Inspection on 27/07/06 for Nortonbrook

This inspection was carried out on 27th July 2006.

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

Other inspections for this house

Nortonbrook 11/12/07

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 David Kidner Key Unannounced Inspection 27thJuly 2006 10:00 Nortonbrook DS0000045740.V303499.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.V303499.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.V303499.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 Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Nortonbrook DS0000045740.V303499.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home provides permanent residential use, for clients aged 16 years to 65 years. 7th March 2006 Date of last inspection 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 has advised that the home would now only accommodate 2 service users. The accommodation comprises, of a large 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. The Registered Provider is Autism Solutions Ltd. There is a vacancy for the post of Registered Manager. Nortonbrook DS0000045740.V303499.R01.S.doc Version 5.2 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. At the time of the inspection there were no service users accommodated at the home under the age of eighteen. Therefore, the supplementary standards were not assessed. One Inspector conducted this Key Unannounced inspection. The Inspector visited the home on two occasions to complete the inspection and attended a case review one week later. The outcomes of the two visits and the care review have contributed to this report. The Providers have been very approachable when the inspector raised issues of concern and have been very proactive in addressing those issues. The Inspector met both service users and spent some time in the lounge and kitchen areas observing care practices and staff interaction. The Inspector had some interaction with both service users. Due to the needs of the service users it is important that the inspection is conducted in a manner that does not cause too much disruption and intrusion into both service users lifestyles. As part of the inspection process the Inspector viewed records in relation to care plans, risk assessments, health and safety, medicines, staff recruitment and viewed all parts of the home. The Inspector spoke to three care staff in private and had detailed discussions with the Manager of the home. Comment cards were sent to both service users parents, care managers, GP and other health care professionals. The comments received indicated that the relatives and care managers are overall satisfied with the care provided. Nortonbrook is in need of a period of sustained stability. It is paramount that the position of Registered Manager is filled. This will ensure that there is continuity and consistency in the leadership of the home. As a result of this inspection the home has nine requirements and three recommendations. What the service does well: The home supports service users with very complex needs. Care plans are detailed and supported by risk assessments as needed. It is evident that the care team are highly committed and wish to provide a high quality service. The care team promotes the individual needs of the service users. Good records are kept of staff training and health and safety. Nortonbrook DS0000045740.V303499.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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 DS0000045740.V303499.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 Nortonbrook DS0000045740.V303499.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The quality outcome is good. The home conducts detailed pre-admission assessments prior to any service user being considered to move to Nortonbrook. EVIDENCE: There have not been any admissions to the home for approximately three years. Therefore, the Inspector was not able to fully assess Standard 2 of the National Minimum Standards. However, the Inspector has previously viewed detailed pre-admission assessments that were completed before the current service users moved to the home. The home follows Autism Solutions Ltd Policies and Procedures for preadmission assessments and protocols. The Directors of the Company take a lead role in the referral and assessment process and involves other appropriate personnel as needed. The Registered manager would be fully involved in this process. Careful consideration would be needed as to how any a prospective service user would be introduced to the home. Nortonbrook DS0000045740.V303499.R01.S.doc Version 5.2 Page 9 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 the following standard(s): 679 The outcome group is good. Care plans are accessible and user friendly. The home offers as much choice as possible and encourages decision-making. Risk is well managed but needs some improvement. EVIDENCE: Since the last inspection the home have reviewed the manner in which the care plans are presented. They are now more user friendly and accessible. The Inspector viewed both service users’ care plans care plans. Care plans contain a life plan; care programme, behaviour management guidelines, risk assessments and an independent skills plan. The care team also keep a monthly running records document that details the care and support given that day. This also records activities that have been undertaken and meals taken and of any untoward incidents. Nortonbrook DS0000045740.V303499.R01.S.doc Version 5.2 Page 10 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. Records stated that skills have improved in life skills and independence. The care plans also contain information in relation to the management of challenging behaviours. This is reported in more detail in outcome group, Concerns, Complaints and Protection, under Key Standard 23. Any restrictions imposed are based on risk assessment and detailed in service users individual care plans. Both service users have complex needs and the care team offer as much choice as possible and encourage decision-making. Care staff are trained in Somerset Total Communication (STC) as