Inspection on 22/06/07 for Norwood 1 Woodcock Dell

This inspection was carried out on 22nd June 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 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Norwood 1 Woodcock Dell 05/04/05

Norwood 1 Woodcock Dell 24/02/05

Norwood 1 Woodcock Dell 26/10/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Norwood 1 Woodcock Dell 1 Woodcock Dell Avenue Kenton Middlesex HA3 0PW Lead Inspector Diane Roberts Unannounced Inspection 22nd June 2007 09:30 Norwood 1 Woodcock Dell DS0000017500.V343853.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 Norwood 1 Woodcock Dell DS0000017500.V343853.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. Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norwood 1 Woodcock Dell Address 1 Woodcock Dell Avenue Kenton Middlesex HA3 0PW 020 8385 0980 020 8908 0469 woodcockdell@norwood.org.uk www.norwood.org.uk Norwood 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) Ms Victoria Hayley Weir Care Home 8 Category(ies) of Learning disability (8), Old age, not falling registration, with number within any other category (8) of places Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4/10/2005 Brief Description of the Service: 1 Woodcock Dell Avenue is a purpose built care home that is registered to accommodate and offer personal care to 8 adults up to 65 years and over who have learning disabilities. At the time of the inspection there were 6 service users living in the care home, with two vacancies. The care home is situated in a residential road in Kenton and provides a Jewish way of life to service users. The home has access to bus routes. The front of the property is paved and offers car-parking facilities. There is a garden at the rear and side of the property. Work has been done to update the garden and it has been paved for access. The home is equipped to cater for wheelchair users and has a passenger lift to the first floor. All bedrooms are single and fitted with wash hand basins. The home is also known as Lady Cohen House. Norwood is a registered charity. The current fees are from £1386.00 to £2846.00 and additional charges are made for toiletries, hairdressing, chiropody etc. Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out as part of the annual inspection programme for this home. The registered manager was available on the fieldwork day of the inspection. The inspection focused upon all of the key standards. A partial tour of the premises was undertaken. Evidence was also taken from the Annual Quality Assurance Assessment completed by the management of the home and submitted to the CSCI. 2 residents, 1 relative, one district nurse and 3 staff were spoken to during the inspection. Feedback sheets were received from 8 relatives and 2 from healthcare professionals including specialist in learning disabilities. Comments from discussions and surveys were taken into account when writing this report. What the service does well: What has improved since the last inspection? What they could do better: The team could develop the care planning further so that resident involvement is progressed. The team need to have access to infection control advice and training. Shortfalls noted in relation to training for fire safety and lifting and handling residents should be addressed. Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 6 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. Norwood 1 Woodcock Dell DS0000017500.V343853.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 Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The team at the home have a very good assessment process in place that ensures that residents are only admitted to the home if they can meet their needs. The assessment process also helps to ensure a smooth transition for the resident and a quicker settling in time. EVIDENCE: Records of a recent admission the home were inspected. Whilst the manager leads the pre-admission assessment process other staff from the home are also involved, along with the resident, their family and key people involved in their care. Records show that a thorough resident led assessment is undertaken and the transition period to move into the home can vary greatly from resident to resident, depending on need. Evidence is available to show that many meetings take place, the resident is able to visit the home at differing times and during that time the assessment process continues. Records show that all of the residents physical, emotional, social and mental health needs are assessed and their preferences, where known, are taken into account. Good detailed records are kept and plenty of information is provided to interested parties. Further records show that the team at the home ensure that all the practical preparations are put into place ready for the admission, Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 9 for example, specialist equipment and facilities. Records evidence that the team at the home communicate well with key people involved with the residents care to ensure that they have a full up to date picture of the needs of the resident prior to admission. Information gained at the time of the assessment helps to develop the care plan that is subsequently put into place. The manager states in her annual quality assurance assessment that she plans to work on the assessment process by further developing the person centred approach. Both the statement of purpose and service users guide are up to date and clearly outline the ethos of the home and the services provided. Relatives who commented quoted information that they had read in the service users guide and confirmed that they had had enough information on the home prior to their relatives admission. The format of the service users guide is written and pictorial and may help with communicating some of the information to residents who generally have high dependency needs in relation to communication. Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Whilst care planning at the home is detailed and contains relevant information a more person centred approach will promote and evidence more resident involvement, choice and objectives. EVIDENCE: The home has a comprehensive and detailed care planning system in place, which is kept under regular review. Aspects of the care planning system are person centred, showing residents preferences and choices whilst others require more detail to evidence this approach. Detail in the care plan is generally very good and people would be able to care for and support residents quite well, even if they did not know them. However, care plans did not always evidence what objective or goal they are aiming for and this should be considered in order to provide good outcomes for residents. The manager states in her annual quality assurance assessment that she plans to work on this aspect of the care planning and develop a more person centred approach. Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 11 Care plans were seen to be in place for all assessed needs and covered physical, social, emotional and psychological care needs. Daily notes reflected the care provided and residents’ current mood and wellbeing. The manager stated that at the current time no residents are actively able to have input into their care plan but records did not show that relatives had been involved either. This should be addressed and input developed. Relatives who commented said that they felt communication from the staff at the home was always good and they knew about the care of their relatives. One relative said that ‘my relative is superbly cared for’. Staff spoken to are ‘happy that they are able to provide a good level of care and support in an individual way’. A wide range of detailed risk assessments are in place within the care plan. These were seen to be up to date and individual to the resident, with evidence that residents are able to take risks within a safe environment. Risk assessments covered a wide range of subjects including falls, community access and fire safety. Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are able to access a wide range of activities, which the staff team are trying to develop further. Some activities need to have objectives to ensure that they are meeting residents’ needs and are of value. Food provision at the home is good. EVIDENCE: Records show that residents are able to take part in a wide range of activities and each resident has a weekly programme in place. The staff team do have an individual approach but records could evidence this more by being more person centred and having objectives and goals of what they are trying to achieve. From discussion staff are trying to promote independence but records do not always identify this. Daily notes do not always show what activity has been offered to the resident or if they have refused to participate. Records show that residents go swimming, sailing and to evening clubs where they can Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 13 do art and craft. Residents also access community resources in local day centres, where they do life skills etc., and also on an individual basis with keyworkers/staff. Some residents are able to attend computer classes held on a one to one basis in the home. A holiday is planned to Disneyland for some residents later this year and residents who decline can take advantage of days out instead. Residents do access the local community but sometimes the dependency level of residents can limit what they are able to take part in. Residents do go shopping and to local cafes etc. but the manager finds linking in with the local community sometimes limiting, although one resident does go out to sing with a local community group. Friends and family are welcomed at the home and invited to specific events and festivals. Relatives do stay for meals and relatives who commented confirmed this. The residents also visit other Norwood homes for special functions where they get to meet other residents. Residents are also able to make full use of a well equipped sensory room that the home has where equipment can be tailored to meet individual needs. Residents do go on home visits and attend the synagogue on weekends should they choose. From discussion, the manager is keen to widen the scope of the activities and resources available to provide more choice and ensure that the skills of residents are optimised and their independence promoted. Norwood do have a volunteer scheme which they actively promote and encourage people to visit the residents in the home. One resident actively takes advantage of this and has a regular visitor via this scheme. Healthcare professionals who commented stated that the home ‘ responds to socio/cultural and religious needs well’. All the staff have a current food hygiene certificate and the chef has worked in the home for some time and knows the residents well. Records show that the chef has an extensive list of residents’ preferences and staff use varying communication tools, such as objects of reference to communicate with residents about meals and other subjects. Residents at the home need different diets and these are appropriately catered for. Where required supplements and thickening agents are used. Pictorial menus are in place with good clear photos and the menus were seen to be varied. Where residents require particular input, the monitoring of their diet was seen to be detailed and would give a full picture for any specialist to review. Residents are also able to eat out of the home and plenty of fresh fruit and vegetables were seen to be available. Residents spoken to say that they enjoyed the food at the home. Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Care provision at the home is resident led and staff, who advocate for them well, proactively ensure that their healthcare needs are met. EVIDENCE: Within the care planning records, detailed notes evidence each residents’ daily routine. These notes show that staff appreciate residents’ choices with regard to the provision of their care. Records evidence that each resident is treated as an individual and that they have a diverse range of needs and preferences. Detailed information on methods of communication also help staff to ensure that residents preferences are understood and that they are satisfied with the care provision. From observation and discussion with staff it is clear that the team have a very resident led approach to the care provided and the statement of purpose outlines the good levels of experience that the staff have to support residents and the qualifications they have achieved. Records show that staff are trained in the specialist healthcare needs of residents as appropriate. Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 15 Records show that resident’s healthcare needs are met in a proactive way and advice offered is followed and recorded in the care plan. Residents have access to a wide range of specialists including physiotherapists, specialist consultants, dieticians, and psychiatrists. All aspects of their physical and mental health are attended to and this is evidenced within the care planning system. Healthcare professionals who commented said that the team at the home ‘always sought advice and advocated for residents appropriately’ and that ‘they had a good rapport with staff and advice was sought and acted upon’. Some residents do also access the services of alternative therapists, for example aromatherpists. The manager states in her annual quality assurance assessment that she plans to introduce health action plans to further develop a proactive approach to the health of residents. District nursing staff commented that the approach to resident’s healthcare at the home was proactive and there was an excellent team working with the residents. On touring the home it was noted that specialist equipment was available and in use by residents, including specialist chairs, beds and mobility aids. Relatives who commented said that they were always kept up to date with any important issues and one said the that the communication from the home was ‘excellent’ and that the staff ‘push to get better provision/services for residents’. The team are using an MDS system, which was checked and found to be managed well. MAR sheets were clear, appropriately signed and there was evidence of medication reviews. A returns system is in place with records maintained and at the current time no controlled drugs are being held. The manager operates a triple signing system and there are weekly medication audits to ensure that the system is being managed efficiently and in the best interests of residents. Training records show that all staff who are involved in the administration of medication are up to date with their training. Where required staff have been appropriately trained to administer specialist medications. Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has systems in place that help to ensure that residents will be listened to and their rights protected. Arrangements for the protection of vulnerable adults are in order. EVIDENCE: The home has a satisfactory complaints procedure in place. This is available in a written and pictorial format. The home has not received any complaints since the last inspection and on discussion the manager would record any level of concern on the complaints system. All complaints would be fully reviewed by a third party to ensure that it had been dealt with appropriately. All of the relatives who commented said that they know of the procedure and would be happy to raise any concerns with the manager. Relatives who commented were very satisfied with the standards of care at the home, often saying that it was ‘excellent’ and the care was of a high standard. Many of the relatives who commented also could also not find any area for improvement as they felt the home was so well run. Up to date adult protection policies are in place and the manager is aware of current local guidance, which she also has at the home. Records show that all staff are up to date with training in adult protection. At the current time none of the residents at the home are using advocacy services. The manager does have information available should the need arise. It may be of value to place this information in the pictorial complaints procedure where advocacy is highlighted. Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 17 Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Woodcock Dell has a pleasant environment to live in that meets the needs of residents. Some systems in the home need to improve to ensure resident and staff safety. EVIDENCE: A partial tour of the home was undertaken and where possible, residents’ rooms were also viewed. A redecoration programme is in place and in the next few weeks the home is going to have the hallways and two bedrooms decorated. Where possible residents are involved in the redecoration of their room although staff often have to interpret residents’ choices due to communication difficulties. Colour choice is often linked to a favourite item of clothing or personal possession. It is positive to see the level of thought is given to residents’ preferences. The manager is also currently arranging the fitting of sealed wooden flooring to the hall areas and landings, giving the home a younger more up to date feel. The lounge will be re-carpeted as this is Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 19 more suitable for residents, as some choose to spend time sitting on the floor. From discussion, changes to the home are very residents led and much thought is given as to what would enhance the home and quality of life for residents. The home has good bathrooms and communal toilets that are homely and not too clinical. Residents’ bedrooms are very personalised and show that a lot of personal interests are respected. Residents’ spoken to were happy with their rooms. The home was seen to be very clean and no odours were noted. Relatives who commented all felt that the home was clean and fresh. Since the last inspection a floor has been replaced in the downstairs bathroom and the floor/platform work in the laundry has been attended to. On inspection, the home has limited infection control procedures and advice in place and this should be addressed. It may be of value to link in with the local community infection control team for up to date local advice. It was also noted from training records that staff are not currently provided with infection control training and this should be reviewed. Work has been carried out in the garden area and this is still underway. Many of the residents enjoy the garden and access is good with plenty of hard standing and raised beds. The staff are planning to provide more sensory plants and create a more welcoming area to enjoy. Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents can be assured that they are cared for by a stable and well-trained staff team who are committed to providing a good level of care. EVIDENCE: The home has a very stable staff team, many of whom have worked at the home a long time. There has been no turnover of staff in the last 12 months and no recent agency use. This is positive with regard to a consistent approach and outcomes for residents. The home currently has 5 care staff on each day duty and 3 awake at night – the manager reports that this relates directly to the dependency of residents and a review is often prompted by changes in care needs. Relatives who commented were very complimentary regarding the staff team and their abilities. Comments included ‘they are always very helpful’, ‘the head of home always employs excellent staff’ and ‘our relatives key workers are great’. The home has only recruited one member of staff in the last two years. Staff files were checked and found to contain all the required checks and documentation to evidence a thorough recruitment process. Interview records Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 21 are also maintained. New staff are undertaking Skills for Care induction and the company do this on a cluster basis. Only one member of staff is currently undertaking this and the records were available for inspection. The induction was seen to be thorough and records very detailed. The manager of the home checks the induction work. The company provides a comprehensive training programme for its staff. Records show