Inspection on 17/09/07 for Norwood Green Care Home

This inspection was carried out on 17th September 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Norwood Green Care Home Tentelow Lane Southall Middlesex UB2 4JA Lead Inspector Mrs Rekha Bhardwa Key Unannounced Inspection 10:20 17 September 2007 th X10015.doc Version 1.40 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 Green Care Home DS0000068283.V343149.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 Older People. 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 Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norwood Green Care Home Address Tentelow Lane Southall Middlesex UB2 4JA 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) 020 8813 8883 020 884 3092 norwood.green@fshc.co.uk Four Seasons (No 7) Limited Mr Robert Dawson Care Home 92 Category(ies) of Dementia - over 65 years of age (64), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (64), Old age, not falling within any other category (28) Norwood Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user under the age of 60 as agreed by the NCSC on 19/08/2003. The home must advise CSCI when that individual either becomes 60 years of age or no longer resides at the home. Sixty four service users in the categories (DE(E)) and (MD(E)) may be accommodated on the first and second floor units. All service users accommodated in the home must be over 60 years of age, unless agreed with the CSCI before admission. Twenty eight service users in the category (OP) may be accommodated in the ground floor unit. 3rd October 2006 2. 3. 4. Date of last inspection Brief Description of the Service: Norwood Green is a large, attractive purpose built home, registered to provide nursing care for 92 service users. The home is divided into three units across three floors, namely Asquith House, Baldwin House and Churchill House. The ground and upper floors are connected by stairways and two passenger lifts, the latter of which facilitate disability access to each floor. Communal areas, the majority of which either overlook the common or an internal patio area, are well lit. The home has a large parking area to the front of the building and an attractive patio and enclosed garden area to the rear of the premises. There is a large park opposite the home. The ground floor (Asquith House) provides care within the category of old age. The first floor (Baldwin House) and the second floor (Churchill House) are registered to provide care for service users with mental disorder or dementia. All rooms are single occupancy, provide en suite facilities and are in excess of 10 square metres. Local public transport facilities are available within close proximity of the home. The fees range from £574 to £830 per week, dependent on assessed need. Norwood Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out as part of the regulatory process. A total of 16 hours was spent on the inspection process, and was carried out by 2 Inspectors. The Inspectors carried out a tour of the home, and service user plans, medication records & management, staff rosters, staff records, financial & administration records and maintenance & servicing records were viewed. 15 residents, 15 staff and 4 visitors were spoken with as part of the inspection process. The pre-inspection Annual Quality Assurance Assessment (AQAA) document completed by the home, plus comment cards from residents, representatives/visitors and health & social care professionals have also been used to inform this report. What the service does well: The home is being effectively managed and this has led to marked improvements throughout the home on an ongoing basis, and improvements are being sustained. The management are approachable and proactive in their work and this is evident throughout the home. Prospective residents are fully assessed prior to admission to ensure the home can meet their needs. Overall the service user plans are well completed and healthcare needs are also being identified and met. Medications are being well managed at the home. Staff care for residents in a gentle, caring and professional manner, respecting dignity, privacy and cultural and diversity needs. The home has an open visiting policy and visiting is encouraged. The food provision is good with good variety on the menu to meet personal and cultural preferences. Complaints and adult protection issues are appropriately managed at the home. The environment is being well maintained with evidence of ongoing redecoration, refurbishment and maintenance. Infection control procedures are in place and are adhered to. Some shortfalls in staffing were apparent, however the management had identified this and they are working actively to address the shortfalls robustly. The training provision is good and the NVQ in care training is being progressed to bring the home up to 50 of care staff with this qualification. Kitchen and domestic staff are also undertaking relevant NVQ qualifications. Systems for the vetting and recruitment of staff are robust and are followed. Systems are in place for effectively reviewing the quality of care provided and for reviewing all aspects of the home for quality assurance purposes. Any monies held on behalf of residents are being appropriately managed and securely stored. Robust systems for the management of health & safety are in place. Overall the comments received via the CSCI comment cards were very positive. Examples of these are: ‘Good communication with relevant agencies and residents families’. Norwood Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 6 ‘I’ve had great support regarding my relative, and my relative receives wonderful care.’ ‘All staff are accessible to both residents and visitors and seem to be very caring and efficient.’ ‘I feel that the management and all the staff at Norwood Green do the very best they can to give the residents good nursing care in a pleasant and secure environment.’ ‘The atmosphere in the home is excellent. Staff seem well motivated, polite and caring.’ ‘The care staff are friendly, pleasant and always have a smile.’ The home ‘provides a pleasant atmosphere with a variety of activities’ ‘The staff are undoubtedly the greatest asset, they are always pleasant and smiling in very difficult circumstances.’ 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. The summary of this inspection report can be made available in other formats on request. Norwood Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Norwood Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents are fully assessed prior to admission, thus the home ensures they are able to meet each persons needs. EVIDENCE: The home has a comprehensive pre-admission assessment document that provides a good picture of the resident and their needs. This is completed for all prospective residents in order to ascertain if the home is able to fully meet their needs. Completed assessments were viewed on each floor and had been well completed. The home also obtains a copy of the needs led assessment undertaken by social services. Norwood Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 & 11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the service user plans were being completed to provide staff with the information to meet each resident’s needs. Shortfalls should be easy to address. Medications are being well managed at the home, thus safeguarding residents. Staff care for residents in a gentle and professional manner, respecting their privacy and dignity. The home provides good end of life care, thus ensuring that residents and their families have their wishes and needs fully discussed, recorded and met. EVIDENCE: Service user plans were sampled on each floor. Overall these were comprehensive and provided a clear picture of each residents’ needs and how these are to be met. New care plans had been formulated for newly identified needs. In two of the service user plans viewed monthly reviews had not always taken place, and for one resident the documentation had not been reviewed following a stay in hospital. The importance of reviewing the documentation monthly and whenever there is a change in the residents’ condition was discussed with the staff on the floors concerned. Risk assessments for falls had Norwood Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 10 been completed and comprehensive updates had been carried out following any falls. Three residents had pressure sores and the documentation for these was viewed. Pressure sore risk assessments had been completed and care plans had been formulated for each wound and wound progress records had been recorded, plus a photographic record kept, thus providing clear information regarding the progress of each wound. Nutritional assessments, moving & handling assessments and continence assessments had been carried out and care plans formulated to address identified needs. Risk assessments for the use of bedrails had been completed and in all but one instance a written consent for their use was available. Staff explained the reason for the delay in obtaining written consent, however verbal consent had been obtained and the staff said they would record this fact. There was evidence of input from the GP and other healthcare professionals relevant to each residents needs. The medication management and records were sampled on each floor. Medications were being securely stored. Liquid medications had been dated when opened. Receipt and administration records were up to date and complete. For one medication that had been out of stock for a few days the correct code had been used, however only one entry of explanation had been made on the back of the medication administration record (MAR). An entry should be made each time the code is used and the Deputy Manager said she would address this with the staff. Any hand written entries on the MAR had been signed by two registered nurses and also by the GP. Some of the medication stocks were checked and found to be correct. Receipt and administration of controlled drugs was clear and complete and these were being correctly stored. The home uses the Softclix-Pro lancing system for monitoring blood glucose levels, which is one of the systems approved for use in a care home setting. On one floor they were using individual lancets only and the Deputy Manager said she would order a new pen without delay. The staff were able to explain the infection control procedures in use to minimise any risks. Fridge and room temperatures were being recorded and one thermometer was reset at the time of inspection as the reading was not clear. Air conditioning units are in each clinical room and the one on Baldwin unit did not appear to be fully functioning so the maintenance man was asked to review it. Medications are being well managed at the home. Staff were seen caring for residents in a gentle and professional manner, respecting their privacy and dignity. Individual clothing is labelled and residents were well dressed, reflecting individuality and respecting culture. The Registered Manager said that they had been looking at having an Asian Unit in one area of the home, however having surveyed residents and representatives the preference was for people to be integrated on each floor. The Registered Manager said that they endeavour to ensure staff who speak some of the main Asian languages are on duty on each unit, and there was evidence of this at the time of inspection. Provision is made for couples to share a bedroom and to Norwood Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 11 have a sitting room as their second room. Some of the bedrooms viewed had been personalised and overall there was a very homely feel, which was also commented on by visitors. Residents can have their own telephones if they so wish. On each unit it was pleasing to see staff interacting well with the residents and being able to communicate effectively with those with communication needs. Residents looked content and well cared for. In the service user plans viewed care plans had been completed for end