both service users use this form of communication. The Inspector observed the care team offering service users choices in food and drink. Currently no service users access Advocacy services. Service users are not able to independently manage their own finances. The parents are their appointees and the home receives money from the parents to keep secure for the service users. The home keeps individual records of all expenditure. The Inspector viewed the records of the transactions. It was noted that one service user has spent approximately £32 in the last two weeks on take away meals. This should be reviewed as the statement of purpose states that food is included in the fee. It was also noted that some entries had been completed in pencil and signed by one member of staff. It is recommended that all entries be made in ink and wherever possible two staff signatures are included in all transactions. The home conducts risk assessments as and when needed to address matters relating to service users accessing community based facilities and independent living skills. These have been recently reviewed. However, it was identified that further risk assessments are needed to address issues relating to episodes of challenging behaviour. This is further identified in outcome group, Concerns, Complaints and Protection, under Key Standard 23. Nortonbrook DS0000045740.V303499.R01.S.doc Version 5.2 Page 11 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 the following standard(s): 12 13 14 15 16 17 The outcome group is adequate. Service users are supported to access the local community and partake in a variety of leisure, recreational and social activities. However, more recently due to staffing levels such activities have been restricted. This is further addressed in outcome group Staffing. The home encourages communication between relatives/visitors. The home provides meals on an individual basis depending on the choice made by service users that day. EVIDENCE: Wherever possible service user’s are encouraged and supported to access a variety of activities. Staff that the Inspector spoke to confirmed that activities that are offered include swimming, walking, drives in the homes vehicle, bowling, and meals out, TV, garden games, video, DVD and music. All activities are recorded in individual records. Nortonbrook DS0000045740.V303499.R01.S.doc Version 5.2 Page 12 However, the Inspector was advised that due to recent staffing difficulties the care team have not been able to support the service users accessing as much community, leisure and social activities as they would have liked. The Inspector viewed records in relation to activities and staffing levels. An immediate requirement was issued at the time of the inspection to address staffing levels to ensure that the home was adequately staff to provide activities and to ensure safe staffing levels are maintained. The Inspector spoke to one of the Directors of Autism Solutions Ltd to discuss this matter in more detail. The Inspector was advised that there is very good contact with the parents of the service users. Comment cards were sent to the parents of both services users prior to this inspection. The comment cards indicted that families are made to feel welcome at the home and that they can visit their relative in private. Contact with parents, relatives and friends are recorded in individual personal files. The Inspector spoke to three 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 and supportive manner. 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. Staff stated they always knock bedroom doors before entering and promote independence as much as possible when assisting with personal care. Both service users have en-suite facilities that further promote privacy as all personal care is conducted in these areas. At the previous inspection staff stated that due to individual needs, service users are not encouraged to assist in household activities such as cleaning, cooking and laundry. The Inspector recommended that this be reviewed and wherever possible service users are supported to develop these skills based on detailed risk assessments. Where needed this has been addressed and risk assessments completed. This needs to be regularly monitored and reviewed to ensure that this continues, based on risk management. The home does not have a set menu. Menus are based on individual needs and choices. Staff confirmed that service users are offered choices for every meal. The Inspector observed staff offering different meals, snacks and drinks. A ‘ healthy diet ’ is promoted and healthy snacks are available between meals. Both service users are of an age where take away and fast food meals are favoured. Nortonbrook DS0000045740.V303499.R01.S.doc Version 5.2 Page 13 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 the following standard(s): 18 19 20 The outcome group is good Service users have access to all appropriate health care professionals. The home has good systems for the management of medicines. EVIDENCE: Individual care records viewed by the Inspector 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. Following discussions with the care team the service has sought advice from psychology services in relation to the management of behaviours. It appears that there has been a difference of opinion with the advice given as to how extreme behaviours should be managed coupled with the philosophy of the service. The Inspector was advised by a number of the care team that the behaviour of one of the service users was causing concern. The registered providers had also identified this. This needed to be addressed promptly. A meeting had been arranged a few days after this inspection with the providers, psychology, psychiatrist and the manager of Nortonbrook. The Inspector Nortonbrook DS0000045740.V303499.R01.S.doc Version 5.2 Page 14 attended this meeting. A positive outcome was achieved with a strategy identified to address this matter. The Inspector viewed the arrangements for the recording of medicines at the home. The home uses MAR sheets. Two staff signatures are entered on the MAR sheets where needed. All records