Inspection on 31/07/07 for Norwood 30 Old Church Lane

This inspection was carried out on 31st July 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Norwood 30 Old Church Lane 04/04/06

Norwood 30 Old Church Lane 01/11/05

Norwood 30 Old Church Lane 20/01/05

Norwood 30 Old Church Lane 11/05/04

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 30 Old Church Lane 30 Old Church Lane Stanmore Middlesex HA7 2RF Lead Inspector Judith Brindle Key Unannounced Inspection 31st July 2007 08:50 Norwood 30 Old Church Lane DS0000017550.V340849.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 30 Old Church Lane DS0000017550.V340849.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 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norwood 30 Old Church Lane Address 30 Old Church Lane Stanmore Middlesex HA7 2RF 020 8954 6566 020 8385 7697 oldchurchlane@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) Peter Patrick Behan Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th April 2006 Brief Description of the Service: 30 Old Church Lane is a Jewish care home registered to provide personal care, and accommodation for 8 adults with learning disabilities. 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. There is parking for several cars on the forecourt area of the care home. Fees vary according to the needs of the people using the service, and information about the fees is accessible from the provider. The care home has accessible information about the service that it provides. Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place throughout a day and a half in July and August 2007. There were no vacancies at the time of the inspection. The inspector was pleased to meet and talk with the people living in the home, and with the staff on duty. Several of the service users who live here are not able to hold lengthy vocal conversations but all can make at least some of their needs known in other ways, such as by signing and/or by various sounds. Due to these needs observation was a significant tool used in this inspection. Staff were very helpful during the inspection, and supplied all documentation, and information requested by the inspector. The registered manager was not present during the first day of the inspection, due to annual leave, but a senior care staff member was present during this time. The registered manager was present during the second day of the unannounced inspection. A resident’ advocate kindly spoke with the inspector during the inspection. The inspection focussed on spending time talking with people living in the care home, and to care staff, and observing interaction between residents and staff. Documentation inspected included, resident’s care plans, residents’ financial records, risk assessments, staff training records, and some policies and procedures. The inspection included a tour of the premises. Assessment as to whether the requirements from the previous inspection had been met also took place during the inspection. Staff and inspection of records confirmed that all but one of these had been met by the service. 27 National Minimum Standards for adults, including Key Standards, were inspected during this inspection. The inspector thanks all the people living in the care home, the staff, and the visitor for their assistance in the inspection process. What the service does well: The care home has a very welcoming atmosphere. Residents live in a homely environment. People living in the home were positive about the care home, and the staff, and confirmed that they were happy living in the home. There is close liaison with healthcare professionals and other specialists as and when required/needed by the residents. Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 6 People living in the care home are supported by staff to make life choices, to develop their independence, and be empowered. Residents are involved in the care home, and participate in completing household duties. Holidays for residents are a regular feature of the care home. Residents’ contact with relatives and others (as agreed by the residents) is fully supported and enabled by the care home. It was evident from talking to people living in the home, and from observation that they participate fully in their home, and are consulted and kept updated about the running of the home. A caring, well trained, and competent staff team demonstrate knowledge, and understanding of the varied needs of people living in the care home. Staff have a good understanding of the religious and cultural needs of people living in the care home, and ensure that these needs are met. The registered manager is experienced, competent, and well qualified. He is motivated and enthusiastic about his role and it was evident that he strives to continually improve the quality of the service for those living in the home. What has improved since the last inspection? What they could do better: There could be development in a variety of different and creative methods to help people who use the service contribute to their care plan, which could include improving the accessibility of the care plan for people using the service. There could be more evidence of the care plans being a working tool used by the resident and all involved staff. Formats of policies/procedures, which are of particular relevance and interest to people using the service, could be improved to ensure that the information is accessible as possible to all residents. Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 7 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 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 8 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 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 9 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): Standard 1 and 2 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Arrangements are in place for prospective service users to have the information that they need to make an informed choice about where to live. Arrangements are in place to ensure that prospective resident’s needs are comprehensively assessed prior to their admission to the care home. EVIDENCE: The statement of purpose, and the service user guide documents include information about the service provided by the care home. The statement of purpose has been reviewed this year, and is displayed in the office. A copy of the service user guide is located within the care plan documentation of each person living in the care home, and it includes pictorial format. Records of resident’s fees were available for inspection. The manager confirmed that he would record in the resident’s terms and conditions documentation the amount of fees paid. The care home has an admission procedure. There have been no new admissions to the care home for several years, and there are at present no vacancies. The admission procedure carried out by Norwood has been assessed during previous inspections. A summary of this procedure is recorded in the statement of purpose documentation. It is evident that this procedure includes a comprehensive initial assessment of a prospective Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 10 resident’s needs and abilities, which is carried out by the provider, with the person’s involvement, and participation from relatives, and others if applicable. The funding Local Authority also completes an assessment of the prospective resident during the referral process. A plan of care is developed from these assessments, and from visits to the home by the prospective resident, before admission, and during a trial period of residency. Staff confirmed that visits to the home prior to admission is supported and encouraged. Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 11 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): Standard 6,7 and 9 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that all residents have a plan of care, which sets out in some detail of how people living in the care home have their current needs and aspirations met through positive individualised support, but there could be development in a variety of different, and creative methods to help people who use the service contribute to their care plan. Residents are supported and encouraged to make decisions and choices, and are supported to take risks as part of an independent lifestyle. Risks are managed positively to help people using the service to lead the life that they want. EVIDENCE: All the people living in the care home have a plan of care. Four care plans were inspected. Each care plan includes comprehensive personal information about the person using the service, a ‘service user’ contract, assessed needs and guidelines to meet those needs. It was evident that since the previous Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 12 key inspection work has been carried out by staff to improve and develop the care plans. There is some comprehensive recorded information in regard to the assessed needs of residents, and staff guidance to meet those needs is very clear and thorough. There could be more evidence that the resident has been involved in his or her plan of care, for example staff had signed guidance, but generally this was not signed by people using the service, nor was it indicated if they were unable to sign. It was evident that care plans are regularly reviewed, but there should to be more evidence that resident’s recorded goals/objectives (short term and long term) are reviewed and evaluated regularly. The care plan should be a ‘working document’, and be more person centred, and include detail of how each individual person using the service aspirations, are to be met. The format of the care plans should include evidence of a variety of different and creative methods to help people who use the service to contribute in the development of their care plan, and the ongoing review process. Residents spoke of making choices. These include shopping for clothes, toiletries, food, and choosing preferred activities. During the inspection, staff were observed to consult with residents, negotiate with them, and to support them in making decisions. Residents have the opportunity to participate in regular resident meetings. It was evident from speaking to residents, observation, and inspection of records that the care home promotes the empowerment of residents, and respect is at the forefront of the service provided by the care home. Some residents have an advocate. The care home has a management of residents’ monies policy/procedure. The inspector was informed that people living in the care home receive varying levels of support regarding the management of their finances. Most (due to their needs), have significant support from staff with their monies. A senior staff member reported that all the residents have their own bank account. There was recorded evidence of assessment of residents’ individual financial needs. Three resident’s monies were inspected. Appropriate records of incoming and outgoing payments, and receipts are maintained. There was evidence of risk assessment documented in the care plans. These include bathing risk assessment, and moving and handling risk assessment. These recorded evidence of being regularly reviewed, but as with the care plans should record more evidence of resident’s participation and agreement of their risk assessments. There are clear agreed comprehensive documented procedures, staff guidance, and staff training regarding any limitations on freedom or choice, such as when there could be need for restraint if a resident might be at risk of injury. Risk assessments in regard to safe working practices were available for inspection. The care home has a missing persons procedure. Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 13 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): Standards 12,13, 14, 15, 16 and 17 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Central to the home’s aims and objectives is the promotion of the individual’s right to live an ordinary and meaningful life, both in the home and in the community. People living in the care home have the opportunity to take part in a variety of activities including those promoting personal development, independence, and being community based. Arrangements are in place to enable people living in the care home to maintain contact with family/significant others, as they wish. People living in the care home have their rights and cultural/religious needs respected and their responsibilities are recognised in their daily lives. Meals are chosen by people using the service, and are varied and wholesome, and meet the cultural and dietary needs of the residents. EVIDENCE: Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 14 The care home is within a few minutes walk or drive to a variety of amenities, which include, shops, banks, restaurants, and pubs. Residents spoke of the variety of activities including evening activities that they chose and enjoyed. These included ‘in house’ and community based activities. Several residents regularly attend a variety of day resource facilities during weekdays. There is a recorded comprehensive activities programme for each resident. Activities include, sing a long sessions, fitness sessions, aromatherapy, dance and movement, music and communication skills. A resident spent time enjoying a session of karaoke, he kindly showed me how the system worked, and demonstrated his singing skills. The manager spoke of there being ongoing development of preferred activities for residents. People using the service are supported to access college courses and employment initiatives. A resident spoke of enjoying the job that she and another person using the service do on a part time basis. People using the service were observed to participate in household duties during the inspection, which included clearing the dining table, taking out the rubbish, and helping to prepare meals. A person living in the home spoke of regularly preparing their own packed lunch. Another spoke of enjoying shopping, such as buying their own toiletries and clothes with staff support. A resident kindly offered and made me a cup of tea during the inspection. Three residents kindly spoke of the recent holidays that they had enjoyed, and of planned holidays. A resident went on a day trip to Brighton on the day of the inspection. A person living in the care home spoke of enjoying a recent barbeque. The registered manager reported that a section of the garden had been allocated for residents to grow flowers and vegetables. Activities supporting residents to meet their cultural needs took place during the inspection. Records, staff and residents confirmed that the diversity/cultural needs of residents were being met. A resident spoke of having enjoyed celebrating a Jewish festival with his family. It was evident from speaking to the residents, from observation, and from inspection of records that residents participate in a variety of chosen and meaningful activities according to their individual interests and capability, and that they were fully involved in choosing and planning their preferred activities. Residents who spoke with the inspector were aware of their activities that they were doing on the day of the unannounced inspection. People using the service have access to public transport, taxis and to two passenger vehicles. A staff member spoke of the support a resident has with communication skills, to enable them to participate as fully as possible in conveying their needs. The manager reported that there were plans for all staff to receive Makaton (a form of communication using signing) training, as some residents have some skills in communicating in Makaton. The manager reported that residents have access to the office computer and a computer located in the art room. Records confirmed that visiting times were flexible. The care home has a visitor’s recording book. Residents spoke of the contact that they had with Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 15 family, friends and significant others. There is an accessible telephone, which residents can use. It was evident that family contact with residents is encouraged and supported (if agreed by the resident). Records confirmed that family members attended care plan review meetings. An advocate spoke of attending theses review meetings, and confirmed that he was kept informed of the progress of the resident. Visitors are able to see residents in their own room or in the communal areas of the home. Staff were observed to respect resident’s privacy, and knocked on resident’s bedrooms doors prior to entering. People living in the care home were seen to choose when to be alone or in company, and made choices whether or not to participate in an activity. Residents were observed to freely access their own bedrooms and communal areas of the care home. The home has a no smoking policy. The menu confirmed that a variety of wholesome meals were provided, and that residents are involved in the planning, and choice of meals. Residents spoke of their enjoyment of the meals, and of being enabled to make snacks, and of participating in shopping for food items. Meals provided meet the cultural needs of the residents, all food is Kosher, and appropriate cooking facilities and food storage facilities are in place. Residents who kindly spoke with the inspector said that they enjoyed the meals provided. Meals were seen to be unhurried, and assistance and encouragement by staff was given to residents who need support with preparing and eating their meals. Residents and staff were knowledgeable of healthy eating. Records and staff confirmed that the care home ensures that fresh produce is used in the preparation of meals. The people living in the care home have their weight monitored. Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 16 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): Standard 18,19 and 20 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that resident’s individual personal and healthcare needs are met. Medication is generally stored and administered safely, but there needs to be improvement in regard to aspects of medication administration. EVIDENCE: The care plans included a record of residents’ personal care needs. Residents spoke of the support that they received in regard to meeting these needs. Personal support from staff is responsive to the varied and individual needs of the people who use the services. Residents are supported to be as independent as they are able in regards to taking responsibility for their care needs. Residents spoke of making choices. There was recorded evidence in the home, and information supplied to the Commission for Social Care Inspection on an on-going basis confirmed that changes in health needs are promptly identified at an early stage, and that advice from the appropriate healthcare professional is