Inspection on 05/04/05 for Norwood 1 Woodcock Dell

This inspection was carried out on 5th April 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 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Norwood 1 Woodcock Dell 22/06/07

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 Avenue Kenton Middlesex HA3 0PW Lead Inspector Andreas Schwarz Unannounced 5 April 2005 09:00 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. Norwood Version 1.10 Page 3 SERVICE INFORMATION Name of service Norwood Address 1 Woodcock Dell Avenue Kenton Middlesex HA3 0PW 020 8385 0980 020 8908 0469 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) Norwood CRH, PC 8 Category(ies) of LD - 8 registration, with number OP - 8 of places Norwood Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: No conditions of registration. Date of last inspection 24th February 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 busroutes. 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.At the time of the unannounced inspection the manager was Ms Vicky Weir. The Registered Provider is Norwood. The home is also known as Lady Cohen House. Norwood is a registered charity. Norwood Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 9.30am. It took part over three and a half hours during the morning. The inspector spoke to one service user, the manager and two members of staff. The manager showed the inspector around the home. The inspector examined records and observed staff interacting with service users. All residents were in the home during this unannounced inspection. What the service does well: What has improved since the last inspection? This inspection followed shortly after the previous inspection and the home received the draft report a day before this inspection. Nevertheless, the manager had resolved some requirements, e.g. evidence that staff read risk assessments, tiles in downstairs bathroom have been replaced, temperature valves have been fitted to regulate water temperature and correct fridge and freezer temperature are now constantly maintained. Overall standards of care have not changed since the last inspection. Norwood Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Norwood Version 1.10 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 Norwood Version 1.10 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 The home has a detailed service users guide and statement of purpose in place, which are available in a format accessible to service users. EVIDENCE: The inspector assessed the homes service users guide and statement of purpose, both documents are of high standards and are available in symbols to make them more accessible to service users. These documents are in service users files and the manager informed the inspector that staff explained the contents to the service users. The manager is however still required to do some additional work to comply with National Minimum Standards, see schedule. Norwood Version 1.10 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 standard(s) 6; 9 The home has good care plans and risk assessments for all service users in place, these documents are reviewed in regular intervals. Risk assessments are read by staff. EVIDENCE: The inspector assessed two care plans and risk assessments during this visit, these were found to be of high standards and very detailed. It was evident that the assessed service users attend regular clinical appointments, such as dentist, psychiatrist, optician, etc. Care plans include personal care guidelines and service users weight is monitored regularly. The inspector found care plans to be reviewed on a monthly basis internally and every six months with social workers. External reviews are minuted, the inspector recommends to be more detailed when writing review minutes. Families, friends, clinicians are actively encouraged to attend. The inspector found the required picture missing in one of the assessed care plans. Risk assessments were found to be of good standard. All risk assessments had an additional signatory sheet; this allows the manager to assess if staffs have Norwood Version 1.10 Page 10 read the risk assessments. Risk assessments are reviewed regular and changed if there is a need to do so. Norwood Version 1.10 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 standard(s) 13; 17 Service users take a positive part and are integrated within the community. Meals are judged as being wholesome and culturally appropriate and service users were observed enjoying the lunch during this inspection. EVIDENCE: The inspector viewed service users day service plans and spoke to the manager. Service users living in the home don’t attend formal day centres; day service is provided by the home. Service users have structured in house activities such as aromatherapy, sensory session, etc. and a go to the local community for swimming sessions, cinema, bowling, etc. The inspector recommends having a separate book to document these sessions. The home adheres to Jewish traditions and celebrates Sabbath and other Jewish festivals. Service users have the choice to participate in these. The home offers the opportunity to attend the synagogue on Saturdays. The inspector observed meal preparation and meal times. The inspector spoke to the cook and viewed the homes menus. The home provides kosher meals and has been assessed by the London Beth Din Kashrut Society commending the home for the food provided. Mealtimes Norwood Version 1.10 Page 12 have been observed as being relaxed and service users needing assistance with feeding receive the appropriate help. The inspector did not sample the food but observed the cook. The meal is served appetising and the smell was wonderful. The home records the food eaten by service users. The inspector recommends including service users likes and dislikes in the homes menu file. Norwood Version 1.10 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 standard(s) 19; 20 Service users physical and emotional needs are judged as being attended too. The overall medication administration and control of medication was judged of being of good standard. EVIDENCE: The inspector