viewed were satisfactory. Nortonbrook DS0000045740.V303499.R01.S.doc Version 5.2 Page 15 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 the following standard(s): The outcome group is adequate. The home has a detailed complaints policy. The home does not insure that service users are not placed at risk in particular to the management of some behaviours and interventions. EVIDENCE: The home has not had any complaints since the last inspection. The Complaints Policy is written in Somerset Total Communication. There is a Whistle blowing Policy and Somerset County Council Safeguarding Vulnerable Adults Document. The home 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 has undertaken an Enhanced CRB clearance and records viewed included POVA first checks. The home has Polices and Procedures in the management of violence and aggression. There are also guidelines for staff to follow when addressing such matters. The guidelines highlight matters relating to restrictive physical intervention, mechanical restraints and physical intervention. The home states that it does not use physical intervention. The home has developed behaviour management guidelines, proactive and reactive strategies, risk assessments and behaviours analysis systems. The Inspector sampled some of these records. The care staff had signed to confirm Nortonbrook DS0000045740.V303499.R01.S.doc Version 5.2 Page 16 their awareness and understanding of guidelines. This was a recommendation at the last inspection and has been met. It was noted that not all behaviours were being addressed in an agreeable method. For one particular behaviour there were not agreed behaviour management guidelines to include proactive and reactive strategies and agreed recording methods and interventions. A risk assessment to address the behaviour had not been developed. These matters were discussed with the manager at the time of the inspection and the Director of Autism Solutions Ltd. and the Inspector visited the home a few days later and attended a review meeting as previously identified. Following this meeting the service will be receiving the support of a clinical psychologist in developing such strategies and support staff training. The home must ensure that such matters are addressed at all times to ensure the safety of service users and the care team. Nortonbrook DS0000045740.V303499.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 25 26 27 28 30 The outcome group is adequate. Nortonbrook aims to provide a small family type of environment. Further improvements are needed to make the environment feel more homely. Overall, on the day of the inspection the home was not clean and hygienic. EVIDENCE: Nortonbrook aims to promote a homely environment. It is acknowledged that the environment can be susceptible to extreme wear and tear due to the needs of the service users. The Inspector viewed all areas of the home including service user’s bedrooms and en-suite facilities, lounge, conservatory, kitchen and dining room and laundry area. The lounge, kitchen and dining area appeared homely but it is considered that further improvements in the lounge area could be made. Nortonbrook DS0000045740.V303499.R01.S.doc Version 5.2 Page 18 The Inspector was advised that one service users bedroom is to be fully redecorated and refurbished in a few weeks. This is urgently needed and dates have been set for this to be actioned. On service users en-suite facility needs constant attention to maintain its presentation. Another service users bedroom and en-suite facility is well-maintained and reflected personal choice and preferences. The kitchen appeared clean and well maintained. Overall, at time of the inspection the home was not clean and hygienic and did not present itself to be a safe environment. The laundry door was open and accessible to service users and contained a number of dustbin bags that presented a strong odour and a number of flies were present. At the previous inspection it was recommended that the laundry door be kept shut at all times to promote health and safety. This must be addressed. One en-suite facility was not clean to an acceptable standard. Parts of the home needed a thorough cleaning as dust and cobwebs had accumulated. The Inspector noted that discussions about developing a cleaning schedule had been made at team meeting in June 2006 developed. It appears that this has not been implemented. The Manager accompanied the Inspector when viewing the home and acknowledged the comments made. These matters must be addressed. Nortonbrook DS0000045740.V303499.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 33 34 35 36 The outcome group is adequate. Staff are provided with regular training. A Training and Development Manager monitor this. On the day of the inspection staffing levels did not meet the needs of the service users. The home has robust recruitment policies and procedures but must ensure POCA checks are undertaken if the home accommodates service users under the age of 18yrs. EVIDENCE: The training and development manager keeps individual records of the training that staff have undertaken. Specialist training that staff have received include managing aggression, STC and autism training. Three care staff are currently undertaking an NVQ qualification. Staff are due to attend training in the use of physical intervention. This has previously been identified under NMS 23. As previously identified in this report the Inspector was advised that due to recent staffing difficulties the care team have not been able to support the service users accessing as much community, leisure and social activities as Nortonbrook DS0000045740.V303499.R01.S.doc Version 5.2 Page 20 they would have liked. The staff rota that the Inspector viewed and other documentation indicated that staffing levels were not meeting the needs of the service users. An immediate requirement was issued at the time of the inspection to address staffing levels to ensure that the home was adequately staffed to provide activities and to ensure safe staffing levels are maintained. The Inspector spoke to one of the Directors of Autism Solutions Ltd to discuss this matter in more detail. 