Inspection on 20/01/05 for Norwood 30 Old Church Lane

Care Homes For Adults (18 ­ 65)30 Old Church LaneStanmore Middlesex HA7 2RFUnannounced Inspection20th January 2005 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment 30 Old Church Lane Address 30 Old Church Lane, Stanmore, Middlesex, HA7 2RF Email address carltonavenue@norwood.org.uk Name of registered provider(s)/company (if applicable) Norwood Name of registered manager (if applicable) Mrs Bridget Ann Iannotta Type of registration Care Home No. of places registered (if applicable) 8 Tel No: 020 8954 6566 Fax No: 020 8385 7697Category(ies) of registration, with (number of places) Learning disability (8) Registration number G110000024 Date first registered 4th December 1997 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 28th July 2003 YES NO 11/5/04 If Yes refer to Part C30 Old Church LanePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 320th January 2005 07:45 am Judith BrindleID Code107224Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMs Mariliya Johnson (Senior Support Worker)30 Old Church LanePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 ­ 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Providers Response Providers Comments Action Plan Providers Agreement30 Old Church LanePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of 30 Old Church Lane. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.30 Old Church LanePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 30 Old Church Lane is a Jewish care home registered to provide personal care and accommodation for 8 adults with a learning disability. The proprietor is Norwood. The home is located on the outskirts of Stanmore. The shops, banks, restaurants and other amenities of Stanmore are within a short drive or walk from the care home. Bus and train public transport services are located close to the home. The home was opened in 1997 and consists of a large detached two-storey building, within a residential area. All the homes bedrooms are single. The home includes a flat where two service users are accommodated. The home has an accessible well-maintained enclosed garden.30 Old Church LanePage 5 PART ASUMMARY OF INSPECTION FINDINGSInspectors Summary (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The unannounced inspection took place during the day in January 2005. The inspector was pleased to meet and talk to several service users and staff during the unannounced inspection. The service users at 30 Old Church have varied needs. The service users (without a verbal impairment) expressed satisfaction with the care that they were receiving from the service. Service users were observed to access communal areas of the home freely, one service user kindly showed the inspector her bedroom. Staff and service users were very welcoming and staff provided the inspector with requested information and documentation. Most of the previous requirements had been met. 17 standards were assessed. All the standards were met or partially met. Choice of Home (Standards 1-5) 1 of the 1 standard assessed was met. Arrangements are in place for meeting the assessed needs of service users. Care plans recorded evidence of comprehensive individual assessment. Individual Needs and Choices (Standards 6-10) 2 of the 2 standards assessed were partially met. All the service users have individual care plans. There needs to be evidence of regular review of guidelines and risk assessments. Lifestyle (Standards 11-17) 4 of the 4 standards assessed were met. Arrangements are in place for meeting the activity needs of service users. Service users are supported in developing independent living skills. Service users maintain contact with relatives and significant others. Meals provided were judged wholesome and varied. Personal and healthcare support (Standards 18-21) 2 of the 2 standards assessed were met. Arrangements are in place for meeting the assessed health and personal care needs of individual service users. Concerns, Complaints and Protection (Standards 22-23) 1 of the 2 standard assessed was met. Policies and procedures are in place in regard to complaints and adult protection. One requirement arose from the assessment of these standards. Environment (Standards 24-30) 3 of the 3 standards assessed were met. The environment of the care home is clean, and warm. Service users access communal spaces freely. The home is well maintained, and homely. Furnishings and fittings are of quality. Staffing (Standards 31-36) 2 of the 2 standards assessed were met Arrangements are in place to meet the staffing needs of the service. All service users have 30 Old Church Lane Page 6 key workers. Staff have knowledge and understanding of the needs of service users. Appropriate staff communication systems are in place. Conduct and Management of the Home (Standards 37-43) 1 of the 3 standards assessed was met. Health and safety monitoring systems are in place. One previous requirement in regard to quality assurance monitoring systems is outstanding. A requirement in regard to accident/incident reporting and recording needs to be actioned.30 Old Church LanePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)30 Old Church LanePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action · Reg 13(4) 14(2) 15,17 There needs to be evidence that the service users recorded individual behaviour guidelines are reviewed regularly. Service users progress records (following each shift) need to be up to date.1YA6 ·1/5/052Reg 13(4)YA9Service user individual night behaviour guidelines/risk assessments need further development and should have specialist input in this development. These behaviour guidelines need to be clear in regard to the staff role in monitoring service users at night.1/5/053Reg 22YA22The registered