sought as and when Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 17 required. Records confirmed that residents have their health needs monitored by having access to care and treatment from a variety of healthcare professionals. These include GP and community nurse appointments, optician, dentist, chiropody and psychiatric care. Residents as needed, access additional specialist support and advice. Records confirmed that residents attend hospital appointments as and when required. A resident attended a dental appointment during the inspection. The care home has a medication policy/procedure. The medication storage and administration systems were inspected. Medication is stored securely. There was judged to be notable medication stock. A senior staff member spoke of plans to set up a separate stock control system to monitor the amount of medication stock. Medication administration records inspected were fully completed, and signed by staff. Records confirmed that staff receive medication training, which includes an ‘in house’ assessment of competency, and regular ‘refresher’ staff medication training. Two staff witness, and administer medication. Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 18 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): Standard 22 and 23 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Arrangements are in place for ensuring that complaints are taken seriously and handled objectively. There could be development in recording systems to ensure that it is evident that people using the service have all ‘concerns’ listened to an acted upon. Arrangements are in place to ensure that service users are protected from abuse, neglect and self-harm. EVIDENCE: The care home has a complaints procedure. This is included in the service user guide documentation, and contains information in regard to timescales in which action will be taken in response to a complaint. There have been no recorded complaints for a year. The manager reported that people using the service are supported and encouraged to communicate ‘concerns’/complaints during regular resident meetings. The manager should further develop ways to ensure that there is recorded evidence that the complaints procedure is accessible to all residents, and that all complaints/concerns are taken seriously and handled appropriately this could include ensuring that there is documentation of all ‘concerns’ communicated by residents. The care home has appropriate required policies and procedures in regard to responding to any suspicion or allegation of abuse. There is an accessible recorded whistle blowing policy. There was recorded evidence that staff had received Protection of Vulnerable Adults training. A recorded risk assessment Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 19 regarding ‘Dealing with Potential Protection of Vulnerable Adults issues’ included clear guidance, and scenarios (in conjunction with Harrow Multi Agency Safeguarding Adults policy and procedures) about reporting and recording suspicion or allegations of abuse. A staff member who kindly spoke to the inspector was aware of reporting and recording procedures in regard to an allegation of abuse. The home reports notifiable significant events that occur in the home to the Commission for Social Care Inspection as required. Records informed the inspector that there were guidelines in place for staff to meet the needs of residents who could challenge the service. Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 20 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): Standards 24, 25 and 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The environment of the home is safe, homely and comfortable. The premises are suitable for the care home’s stated purpose. Resident’s bedrooms are individually personalised, and meet their individual needs. The care home is clean, and odour free. EVIDENCE: The inspection included a tour of the premises. The physical environment of the home provides for the individual requirements of the people who use the service. The home is clean, light and airy. It was evident from speaking to residents and through observation, that people living in the care home are supported and encouraged to see the home as their own. Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 21 The home is generally well maintained. There have been some environmental improvements to the home since the last key inspection. These include redecorating of some communal areas and some bedrooms. Staff spoke of there being a rolling programme of general maintenance, and redecoration, and that that more refurbishment and redecoration is planned to the interior of the home. The home has a well maintained enclosed garden. The home has good access to local amenities and facilities. Public bus and train services are accessible close to the home. Residents spoke of ‘catching buses’ regularly as well as taking taxis. People living in the home were observed to freely access all areas of the home, including the office area. A resident kindly showed the inspector his room. The room was individually personalised. The home has an infection control policy/procedure. The laundry facilities are located away from food preparation and food storage areas. Residents and records confirmed that people living in the home participate in the care of their laundry. Staff have access to protective clothing such as disposable gloves, and aprons. Soap and hand towels were accessible in the bathrooms inspected. Records confirmed that staff had received infection control training. Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 22 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): Standards 32,33,34, 35 and 36 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff receive training to ensure that they are competent and skilled in regard to carrying out their roles and responsibilities. Arrangements are in place to ensure that residents are supported and protected by the care home’s recruitment policy and procedures. EVIDENCE: Staff were observed to interact with people living in the care home in a positive and respectful manner. Staff, records and residents confirmed that staff have understanding and knowledge of the varied needs (including cultural needs) of the people living in the care home. People living in the care home spoke positively about the staff, and it was evident during the inspection that residents knew staff well, and communicated with them freely. A resident spoke of the staff being ‘nice’. Residents who kindly spoke to me knew who their key worker was and spoke of the key worker as being supportive. Staff were observed to interact with residents in a positive and sensitive manner. Staff confirmed that staffing levels during the day reflect the needs of the people using the service, and that staff rotas are flexible in order to meet the lifestyle of residents, and their changing needs. Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 23 There were four staff on duty plus the manager and/or a senior staff member during both days of the inspection. There is a ‘sleep in’ member of staff on duty at night. The people using the service have varied multiple needs. The manager has recorded night risk assessments of each individual person using the service. Not all of these confirm that the people living in the care home are of minimal risk at night when there is not a waking night staff. Several residents, who have communication needs and more than a mild learning disability, have been assessed as being unable to initiate waking the ‘sleep in’ staff member if they had a need for support and care during the night. The inspector was informed that one resident does not ‘like’ climbing the stairs (the ‘sleep in’ staff sleeps up stairs). There is no call bell system in the home. There is an alarm system located upstairs which indicates when residents leave their bedroom at night, but this system is not linked to the ground floor bedrooms. The issue of staffing at night has been under review for sometime particularly following an allegation of a significant event having taken place at night. The registered person needs to provide evidence that all residents are of minimal risk to their health and safety in not having a wake night staff member on duty, particularly in regard to those residents who are unable to communicate whether they need care and/or support at night. Appropriate action needs to be put in place to meet any identified need. It is strongly recommended that that the Organisation’s person who carries out initial assessments of residents carries out an assessment review of the night needs of all the people using the service at 30 Old Church Lane. The care home has a staff recruitment policy and procedure. Staff personnel records were available for inspection. Three staff records were inspected. These included evidence that required checks had been carried out, including satisfactory enhanced Criminal Record Bureau checks. One staff file included one reference. There needs to be evidence of at least two references obtained prior to employment of staff to ensure that residents are supported and protected by the home’s recruitment practices. This was a previous inspection requirement. The dates of a staff member’s residency and work permit information was not clear. This was discussed with the registered manager, who confirmed following the inspection that this was being ‘looked into’ by the human resources department. Records and staff confirmed that staff receive a comprehensive twelve week induction programme (linked to Skills for Care) when they commence working in the home. On the first day of the inspection a ‘cluster’ (a staff member who works in several Norwood care homes) staff member was ‘shadowing’ staff during the inspection as part of her induction and orientation programme. The induction programme includes health and safety training, gaining knowledge and understanding of residents’ cultural and religious needs, and of getting to know the residents and of how to support them, and includes training/knowledge of the Jewish needs of the residents. Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 24 The care home has a training plan. Staff receive varied training, which includes statutory training such as food and hygiene training, moving and handling training, First Aid training, and specialist training such as managing challenging behaviour, risk assessment training, and ‘Service users point of view’ training, and diversity and equality training. Staff spoke of receiving ‘lots’ of training in which they have developed and gained their knowledge and skills. Staff confirmed that staff teamwork in the care home was good. It was evident that staff receive relevant training that is targeted and focused on improving outcomes for people who use the service. The manager reported that all staff had recently received appraisals, which he spoke of being a useful process in identifying the need, aims and objectives of the staff team. Records and staff confirmed that staff receive regular 1-1 supervision. The staff training programme includes NVQ level 2, 3 and 4 care (and management) courses. A senior staff member confirmed that one staff member is in the process of achieving an NVQ level 2 care qualification and that all other staff have completed NVQ level 2 and 3 care courses. Two senior staff members have recently achieved relevant NVQ 4 qualifications. This is commendable. Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 25 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): Standards 37,39 and 42 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The management approach of the care home creates an open, positive and inclusive atmosphere. The registered manager is qualified, competent and experienced to run the care home. Arrangements are in place to ensure that effective quality assurance and quality monitoring systems are in place to monitor and improve the quality of the service provision by the care home. Arrangements are in place to ensure that so far as reasonably practicable the health, safety and welfare of residents and staff is promoted and protected. EVIDENCE: The manager has managed the care home for over a year. He has had worked in care homes for a number of years and joined Norwood in 1999 and has Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 26 worked with adults with a learning disability since then, including working at 30 Old Church Lane. Prior to managing 30 Old Church Lane he managed another Norwood care home. In August 2006 he achieved an NVQ level 4 in Care and