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 viewed the individual records of staff training. Dates have been identified where staff need refresher training in food hygiene and first aid. The recruitment files of recent appointments were viewed. All care staff working at the home has undertaken an Enhanced CRB clearance and records viewed included POVA first checks. However, the home must ensure that POCA checks are undertaken when obtaining an Enhanced CRB disclosure. Currently the home is not providing a service to users under the age of 18yrs. Staff that the Inspector spoke to stated that they receive regular supervision. There was evidence of good record keeping in relation to supervisions. Nortonbrook DS0000045740.V303499.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 38 39 42 The outcome group is adequate. NMS 37 could not be fully assessed, as there is a vacancy for the post of Registered Manager. The home needs a sustained period of stable management. The manager has been in post for a number of weeks. It is noted that there have been occasions when the home should have notified the CSCI of significant events. This was discussed with the manager at the time of the inspection. The home strives to promote health and safety. Quality assurance and quality monitoring systems need further development. EVIDENCE: The home has a vacancy for the post as Registered Manager. A manager has been appointed and the Commission for Social Care and Inspection is waiting Nortonbrook DS0000045740.V303499.R01.S.doc Version 5.2 Page 22 for receipt of the application. Nortonbrook has experienced instability in relation to the Registered Managers post. The home needs a sustained period of stability and leadership. It is noted that there have been occasions when the home should have notified the CSCI of significant events. This was discussed with the manager at the time of the inspection and must be addressed. At the previous inspection the Inspector recommended that the home 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. This remains a recommendation. The home has reviewed the environmental risk assessments. The homes Gas Safety Certificate is dated 16/03/06. All staff have received fire training and have signed their awareness of the homes’ fire procedure and action plan. The fire risk assessment in relation to fire drills is dated January 2006. The home has three battery operated fire detectors. These are located as suggested by the local fire officer. The detectors are tested weekly. The fire fighting equipment was serviced in July 06. The door leading to the garage area that houses the laundry facilities must be kept shut at all times to promote health and safety. The home keeps daily records of fridge and freezer temperatures and hot water temperatures. First aid kits are checked regularly and daily checks are conducted on the home’s vehicle. The Inspector viewed the documentation of accidents at the home. It appears that the number of accidents at the home have increased since the last inspection. The possible cause for this has been identified and is in the process of being addressed. The Inspector recommends that the manager countersign all accidents at the home as part of the home’s audit process. This was a recommendation at the last inspection. Nortonbrook DS0000045740.V303499.R01.S.doc Version 5.2 Page 23 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 1 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 3 28 3 29 X 30 1 STAFFING Standard No Score 31 X 32 2 33 1 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X X 2 2 X X 2 X Nortonbrook DS0000045740.V303499.R01.S.doc Version 5.2 Page 24 Yes 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 YA13 Regulation 16 (2) (m) Requirement The home must make arrangements to enable service users to engage in local, social and community activities. (An immediate requirement was issued at the time of the inspection) The home must ensure that behaviour management protocols are developed and reviewed at regular intervals. The use of physical intervention must be recorded. Care staff must receive training in physical intervention to prevent service uses being harmed or suffering abuse. Detailed risk assessments must be conducted to accompany behaviour management strategies. The home must ensure that all areas of the home are kept clean and hygienic. The home must ensure that there are adequate staffing levels to meet the needs of the DS0000045740.V303499.R01.S.doc Timescale for action 27/07/06 2. YA23 12 (1) (a) 15 (2) (b) 17/08/06 13 (7) (8) 3. YA23 13 (6) 31/08/06 4. YA23 13 (4) (c) 17/08/06 5 6. YA30 YA33 23 (2) (d) 12 (1) (a) 18 (1) (a) 17/08/06 27/07/06 Nortonbrook Version 5.2 Page 25 7. YA34 19 8. 9. YA38 YA42 37 13 (4) service users at all times. (An immediate requirement was issued at the time of the inspection) The home must ensure that 17/08/06 POCA checks are undertaken when obtaining Enhanced CRB disclosure. The home must notify the CSCI 17/08/06 of significant events that affects the service. The laundry room door should be 17/08/06 kept shut at all times. 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 YA7 Good Practice Recommendations The home should ensure that all financial transactions are completed in ink, wherever possible two staff to countersign all transactions and review the amount of expenditure by one service users in relation to take away meals. The home should consider ways of making the environment more homely. 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. This was a recommendation at the last inspection conducted on 12.09.06. The Registered Manager should countersign all accidents at the home as part of the homes audit process. This was a recommendation at the last inspection conducted on 12.09.05. 2. 3. YA24 YA39 4. YA42 Nortonbrook DS0000045740.V303499.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street 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 DS0000045740.V303499.R01.S.doc Version 5.2 Page 27 - 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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