Inspection on 04/04/06 for Norwood 30 Old Church Lane

This inspection was carried out on 4th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Norwood 30 Old Church Lane 31/07/07

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 4th April 2006 08:45 Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 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.V287525.R01.S.doc Version 5.1 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.V287525.R01.S.doc Version 5.1 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 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) Norwood Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st November 2005 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. Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection took place throughout 8.25 hours during a day in April 2006. There is no registered manager in post at present. An interim manager (who is the registered manager of another care home of Norwood’s) is presently managing the care home; with support from two senior care staff. There were no vacancies at the time of the inspection. The inspector was pleased to meet, and talk with the residents, whose verbal communication needs are varied. Some of the resident’s use sounds, gestures, and some words in response to verbal interaction. The inspector also spoke with the care staff, and the interim manager who were on duty during the unannounced inspection. 14 Commission for Social Care Inspection comment/feedback cards were received from relatives, residents, and health and social care professionals in regard to the service provided by the care home. This feedback was generally very positive. Verbal feedback was also received from a visitor to the care home, prior to the inspection. Staff were very helpful during the inspection, and facilitated the inspection process fully. This inspection focussed on spending time talking with residents, and observing interaction between residents, and staff. 22 key standards were assessed, and inspection requirements from the previous inspection were also assessed as to whether they had been met. Documentation inspected included, resident’s care plans, residents’ financial records, complaint records, risk assessments, staff training records, staff personnel records, and accident/incident record documentation. Documentation inspected during a previous inspection confirmed that residents receive a statement of terms and conditions, which includes a record of fees. A tour of the premises also took place. The interim manager provided the Commission for Social Care inspection with all the appropriate requested documentation prior to the inspection, and kindly supplied other documentation requested by the inspector following the inspection. It was evident that he is working hard with the staff team to ensure that a good service is provided to all the residents. The inspector was made most welcome, and thanks all those in 30 Old Church Lane for the hospitality received. What the service does well: The care home has a welcoming atmosphere. The home enables, and supports residents to participate in varied in-house and community based activities of their choice that meet their individual needs. Staff have a good knowledge and understanding of residents varied, and complex needs. Interaction between staff and residents was positive and respectful during the inspection. Residents who kindly spoke to the inspector Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 6 confirmed that they were happy with the care that they received by the service. Staff demonstrated competency, and motivation. The home liaises with health and social care professionals as and when residents need. Residents have full access to advice, care, treatment and support from these specialists. The home is clean, light airy, generally well decorated, and homely. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 1,and 2 Arrangements are in place to ensure that prospective residents have the information that they need to make an informed choice about where they live. Arrangements are in place to ensure that residents receive a comprehensive assessment of their needs prior to their admission to the care home. EVIDENCE: Care plans inspected included service user guide documentation. The statement of purpose for 30 Old Church Lane was displayed in the care home. The interim manager supplied the Commission for Social Care Inspection a recently reviewed copy of the statement of purpose. Recorded feedback from three relatives/visitors to the care home informed the inspector that they were not aware of how to access the inspection reports. This was discussed with the interim manager. He placed a copy of the inspection report in the communal area of the care home during the inspection, and spoke of informing all the relatives/significant others of where they can access the inspection reports. The care home has an admission procedure. There have been no new admissions to the care home since 2001, and there are presently no vacancies. The admission procedure has been fully assessed in previous inspections, and the interim manager confirmed that there have been no significant changes to this procedure. He confirmed that all prospective residents receive comprehensive assessment of their needs by the provider, and the purchasing authority prior to their admission. This assessment includes consideration of Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 9 any challenges that a potential resident may present to the care home. A plan of care is developed from this initial assessment. Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 6,7 and 9 Arrangements are in place to ensure that all residents have a plan of care based upon a comprehensive assessment of their needs. There needs to be continued development in improving the content and accessibility of the information in the care plans. Residents are supported, and enabled to participate in the making of decisions about their lives. Arrangements are in place to ensure that risks to residents are identified, and that staff are aware of their role in managing residents’ risks. EVIDENCE: All the residents have a plan of care. The interim manager spoke of being in the process of reviewing all the care plans, to ensure that up to date comprehensive information in regard to staff meeting the assessed needs of residents, is easily accessible. Four care plans were inspected. Two of these care plans recorded evidence of the care plan format having been reviewed, and of some staff guidance having been developed. Care plan information included documentation, and staff guidance in regard to meeting resident’s health, personal, cultural and social needs. The process of development of Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 11 residents care plans needs to continue, and include outcomes for residents and involvement (as far as they are able) by them in this documentation. There was recorded evidence that care plans had received some review. The interim manager informed the inspector that annual reviews (when care managers, family/friends and significant others are invited) take place. Records and the manager confirmed that three resident’s annual reviews had taken place recently, and that the residents had attended their review meeting. The manager informed the inspector that there would also be development of a sixmonth review in which all those who have significant contact with the resident would be invited, as in the annual review. Care plans with the resident (involving significant professionals, family, friends and advocates as agreed with the resident) should be reviewed every six months and updated to reflect changing needs. The manager confirmed that review, and development of residents’ individual goals would be included in this process, and an individual action plan developed. This is positive. Staff sign when they have read care plans. Staff keep a record of the monitoring of resident’s progress on a daily basis. There needs to be a record maintained of residents progress at night. This was discussed with the manager. Records and staff confirmed that residents are enabled and supported to be involved in making choices (as far as they are able). Staff were observed to have knowledge and understanding of ways to enable residents, including those with complex needs to make choices Regular resident meetings take place. A resident has an advocate. Information about an advocacy service was accessible in the care home, and there was recorded evidence that a referral for an advocate for a resident had been made. Residents were observed to make choices throughout the inspection. Staff informed the inspector that residents receive varying degrees of staff support (depending on residents assessed needs) to manage their finances. The inspector observed that two staff checked all residents’ financial records, and balances during the inspection. This procedure takes place during each shift. These financial records were up to date and fully recorded. Recorded risk assessments, as part of the care planning process were evident. There was recorded staff guidance in regard to meeting assessed risk. The manager spoke of plans to develop, and review this risk assessment documentation. There needs to be evidence that all risk assessments are regularly reviewed. Two care plans that had been recently reviewed by staff included recorded assessment of the resident’s night care needs. All residents need recorded night support needs assessment, which includes personal care needs, and assessment of any risk. This was discussed with the manager. Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 12,13,15,16 and17 Staff support residents to continue their education, and to find, and keep appropriate jobs, and/or take part in fulfilling activities. Arrangements are in place to ensure that residents have the opportunity to participate in, and be part of the local community. Residents are supported, and enabled to maintain contact (if they wish) with family, friends and significant others. Daily routines promote, and support resident’s independence. Meals provided are varied, and wholesome. EVIDENCE: Residents, records, and staff confirmed that residents have the opportunity to complete college courses. Residents attend a variety of day resource centres in which they are supported to develop their knowledge, and skills. Two residents spoke positively of their part time jobs. The care home works hard to ensure that residents have the opportunity to participate in numerous activities of their choice. Residents have an individual Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 13 activity programme, which is adhered too. Residents who spoke with the inspector were aware of their activities that they were doing on the day of the unannounced inspection. Records, residents, and staff confirmed that residents have the opportunity to become part of the local community. The care home is within a few minutes walk or drive to a variety of amenities, which include, shops, banks, restaurants, and pubs. The care home has access to two passenger vehicles. Residents also use taxis, and public transport. Residents spoke of enjoying buying their own toiletries and clothes with staff support. A resident had plans to go shopping during the inspection. Other residents participated in (or had planned) a number of community based activities on the day of the unannounced inspection. Residents also took part in 1:1 activity sessions with