Management qualification. He was registered with the Commission for Social Care Inspection in June 2007. The manager spoke of undertaking periodic training to maintain and update his skills and knowledge, and gave examples of recent training courses that he had undertaken. It was evident that the manager knows the people living in the care home very well. Records, staff, residents and observation during the inspection confirmed that the manager is motivated and pro active in ensuring that people living in the care home are supported and enabled to be as independent as they are able, and to lead a fulfilling and positive lifestyle. Records, staff and residents confirmed that there are clear lines of accountability within the care home. Records confirmed that the manager had ensured that there was clear guidance for staff regarding provision of the service whilst he was away on annual leave. Observation and talking to staff during the inspection confirmed that they had knowledge of their roles and were carrying out their responsibilities competently. It was evident from speaking to the manager and from contact since the last inspection, records, and from talking to residents and staff that he communicates a clear sense of direction in ensuring that the care home provides a quality service, which is resident led. There is recorded evidence that since being in post the manager has worked hard to improve and to continue to develop systems in the care home to ensure that a quality service is provided to people using the service. The manager confirmed that he produces a business/annual development plan for the home annually. A copy of this plan was supplied to the Commission for Social Care Inspection in 2006. The manager reported that he supplies stakeholders including relatives and advocates of people using the service with annual questionnaires to obtain their views of the care home and the service that it provides. He reported that he, and a resident were in the process of developing an improved questionnaire for residents to complete. This includes pictorial format. This is positive. Records including policies and procedures recorded evidence of having been regularly reviewed and updated. Formats of policies/procedures of particular relevance and interest to people using the service could be improved to ensure that the information is accessible as possible to all residents. Staff meetings and also resident meetings take place on a regular basis. Certificates of worthiness in regard to the servicing of gas and electrical systems in the care home were up to date. Required fire safety checks are carried out. The home has a fire risk assessment, which has recently been reviewed. Each resident has an individual fire risk assessment, which includes his or her reaction and response to the fire alarm system going off. A copy of this documentation should be Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 27 filed with the fire risk assessment to ensure that this information is easily accessible. Fire drills are carried out regularly as required. The care home has a health and safety policy. Health and safety monitoring systems are in place. These include daily checks of fridge and freezer temperatures. The health and safety poster was displayed as required. Systems are in place to ensure that accidents and incidents are responded too and reported appropriately. The certificate of employer’s liability insurance was displayed and up to date. Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 28 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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X X X 3 X X 3 X Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 29 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 YA33 Regulation 12, 18(1)(a) Requirement The registered person needs to provide evidence that all residents are of minimal risk to their health and safety of not having a wake night staff member on duty, within this evaluation there needs to be assessment of those people using the service who do not having the ability to call and/or wake the ‘sleep in’ staff, and in regard to there not being a call bell system in place. There needs to be evidence of at least two written references obtained before appointing a staff member. Previous requirement not met. Timescale 01/03/07 Timescale for action 01/11/07 2. YA34 13(6) 7,9,19 01/10/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 30 1 YA6 2 3 YA9 YA22 4 YA33 5 6 YA34 YA39 7 YA42 There could be development in a variety of different and creative methods to help people who use the service contribute to their care plan. The format of the care plans could be reviewed and there be more evidence of the care plans being a working tool used by the resident and all involved staff. • There should to be more evidence that resident’s recorded goals/objectives (short term and long term) are reviewed and evaluated regularly. There should be more recorded evidence that people living in the care home have an understanding of, and have agreed to their risk assessments. The manager should further develop ways to ensure that there is more evidence that the complaints procedure is accessible to all residents, and that all ‘concerns’ communicated by them, are taken seriously and recorded. It is strongly recommended that that the Organisation’s person, who carries out initial assessments of residents, carry out an assessment of the night needs of all the people using the service at 30 Old Church Lane. The dates of a staff member’s residency/work permit documentation should be reviewed. Formats of policies/procedures of particular relevance and interest to people using the service could be improved to ensure that the information is accessible as possible to all residents. The individual resident’s fire risk assessment documentation should be filed with the fire risk assessment to ensure that this information is easily accessible. • Norwood 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Harrow Area Office 4th Floor, Aspect Gate 166 College Road Harrow London 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 30 Old Church Lane DS0000017550.V340849.R01.S.doc Version 5.2 Page 32 - 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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