person needs to ensure that all concerns from relatives/significant others, 1/5/05 and service users are recorded and actioned. (Previous requirement.) The volunteer procedure needs to include documentation of the need for volunteers to receive a CRB check. (Previous requirement) The registered person needs to ensure that there are clear recorded details of student nurses role and responsibility, and that the student has a copy of this information.4Reg 13(6)YA311/5/055Reg 13(4)(6)YA331/6/0530 Old Church LanePage 9 6Reg 24YA39An extensive quality assurance system and annual development plan in regard to the service provided by the home needs to be developed. (Previous requirement) All accident/incidents need to be recorded in the accident recording documentation. Staff who carry out `in house activity sessions need to be aware of the accident procedure.1/6/057Reg 13(4) 17(2)YA421/5/05RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard * The registered person should review the issue that staff sometimes do not have time to record the daily progress records, particularly following the morning shift. There should be recorded evidence of more recent dental check ups for service users. · 3 YA24 · 4 YA33 It is recommended that the registered person contact the council regarding the collection of the household waste. The litter located at the front of the house should be cleared.1YA62YA19The CSCI should be kept informed of the progress of the temporary arrangement where the manager is managing another property as well as 30 Old Church care home.·Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.30 Old Church LanePage 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other enter details here `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES NA YES YES NA NO NA YES NO YES NO YES YES NA NA NA YES NO YES 4 0 0 YES NO YES YES X 0 20/1/05 7.45 5.030 Old Church LanePage 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.30 Old Church LanePage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · Prospective service users have the information they need to make an informed choice about where to live. Prospective service users individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 ­ 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users guide. X X Range of fees charged From To £ £ (per week) YES Any charges for extras If yes, please state what the extras are Key findings/Evidence This standard was not assessed. Toiletries, newspapers/magazines and hairdressing appointments. 0 Standard met?Standard 2 (2.1 ­ 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 0 Key findings/Evidence Standard met? This standard was not assessed.30 Old Church LanePage 13 Standard 3 (3.1 - 3.10) The registered person can demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The three care plans that were inspected all confirmed that service user needs were assessed and that these assessed needs were regularly reviewed. Prospective service users receive an initial assessment (Halo) from the manager and the Organisations allocations co-ordinator. The care home is a Jewish home providing kosher service. All the service users are Jewish. Records and staff confirmed that staff receive training in understanding the Jewish way of life, and in the communication needs of service users. Service users have the opportunity to participate in the Jewish Way of Life weekly sessions. Staff were observed to interact with service users in an understanding, sensitive and positive manner. Records informed the inspector that arrangements were in place for meeting service users health, social and welfare needs. One service user has an advocate. The home does not provide intermediate/short term placements. Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 0 Key findings/Evidence Standard met? This standard was not assessed.30 Old Church LanePage 14 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: · · · · · 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.Standard 6 (6.1 ­ 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 2 Key findings/Evidence Standard met? All the service users have an individual service user plan. A sample of three care plans was inspected. These recorded evidence of review. Dates of planned individual care plan review meetings were recorded. The care plans included comprehensive documentation in regard to assessment of service users needs. These needs included medical and health needs, religious needs, interests, and preferred routines. Specific guidelines in regard to service users behaviour that might challenge the service were recorded. There was evidence of specialist psychologist input into the development of these guidelines. Some recorded behaviour guidelines need evidence of having been reviewed recently, some were dated 5/1/00, others May 2002 and May 2003. In a care plan inspected it was recorded that a procedure and guidelines in regard to a service users behaviour needed to be reviewed monthly. The procedure according to records had not been reviewed since October 2004. Individual risk assessments were recorded. Individual goals were recorded in the care plans inspected. Behavioural observation charts were generally well recorded. Daily records of individual service users progress were recorded, but there were gaps in some recording, particularly following the morning shift. Staff informed the inspector that there was often little time to complete these records (particularly in the morning) and to review care plans. The registered person should review this. Daily progress records need to be recorded and up to date.30 Old Church LanePage 15 Standard 7 (7.1 ­ 7.7) Staff respect service users right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 8 (8.1 ­ 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 9 (9.1 ­ 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service users individual Plan and of the homes risk assessment and risk management strategies. 