that compliance levels with training such as manual handling, health and safety, first aid and food hygiene are generally good but records are unclear and therefore show some shortfalls, which should be addressed. Staff spoken to at the home were positive regarding the training provided however there were concerns with regard to the manual handling training as this did not cover the resident group and equipment they used. This must be reviewed in order to ensure that residents’ needs are fully and safely met. NVQ training is also encouraged in the home and 15 out of the 17 staff have achieved NVQ level 2 and above. Additional training is also provide to staff that relates directly to the resident group and care provision. Subjects are, for example, challenging behaviour, continence, sensory impairment awareness, epilepsy, autism, diabetes, person centred planning, risk assessments, makaton, equality and diversity. Records show that the staff team is quite diverse and have a good overall balance of skills and knowledge. Staff meetings are held regularly and records show that a wide range of subject areas are covered including aspects of individual residents care, which showed great insight into care provision and advocacy on behalf of residents, training needs, health and safety in the home, the premises, organisation of residents’ activities and holidays etc. Action points are raised and the subjects covered evidenced a very resident led and professional approach by staff, which benefits residents. Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home is professional and efficient which helps to maintain and improve standards in the home so that outcomes for residents are positive. EVIDENCE: Good systems, records and standards of care at the home evidence that the manager runs the home in an efficient and professional manner. Records from meetings show that the manager has an open approach and deals with issues well, giving staff opportunities to raise any issues. Relatives who commented said ‘the home is well run and I am happy with the care of my relative’ and ‘the head of home is the best we have seen and so very good at her job’ Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 23 Regulation 26 reports by the company are inconsistent and no records were available to show that the manager and home had been visited at all in 2007. This must be addressed. The manager has a business plan in place, which contains some good development information, with some areas very service user orientated and empowering. It would be good to see this develop further and to show they are going to achieve the objectives identified. The manager is still developing the quality assurance programme at the home and on discussion; this is the main area for work in the home. Residents are only able to have a limited input but more thought could be given as to different ways to obtain their feedback other than questionnaires. Good questionnaires have been developed for relatives but on use their was a poor response rate as relatives had no issues with the home and said they would come to see the manager if there was. Again different ways should be sought for obtaining feedback in order to help developments in the home. Relatives who commented to the CSCI said that ‘The standards at the home are very high and I cannot suggest any improvements’ - ‘my relative could not be in a better home, the staff and facilities are wonderful’ - ‘we know our relative is in safe hands’ and ‘I cannot think of anything that the home doesn’t do well’. Internal business checking systems are in place along with audits on health and safety, medication, residents’ finances etc. The home has a health and safety policy in place and safe working practice risk assessments have been completed. These were seen to be up to date. A health and safety audit was completed in January 2007, completed by the company’s health and safety officer and the manager. No real issues were raised and the results were good results as expected. Accident records were reviewed and a minimal number of accidents were noted. Staff record detailed records and these are more on odd incidents or bruises noted rather than accidents. This is seen as a good level of recording. Arrangements for fire safety were seen to be in order with equipment being maintained and checked, fire drills being carried out and a comprehensive fire risk assessment system in place. Training records show that staff are generally up to date with fire safety training but there are shortfalls that need to be addressed, where staff have not had up to date training. Maintenance and safety certification for fixtures and equipment in the home were randomly checked and found to be satisfactory with no outstanding remedial work. Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 24 Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 25 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 4 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 4 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X 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 4 X 3 X 2 X X 3 x Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 26 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 YA7 Regulation 15 Requirement Where possible either the resident or their representative should be involved in the care planning process. All staff should be up to date with fire safety training and infection control training. Staff must be provided with appropriate manual handling training that relates to the needs of the residents and equipment used within the home. This is a repeat requirement. The registered provider should visit the home monthly and provide written evidence of the visit that is available for inspection. This is a repeat requirement. Timescale for action 30/08/07 2 3 YA35 YA42 YA35 18 and 23 18I(i)&13(5) 30/08/07 30/08/07 4 YA37 26 30/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 27 No. 1. 2. 3. 4 Refer to Standard YA6 YA14 YA30 YA39 Good Practice Recommendations Care plans should be developed further to incorporate a more person centred approach with individual goals and objectives identified. Records should improve with regard to activities offered to residents that they have refused. Up to date infection control procedures should be in place and local guidance should be sought from the Community Infection Control Nurse The quality assurance systems in the home should continue to be developed especially in relation to feedback from residents. Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH 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 Norwood 1 Woodcock Dell DS0000017500.V343853.R01.S.doc Version 5.2 Page 29 - 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. 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