assessed service users health records; guidelines and any other documentation within service users care plan files. It was evident that the home has good links with Harrow and Brent Learning Disability Teams to receive clinical input such as Psychology, Speech and Language Therapy, Psychiatry, etc. Clinicians are actively encouraged to attend service users review meetings. Necessary equipment such as hoist, wheel chairs and lift are serviced at regular intervals. All service users have a key worker allocated, who ensures care plans are reviewed regularly and service users health and emotional needs are attended to. The inspector viewed guidelines in regards to service users behaviour, which are of high standards. The inspector viewed the homes medication policy, records and storage. The home has a robust medication policy in place, which is written with regard to Royal Pharmaceutical Guidelines. Each service user has individual Norwood Version 1.10 Page 14 medication procedures. PRN medication is checked weekly. The inspector did assess one service users medication, which was found to be in order. Norwood Version 1.10 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 standard(s) 23 The homes Protection of Vulnerable Adults (POVA) procedures are judged as being satisfactory and service users are protected from abuse. EVIDENCE: The inspector viewed Norwood’s POVA policy, which is of good standard, but was found not to be detailed enough. The policy did not include the CSCI address and the Social Services address; this is required. The home has policies relating to issues of abuse, i.e. Bullying, Staff accepting Gifts and Protection of Service Users money. Staff confirmed that they have received abuse training and showed good understanding of what to do when dealing with allegations of abuse. Norwood Version 1.10 Page 16 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; 30 The inspector judged the home as being personal, homely, comfortable and safe. On the day of the inspection visit the home was clean and free of any offensive smells. EVIDENCE: The home is a large home and is throughout accessible for people needing to use a wheel chair. The home has a large lounge, dinning area, separate room for activities and Sensory room. Service users rooms are spacious and allow for movement with a wheel chair. The inspector judged the ground floor bathroom of needing redecoration; this is required. The home does not offer short-term placements. The inspector judged the home as being clean and with a lot of sources of natural light. The home is close to local bus routes, Harrow shopping centres, Wembley, etc. Furnishing is of good standards and the home has a maintenance programme in place. The inspector found some previous requirements outstanding; please see schedule. The manager showed the inspector around the home, laundry facilities were judged as being adequate. The home has a commercial washing machine and dryer. The washing machine has a sluice programme. The laundry room is separate to food preparation areas. The floor in the laundry room is of Norwood Version 1.10 Page 17 acceptable standard, however the raised platform in the laundry room needs waterproofing and sealing. The home has relevant policies in place. Norwood Version 1.10 Page 18 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) 34 The inspector judged the homes recruitment policies and procedures satisfactory. EVIDENCE: The inspector viewed the homes recruitment policy, which was found to be of good standards and new employees provide relevant documentation. The manager has not been registered with the CSCI and is required to do so. The manager informed the inspector that new staff will have a probationary period and CRB checks are obtained for all new staff. The home recruits centrally and has an Equal Opportunities Policy in place. Norwood Version 1.10 Page 19 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) The inspector did not assess the above standards. EVIDENCE: Norwood Version 1.10 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 x x x x Standard No 22 23 ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 2 Standard No 11 12 13 14 15 16 17 x 3 x x x x 4 Standard No 31 32 33 34 35 36 Score x x x 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x Norwood Version 1.10 Page 21 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 YA1 Regulation Requirement Timescale for action 31/05/04 2. 3. 4. 5. 6. 7. 8. 9. 10. YA1 YA1 YA1 YA6 YA23 YA24 YA24 YA30 YA34 4c The manager is required to Sdhedule1 include the registerd providers name, address and qualification in the Statement of Purpose. 4(2) The manage is required to supply a copy of the Statement of Purpose to the inspector 5(1)(f) The manager is required to include CSCI name and address in the srvice users guide 5(2) The manager is required to supply a coppy of the service guide to the inspector. 17(1)(a) The manger is required to Schedule include service users picture in 3(2) care plans 13(6) The manager i equired to include CSCI and Social Services address in POVA policy. 23(2c) The manager is required to arrnage for the ground floor bathroom to be redecorated. 23(2c) Downstairs bedroom doors which are damaged must be renovated 23(2c) The manager is required to waterproof and seal the raised platform in the laundry room 8;9;10 The manager is required to register with the CSCI. 31/05/05 31/05/04 31/05/05 31/05/05 30/06/05 30/09/05 31/05/05 31/05/05 31/07/05 Norwood Version 1.10 Page 22 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. 4. Refer to Standard YA6 YA13 YA17 Good Practice Recommendations The inspector recomends to provide more detailed review minutes. The inspector recomends to have a book to document service users activities. It is recomended to document service users likes and dislikes. Norwood Version 1.10 Page 23 Commission for Social Care Inspection 4th Floor, Aspect Gate 166 College Road Harrow Middlesex, HA1 1BH 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 Norwood Version 1.10 Page 24 - 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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