2 Key findings/Evidence Standard met? The home has a risk assessment policy, and a missing persons policy. The care plans inspected recorded evidence of individual forms in regard to missing persons, which included a photograph of the service user. There was accessible comprehensive documentation in regard to the staff on call and emergency procedure. All the care plans inspected recorded evidence of individual risk assessments. Night staff guidelines were recorded. Service user individual night behaviour guidelines/risk assessments need further development and should have specialist input in their development. These guidelines need to be clear in regard to the staff role in monitoring service users at night.30 Old Church LanePage 16 Standard 10 (10.1 ­ 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the homes written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 0 Key findings/Evidence Standard met? This standard was not assessed.30 Old Church LanePage 17 LifestyleThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 11 (11.1 ­ 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? There was recorded evidence of each service user having a comprehensive individual activity programme. Records, staff and a service user, informed the inspector that service users were encouraged and supported, in the participation of in everyday living skills. Care plans included aims, needs, action in regard to domestic skills and life skills. A service user was observed being supported by staff to prepare her breakfast. A service user spoke of tidying his room. Recorded planned service user activities on the day of the inspection included college, dance and movement, and fitness. Jewish festivals are celebrated within the home. The home has access to a cultural advisor who visits the home on a weekly basis. Records and a service user confirmed that the home promotes and encourages cultural awareness. Standard 12 (12.1 ­ 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 0 Key findings/Evidence Standard met? This standard was not assessed.30 Old Church LanePage 18 Standard 13 (13.1 ­ 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? Local facilities and amenities are several minutes walk from the home. Service users have access to transport, which includes taxis. Service users accessed community facilities during the unannounced inspection. Each service user has an individual activity plan. Service users were aware of this their activity plans. Records, service users and staff informed the inspector that service users have the opportunity (supported by staff, family, advocate and significant others) to participate in the community. Activities included, holidays, meals out, the pub, walks, swimming, shopping, cinema, and the hairdresser. The individual care plans recorded goals in regard to community presence and community participation. Standard 14 (14.1 ­ 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. Key findings/Evidence Standard met? This standard was not assessed. (See standard 11 and 14.)0Standard 15 (15.1 ­ 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Records, service users and staff confirmed that all service users maintain family links and friendships outside the home. A service user spoke of visiting his family regularly. Records informed the inspector that relatives/significant others regularly visit service users 30 Old Church Lane. There are communal areas, and service users own rooms accessible to meet friends and relatives. There are also rooms within the home, which could be used if service users wish to meet visitors in private, away from their room. An appropriate risk assessment in regard to intimate personal relationships was recorded in a service user plan inspected. This was dated 29/4/04 and should be more frequently reviewed (see Standard 9 in regard to review of risk assessments) particularly in regard to on going issues.30 Old Church LanePage 19 Standard 16 (16.1 ­ 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 17 (17.1 ­ 17.9) The registered person promotes service users health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The menu was displayed and available for inspection. This recorded varied and wholesome meals. As a Jewish home the food provided is kosher. A variety of foods were stored. These included fresh, frozen, dried and tinned foods. Fresh fruit was accessible. Eating and drinking risk assessments were recorded in individual service user plans. Specialist dietary needs were recorded. A service user was observed to freely access food (with staff support) for her breakfast.30 Old Church LanePage 20 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: · · · · 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 homes 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.Standard 18 (18.1 ­ 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users privacy, dignity, independence and control over their lives. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 19 (19.1 ­ 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) XX3 Key findings/Evidence Standard met? Arrangements were in place for meeting the personal support needs and healthcare needs of the service users. Records confirmed that service users have access to chiropody services, an optician, and dental services. One care plan inspected recorded that a service user had a dental check up on 9/9/02. There should be recorded evidence of more recent dental check ups. All the service users have key workers. Records informed the inspector that service users are supported in accessing specialist healthcare services as and when they need.30 Old Church LanePage 21 Standard 20 (20.1 ­ 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the homes policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 3 Key findings/Evidence Standard met? This standard was partially inspected. The home has an accessible medication policy and procedure. Medication is stored in a locked facility. Medication administration records were fully recorded. Two staff were observed to administer the medication. Records informed the inspector that staff had received administration of medication training in September 2004.Standard 21 (21.1 ­ 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 0 Key findings/Evidence Standard met? This standard was not assessed.30 Old Church LanePage 22 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: · · Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 ­ 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 0 0 0 0 2 X 2 Key findings/Evidence Standard met? Service users plans inspected recorded evidence that service users had received information/documentation in regard to the complaints procedure. The complaints procedure was displayed within the home. It is accessible in written and pictorial format. Records informed the inspector that the last recorded complaint was in 2001. There should to be evidence that service users, relatives and significant others are supported in communicating concerns as well as complaints, and that all complaints and `concerns are recorded and action taken by the registered person.30 Old Church LanePage 23 Standard 23 (23.1 ­ 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YESX3 Key findings/Evidence Standard met? The home has an adult protection policy and a whistle blowing policy (which was displayed). The home has the local authority policy/procedure and the organisations adult protection procedure, which is linked to the local authority procedure. Staff have received adult protection training. The home has a counter bullying procedure, harassment policy, and a protection of clients monies policy. Records informed the inspector that training for staff in regard to challenging behaviour was planned for February 2005, and that staff and service users had received assertiveness training in December 2004. Procedures and guidelines were recorded for staff to action in regard to behaviour from service users that might challenge the service.30 Old Church LanePage 24 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · 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.Standard 24 (24.1 ­ 24.13) The homes premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The home is located within a short drive or walk from Stanmore. It is in keeping with other houses in the area. The inspector inspected some communal rooms, kitchen, bathrooms, and a service user kindly showed the inspector her room. Service users were observed to access communal areas freely during the unannounced inspection. The home was clean, warm and free from offensive odours. Furnishings and fittings were judged to be of quality. There was evidence of litter located at the front of the house and waste bins that should be emptied. It was recommended to the senior support worker to contact the council in regard to collection of the household waste (which the staff informed the inspector had accumulated due to not having been collected for two weeks). The litter located at the front of the house should be cleared.30 Old Church LanePage 25 Standard 25 (25.1 ­ 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) ­ single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite Key findings/Evidence This standard was not assessed. YES NO NO 8 7 0 0 Standard met? 0 8 00 0 0 030 Old Church LanePage 26 Standard 26 (26.1 ­ 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. Key findings/Evidence This standard was not assessed. Standard met? 0Standard 27 (27.1 ­ 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 28 (28.1 ­ 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? The home has a large kitchen, sitting room, and a separate dining/sitting room. There is also an art activity room and a music room accessible for service users art and music sessions. Service users were observed to freely access communal rooms during the unannounced inspection. There is a maintained enclosed accessible garden.30 Old Church LanePage 27 Standard 29 ( 29.1 ­ 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the homes stated purpose and the individually assessed needs of all service users. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 30 (30.1 ­ 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? The home was clean, airy and odour free during the inspection. The home has a clinical waste policy, and health as safety policies. The home employs a domestic staff member part time. The laundry is located away from food storage and food preparation areas. Soap and towels were accessible.30 Old Church LanePage 28 StaffingThe intended outcomes for the following set of standards are: · · · · · · 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 homes 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.Standard 31 (31.1 ­ 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and others roles and responsibilities. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 32 (32.1 ­ 32.6) Staff have the competencies and qualities required to meet service users needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 0 Key findings/Evidence Standard met? This standard was not assessed.30 Old Church LanePage 29 Standard 33 (33.1 ­ 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X X No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing 0 0 0X03 Key findings/Evidence Standard met? The staff rota was available for inspection. The staff names on duty were recorded on a notice board in the office. It records which service users are supported by which staff during the shift. Management `on call guidelines were recorded. There is generally four staff on duty in the morning and three to four staff in the afternoon. There is one member of staff on duty at night. At the time of the inspection the registered manager was working two days per week in the home and three days per week in another of Norwoods establishments. The CSCI had been informed that this is a temporary arrangement. The CSCI should be kept informed of the progress of this arrangement. Records confirmed that specialist services such as dietician, and psychologist, are accessed via a referral system as required. There was a student nursing completing a three week placement at 30 Old Church at the time of the inspection. She was aware of her role and informed the inspector that she shadows staff and does not assist with the personal care of service users. She informed the inspector that she has completed a satisfactory Criminal Records Bureau check. The registered person needs to ensure that there are clear recorded details of student nurses role and responsibility, and that the student has a copy of this information.30 Old Church LanePage 30 Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? The home has a supervision policy. The home has an accessible grievance and disciplinary procedure. Records confirmed that staff had planned supervision, and that staff meetings take place. It was recorded in staff meeting minutes that staff management of service users behaviours was discussed. The inspector was informed that there was a staff meeting planned for the day following the inspection. Staff shift handovers take place. Appropriate communication systems were in place. These included a service diary; communication books and staff shift planners. Staff shift duties were displayed on a notice board in the office. Key worker responsibilities are recorded. Regular service provider audits take place.30 Old Church LanePage 31 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: · · · · · · · 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 homes policies and procedures. Service users rights and best interests are safeguarded by the homes 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.Standard 37 (37.1 ­ 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. Key findings/Evidence This standard was not assessed. YES 0Standard met?Standard 38 (38.1 ­ 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not assessed.30 Old Church LanePage 32 Standard 39 (39.1 ­ 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 2 Key findings/Evidence Standard met? A previous requirement needs to be met.Standards 40 (40.1 ­ 40.6) The homes written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 0 Key findings/Evidence Standard met? This standard was not assessed.Standard 41 (41.1 ­ 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met ? This standard was not assessed.30 Old Church LanePage 33 Standard 42 (42.1 ­ 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? There is a fire risk assessment, which had been reviewed in December 2004. Service user care plans included information and documentation in regard to individual fire risk assessment. The last recorded fire drill, took place on 15/1/05. Fire equipment is regularly serviced. Health and safety monitoring checks take place. The home has a food policy. This policy had been signed as read by staff. Records confirmed that staff had received food and hygiene training. The temperatures of the fridges and freezers are checked by staff and a record maintained. Accidents/incidents records were available for inspection. There was information recorded in the daily records in regard of an accident/incident dated 18/1/05. This needs to be recorded in the accident recording documentation. Staff who do `in house activity sessions need to be aware of the accident procedure. Standard 43 (43.1 ­ 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 3 Key findings/Evidence Standard met ? There were no indicators during the announced inspection that the home was not financially viable. 30 Old Church Lane forms part of a group of care homes for which Norwood is the registered provider. The inspector viewed the current Certificate of Employers Public Liability Insurance certificate, which was displayed in the home; this expires on 31/3/05.30 Old Church LanePage 34 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second InspectorJudith BrindleSignature Signature SignatureRegulation Manager Gail Freeman Date 11/3/0530 Old Church LanePage 35 Public reports It should be noted that all CSCI inspection reports are public documents.30 Old Church LanePage 36 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 20/01/05 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleAction taken by the CSCI in response to provider comments: 30 Old Church Lane Page 37 Amendments to the report were necessaryNOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateNONONONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 9 March 2005 , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESNONOOther: enter details here NO30 Old Church LanePage 38 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Norma Brier of Norwood, 30 Old Church Lane confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I Norma Brier of Norwood, 30 Old Church Lane am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.30 Old Church LanePage 39 30 Old Church Lane / 20th January 2005Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000017550.V183168.R01© This report may only be used in its entirety. 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