staff, which included a cooking session during the unannounced inspection. Residents were observed to also have the opportunity to choose their own activities. One resident chose to spend time in the music room independently during the inspection. Residents and records confirmed that resident’s cultural and religious needs were fully met by the care home. The manager confirmed that the residents were recorded on the electoral role. A staff member, records, and a resident informed the inspector that residents’ contact with relatives, and significant others was supported and maintained. The manager spoke of ensuring that relatives/significant others were kept up to date with resident’s progress (following resident’s agreement). Examples of methods used are via email, telephone, and regular meetings with resident’s relatives/significant others/ advocate. This is positive. One visitor feedback form received by the Commission for Social Care Inspection had recorded that they weren’t kept up to date with a resident’s progress. This was discussed with the manager. He confirmed that since he had been managing the care home this contact had developed and that he would contact relatives/significant others following the inspection. A resident spoke of his plans to go and stay with his family. Another resident spoke of plans to go on holiday with family members. Residents who kindly spoke to the inspector gave examples of how their independence was encouraged by staff. Evidence of this, was observed during the inspection. The inspector was informed that several residents have a key to their room. Residents open their own mail (if able). Residents were observed to participate in household tasks, freely access communal areas of the home, and their own bedrooms, during the inspection. The care home has a smoking policy, which has been recently reviewed. The home has a menu, which is displayed. This is in written format. Staff should develop a format, which is more accessible to the residents who cannot read. The menu confirmed that a variety of wholesome meals were provided. Residents spoke of their enjoyment of the meals, and of being enabled to make snacks. Staff were observed to offer residents choice in what they wanted for breakfast, and lunch. It should be recorded on the menu that Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 14 residents are offered choice of preferred meals. The meals meet the cultural, and specific needs of the residents, and staff were knowledgeable of these needs. There was recorded staff guidance in regard to meeting some residents’ healthy eating needs, such as monitoring, and guidance in regard to carbonated drinks. Healthy eating was discussed with the manager. He spoke of this being an issue recognised in the care home, but that there were plans to make improvements in regard to this, such as frying foods less often. This is positive. Residents weight is monitored. Some records of food eaten by residents were not up to date/not recorded. Food eaten by residents needs to be fully recorded. Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 18,19 and 20 Arrangements are in place to ensure that residents receive personal support in the way that they prefer. Arrangements are in place to ensure that the health needs of residents are assessed and met. Medication within the care home is stored and administered safely. EVIDENCE: The care plans inspected recorded assessment of resident’s individual personal care needs. During the inspection resident’s privacy was respected. Staff, and a resident spoke of the flexibility of times for ‘getting up’, and going to bed, and that residents have ‘lie ins’ if they wish’ particularly during weekends. Staff guidance in regard to meeting personal care needs (during the day) of individual residents was recorded in the care plans inspected. (See Standard 6 in regard to assessment of resident’s personal care needs at night). Records, residents, and staff confirmed that residents receive additional specialist support, and advice as needed by them. This includes physiotherapy and psychology support and assessment. Staff informed the inspector that all the residents have a key worker. A resident who kindly spoke with the inspector knew who her key worker was, and was aware of the key workers’ role. Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 16 Records confirmed that residents have their health care needs assessed, and that there is staff guidance to meet those needs. Residents receive care, and treatment from a GP, dental services, chiropody services, psychiatrists, and optician services. Resident’s health needs are monitored, and staff guidance to meet individual health needs is recorded. The home has a medication policy and procedure. The medication storage and administration systems were inspected. Medication is stored securely. Records confirmed that staff receive medication training. Records confirmed that there had been recent medication refresher training for staff. The manager spoke of their being an annual assessment of staff competence in the administration of medication. Two staff witness, and administer medication. This was observed during the inspection. Medication administration records were up to date. Staff were observed to check that these records were fully recorded. Staff need to record the date of when nasal spray medication is first used, and ensure that they have knowledge of how long this medication can be used from the container, before a new bottle is commenced. Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 22 &23 Arrangements are in place to ensure that there is a clear and effective complaints procedure. Arrangements are in place to ensure that residents are protected from abuse, neglect and self-harm. EVIDENCE: The care home has an appropriate complaints procedure in written and pictorial format. The complaints procedure was displayed in the home. Recorded feedback from visitors confirmed that they were generally aware of the complaints procedure, but one feedback form from a visitor indicated that they were not aware of this procedure. This was discussed with the interim manager who confirmed that he would ensure that all relatives and significant others were aware of the procedure. All relatives/significant others should know how and where to access the complaints procedure. There had been no recorded complaints within the last twelve months. The issue of recording ‘concerns’ from residents and others was discussed with the manager, who confirmed that this would be supported, recorded, and appropriate action taken by staff. This should be actioned. The home has a policy in regard to protection of vulnerable adults. The care home has demonstrated that this procedure has been followed appropriately. Staff who spoke to the inspector generally had knowledge, and understanding of this procedure, but the manager needs to ensure that all staff are fully knowledgeable of the reporting procedures in regard to protection of vulnerable adults. This was discussed with the manager. Staff spoke of having received protection of vulnerable adults training. Records informed the inspector that there were guidelines in place for staff to meet the needs of residents who could challenge the service. The guidance recorded in a resident’s care plan needs development to ensure clarity in Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 18 regards the use of physical restraint techniques, which needs to be agreed by members of a multi-disciplinary team, clearly individually documented, and that there be evidence that staff are trained in appropriate restraint techniques that meets Department of Health Guidance, and that they receive regular refresher training in physical intervention techniques. This was discussed with the interim manager. Resident’s monies were judged to be managed appropriately. Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 24 and 30 Residents live in a homely premises, which is suitable for it’s stated purpose. Arrangements are in place to ensure that the home is always clean. EVIDENCE: A member of the care staff kindly accompanied the inspector on a tour of the premises. The care home was clean, warm, well lit, and homely. A resident spoke of being happy with their room, and kindly showed the inspector their bedroom. It was individually personalised, and had furnishings of quality. A staff member explained the alarm system that was now in place at night to alert the ‘sleep in’ staff when residents are up and about during the night. Several communal areas including the stairway, and bathroom areas should be redecorated; paintwork was observed to be shabby in places. The inspector was informed that the care home has a planned maintenance and renewal programme. The bathroom fan in the flat needs to be clean and in working order. Laundry facilities are located away from food storage and food preparation areas in both the main house and the flat. The washing machine, and the dryer are industrial quality in the main house. Residents spoke of their participation in the care of their laundry. The flooring in the laundry area in the flat is very stained, and needs replacing. Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 32, 34 and 35 Staff have the competencies, and qualities required to meet resident’s varied needs. The recruitment policy, and procedure is thorough to ensure that when appropriately followed, residents are ensured protection. Resident’s needs are being met by a staff team that is appropriately trained. EVIDENCE: Staff who kindly spoke with the inspector had knowledge, and understanding of residents needs, how to access required records and documentation to assist them with understanding residents’ individual needs. Staff were observed to be respectful, and sensitive in supporting residents to meet their assessed needs. A staff member spoke of their key worker role. The care home has worked hard to ensure that staff have the opportunity to complete NVQ 2 or 3 care qualifications. Pre inspection information supplied by the interim manager informed the inspector that 70 of staff have achieved this qualification. The care home has a staff recruitment policy and procedure. Staff personnel records were available for inspection. Four staff records were inspected. These included appropriate required information and documentation, but one staff record had evidence of only one reference and this was a verbal reference. There needs to be evidence of at least two written references obtained before appointing a staff member. Staff personnel files should be Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 21 reviewed to ensure that information/documentation is in order so more easily accessible. The manager reported that all staff receive a staff code of conduct, and that new staff have a six-month probation period. Staff reported that they receive a comprehensive induction programme. This induction programme is linked to TOPSS (Skills for Care). The staff training plan, including individual training records were available for inspection. These recorded evidence of varied appropriate staff training, and included training/knowledge of the Jewish needs of the residents. The staff training records should be reviewed and updated. Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 37,39, and 42. Service users benefit from a well run home by an interim manager, but a permanent/registered manager needs to be employed who has experience and competence to ensure that the care home meets its stated purpose in continuing to meet the needs of the residents, and meet regulations. Arrangements are in place to monitor, and continue to improve the quality of the service provided to residents. The health and safety of residents is promoted and protected. EVIDENCE: Service users benefit from a well run home by the interim manager, but the registered person needs to ensure that a permanent manager is appointed to manage the care home, and be registered with the Commission for Social Care Inspection. The interim manager reported that the process of employing a manager for 30 Old Church Lane was in progress. Records confirmed that an up to date business development plan for the care home was available for inspection. Records confirmed that records were generally regularly reviewed and that residents participated in resident Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 23 meetings. The manager reported that he would ensure that feedback questionnaires were supplied to residents and relatives/significant others. The methods of communication between the care home and others continue to be developed and improved. There were required up to date certificates of worthiness in regard to the electrical and gas systems of the care home. Pre inspection documentation informed the inspector that other safety checks are monitored. Required regular fire checks are carried out. Records confirmed that fridge and freezer temperatures are monitored. Control of Substances Hazardous to Health risk assessments should show evidence of review. The manager spoke of his plans to complete this task. There needs to be risk assessment in regards assessing the safety risk to people during the tile replacement maintenance work being carried out at the time of the unannounced inspection. Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 24 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 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 X 3 X X 2 X Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 25 No 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 YA6 Regulation 15(2) 17(3) • Requirement The process of development of residents care plans needs to continue, and include outcomes for residents and involvement (as far as they are able) by them in this documentation. • There needs to be evidence that all the residents’ progress at night is monitored. • There needs to be evidence that all risk assessments are regularly reviewed. • Residents who have not received a night care needs assessment; need to have in place recorded night support needs assessment, which includes personal care needs, and assessment of any risk. Food eaten by residents needs to be fully recorded. Staff need to record the date of when nasal spray medication is first used, and ensure that they DS0000017550.V287525.R01.S.doc Timescale for action 01/09/06 2 YA9 12,13(6) 01/08/06 3 4 YA17 YA20 12,17 13(2) 01/07/06 01/06/06 Norwood 30 Old Church Lane Version 5.1 Page 26 5 YA23 6 YA24 7 YA34 8 YA37 9 YA42 have knowledge of how long this medication can be used from the container, before a new bottle is commenced. 12,13(4)(6) • The registered person needs to ensure that all staff are fully knowledgeable of the reporting procedures in regard to adult protection. • The use of physical intervention techniques, need to be agreed by members of a multidisciplinary team, clearly individually documented, and there be evidence that staff are trained in appropriate restraint techniques that meets Department of Health Guidance, and that they receive regular refresher training in physical intervention techniques. 23 • The bathroom fan in the flat needs to be clean and in working order. • The flooring in the laundry area in the flat is very stained, and unsightly, and needs replacing 13(6) There needs to be evidence of 7,9,19 at least two written references obtained before appointing a staff member. The registered person needs to 8(2) ensure that a permanent manager is appointed to CSA 11(1) manage the care home, and be registered with the Commission for Social Care Inspection. 24(2) There needs to be risk assessment in regards assessing the safety risk to people during the tile replacement maintenance work being carried out at the time of DS0000017550.V287525.R01.S.doc 01/07/06 01/08/06 01/06/06 01/09/06 01/06/06 Norwood 30 Old Church Lane Version 5.1 Page 27 the unannounced inspection. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations Care plans with the resident (involving significant professionals, family, friends and advocates as agreed with the resident) should be reviewed every six months and updated to reflect changing needs. • Staff should develop a menu format, which is more accessible to the residents who cannot read. • It should be recorded on the menu that residents are offered choice of preferred meals. • All relatives/significant others should know how and where to access the complaints procedure. • ‘Concerns’ from residents and others should be recorded, and appropriate action taken by staff to resolve these. Several communal areas including the stairway, and bathroom areas should be redecorated, Staff personnel files should be reviewed to ensure that information/documentation is in order so more easily accessible. The staff training records should be reviewed and updated. Control of Substances Hazardous to Health risk assessments should show evidence of review. 2 YA17 3 YA22 4 5 6 7 YA24 YA34 YA35 YA42 Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Harrow Area office Fourth Floor Aspect Gate 166 College Road Harrow HA1 1BH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Norwood 30 Old Church Lane DS0000017550.V287525.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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