDs certified suitable for over 18s. Service users have access to their records if they so wish. They are stored safely. Accident records should be stored in line with the Data Protection Act 1998. The Gas Safety Certificate was issued on 08.12.04. Portable Appliance testing was conducted on 24.10.04. The home had a visit from the Fire Officer on the 03.12.04. He reported a “satisfactory standard ”. All staff have received fire training and have signed their awareness of the homes’ fire procedure and action plan. It is recommended that this plan be dated. The home has three battery operated fire detectors. These are located as suggested by the local fire officer. The detectors are tested monthly. The Registered Manager advised that they would be tested weekly in future with records kept. The fire extinguishers were serviced on the 23.10.04. The home has completed detailed environmental Risk Assessments. It was not noted that a risk assessment has been completed in relation to the flooding of the rear garden. It is recommended that a risk assessment be conducted to address this matter if this is the case. The home has a COSHH Policy and all cleaning agents are kept in a locked cupboard. The home has a cleaning schedule and a copy of Somerset Health Protection Unit Guidance for Infection Control. All staff have received first aid and food hygiene training. The home keeps daily records of fridge and freezer temperatures. It was noted that the wardrobe in one service user’s bedroom was not secured to the wall so as to promote health and safety. This must be addressed. The Inspector viewed the documentation of accidents at the home. It appears that the number of accidents at the home have decreased considerably since the last inspection. This appears to be due to the change of the service user group. The Inspector recommends that the Registered Manager countersign all accidents at the home as part of the home’s audit process. Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 x 3 3 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Nortonbrook Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 3 2 2 x D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 Page 25 Are there any outstanding requirements from the last inspection? NO 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 YA42 Regulation 13 (4) Requirement The Registered Manager must ensure that all wardrobes are secured to the wall unless supported by a detailed risk assessment. This will promote health and safety. Timescale for action 03.10.05 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. 3. Refer to Standard YA20 YA23 YA39 Good Practice Recommendations The home should ensure that two staff signatures supports all hand transcribed medicines. All care staff should sign the behaviour guidelines/ protocols to confirm their awareness and understanding of such documents. The Registered Manager should conduct surveys to gain views from service users, family, friends and other interested stakeholders as part of the homes’ quality assurance and quality monitoring systems. Accident records should be stored in line with the Data Protection Act 1998. It is recommended that the home’s registration be amended to accommodate 2 service users. The Registered Manager should countersign all accidents at the home as part of the home’s audit process. D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 Page 26 4. 5. 6. YA41 YA1 YA42 Nortonbrook 7. YA42 If not already addressed, the Registered Manager should complete a detailed risk assessment in relation to the flooding of the rear garden and forward a copy to the Commission for Social Care and Inspection. Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier, Taunton TA1 4AL National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Nortonbrook D53_D02 S45740 Nortonbrook V232698 120905 Stage 4.doc Version 1.30 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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