of life care needs and wishes. Families had also completed documentation regarding being contacted in the case of health deterioration and also providing information regarding care after death. Norwood Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The activity provision for the home is good, providing a variety of activities, outings and entertainments to meet the residents needs. The home has an open visiting policy, thus encouraging residents to maintain contact with family and friends. Information regarding advocacy services is available, thus ensuring the service users right to independent representation is respected. The food provision in the home is good, offering variety and choice, with resident’s choices being respected. EVIDENCE: The home has one full time and one part time activities co-ordinators in post. An activities programme is displayed throughout the home. One of the activities co-ordinators was seen conducting one to one conversations with residents and there was good interaction. On the morning of the inspection a group of residents from each floor met up to watch a film. Outings are arranged and plans are in place for the home to develop a sensory garden. Residents can choose if they wish to join in with activities. Outside entertainers also visit the home. Norwood Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 13 The home has an open visiting policy and visiting is encouraged. Visitors spoken with said that they are made very welcome at the home and refreshments are offered. Visitors commented about the ‘homely’ atmosphere throughout. Residents can choose to receive visitors in their own bedrooms or in one of the communal rooms, as they so wish. Information regarding advocacy services had yet to be displayed in the main entrance of the home. The Deputy Manager stated that the in the event of a resident requiring an advocate the home would contact Age Concern, Alzheimer’s Society or MIND. One Inspector viewed the kitchen. This was clean and tidy and all the records were up to date. Residents are offered a choice of meals and documentation to evidence this was available. There are three meal choices for lunchtime, to include an Asian diet option. Residents spoken with said that they do enjoy the food, although comment was received that meals are sometimes not hot enough. The lunchtime meal was observed. All meals are received on the units individually plated up, so that should a resident have changed their mind about their choice there is not the facility to meet this. Also, a choice of size of meal is not an option using this system. The management of serving hot meals needs to be reviewed so that individual wishes can be better taken into consideration and food is better stored to maintain its’ heat. Pureed meals are well presented and it is accepted that the method in use does allow for these particular meals to be plated up and well presented. Norwood Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has clear complaints procedures in place to address any concerns raised by residents and their visitors. There is a robust system in place for the safeguarding of residents from abuse. EVIDENCE: Details of the complaints procedure are available in the Statement of Purpose and Service User Guide, and are also displayed in the home. There had been 4 complaints since the last inspection. These had all been fully investigated and where any shortfalls had been identified an action plan had been formulated. A register of complaints is maintained and the documentation viewed was comprehensive. The Registered Manager has an ‘open door’ policy for visitors, and does deal promptly with any concerns raised. Representatives spoken with said that the Registered Manager is approachable and deals promptly with any issues. On some of the surveys returned comment was received that people were unsure of how to make a complaint. The Registered Manager said that this had already been identified by Four Seasons and was being addressed. The home has adult protection policies and procedures in place that dovetail with the Ealing Safeguarding Adults documentation. Staff spoken with said that they had received POVA training and were clear to report any concerns. Whistle Blowing was discussed and generally staff understood this. The Registered Manager reports to CSCI and the Ealing Safeguarding Adults Team Norwood Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 15 any incidents that he feels might require investigation under safeguarding adults procedures, and appropriate procedures are followed. Norwood Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall the home is being well maintained, thus providing a clean, homely and safe environment for residents to live in. Procedures are in place for infection control and these are practiced, thus minimising the risk of infection. EVIDENCE: A tour of each unit was carried out. Overall the home is being well maintained and there is evidence of ongoing redecoration and refurbishment, to include new carpets, profiling beds and other furnishings. Some wheelchairs were being stored in bathrooms and this was promptly addressed at the time of inspection. The ‘snack kitchens’ have been moved into the dining rooms and this has freed up space for a designated smoking room for residents and storage areas for the moving & handling equipment. Previously the home could get uncomfortably hot during the summer months, and following the last inspection air conditioning has been installed in all the corridors, so that a pleasant temperature can be maintained. The home has a courtyard garden Norwood Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 17 and there are plans to have a sensory garden in one area, which would especially benefit residents with dementia care needs. New garden furniture had been purchased since the last inspection. The Deputy Manager reported that the home has a new gardener who is working well to improve the grounds overall. There has been an improvement to the outside of the building with new plants and shrubs being planted and hanging baskets in place. One Inspector viewed the laundry facilities. The room was clean and the laundry was being well managed, to include personal clothing items. The washing machines have a sluice programme for infection control. Protective clothing to include gloves and aprons was available throughout the home. Infection control procedures are in place and were being followed. The home was clean throughout and overall smelled fresh. Carpets have been replaced to assist with odour control and the Registered Manager said that more individual carpets would be replaced as required in the future. Norwood Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is mostly appropriately staffed to ensure that the needs of the service users can be met, and prompt action is being taken to address identified shortfalls. Systems for vetting and recruitment practices are in place and protect residents. There is a comprehensive ongoing training programme, providing staff with the skills to meet the needs of residents, to include specialist care needs. EVIDENCE: The 3 units are being separately staffed. On the morning of inspection there was two registered nurses and 4 care staff on the dementia care units, and two registered nurses and 3 care staff on the general nursing unit. Both dementia care units were understaffed by one carer on the day of the inspection. The Deputy Manager stated that there had been sickness and three permanent staff had left recently and that this had had an impact on the staffing levels on Churchill unit. Churchill unit accommodates residents who have challenging behaviour it is essential that staffing is determined according to the assessed needs and dependency needs of the residents. The inspection highlighted the need to increase the afternoon staffing levels by one carer on Churchill Unit. Following the inspection the Deputy Manager informed CSCI that the current recruitment for staff would include an additional afternoon carer for this unit. The Deputy Manager said that when necessary agency staff are booked, but it Norwood Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 19 is difficult to do this for very short notice sickness cover. It was clear that wherever possible temporary staff shortages are addressed. Domestic, maintenance and administrative staff are employed in appropriate numbers to meet the needs of the home. A separate duty roster is available for each unit and for the ancillary staff. Comments were also received by the CSCI these included ‘staff turnover is a bit of a concern, insufficient continuity and build up of client/carer relationships’ ‘Short staffed on occasions’ ‘Need more staff’ ‘Staff are most caring and endeavour to attend to needs as quickly as possible’ Staff comment included ‘when the home is fully staffed I enjoy working my shift’. The home has accessed NVQ in care training with several staff now registered to undertake level 2, and 11 members of staff having completed the training. Four Seasons Healthcare are corporately aware of the need for 50 of all care staff to be qualified to NVQ level 2 or above, and this needs to be progressed. The Registered Manager confirmed that 30 of the care staff have obtained their NVQ 2 or equivalent. The chef said that two of the catering staff are doing NVQ level 2 in cookery and 2 domestic staff are doing NVQ level 2 in housekeeping. Two sets of staff employment records were viewed. These contained all the information required under the Care Homes Regulations 2001. The home has an induction programme that meets the Skills for Care common induction standards. Some members of staff had indicated in the staff surveys that they had completed this training. The Deputy Manager is in the process of completing the Registered Managers Award. The training matrix viewed indicated that staff had received periodic training in topics relevant to the needs of the residents. On the dementia units one Inspector was informed that not all staff had received training in dementia care, the Deputy Manager reported that she was aware of this, as some of the staff are new, and that this training had been planned. All staff must be kept up to date with training to ensure they have the knowledge and skills to meet the resident’s needs. Norwood Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager is competent and skilled and has developed an atmosphere of openness and respect, thus making residents, visitors and staff feel valued. Systems for quality assurance are in place, thus providing an ongoing process of review and feedback. Resident’s monies are well managed and securely stored. Systems for the management of health and safety throughout the home are good, thus safeguarding residents, staff and visitors. EVIDENCE: The Registered Manager is a first level registered nurse with a mental health qualification, plus he has completed the Registered Managers Award, NVQ level 4. He has several years experience in managing care homes for older people and has the skills and experience to manage residents, visitors and staff Norwood Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 21 effectively and with respect. Staff and visitors spoken with said that the Registered Manager is approachable and supportive and listens to their opinions, and any issues are promptly addressed. There are clear lines of accountability within the home and the Registered Manager communicates a clear sense of direction and leadership and staff feel valued. The processes of running the home are open and transparent. Comments received by the CSCI included ‘Manager and Deputy always very responsive‘. Several staff who had worked at the home long term commented on the marked improvements in the home under the current management. The Registered Manager and Deputy Manager are to be commended on their approach and on the improvements achieved throughout the home. The home has in place effective quality assurance and monitoring systems. Audits for accidents, wound care, medication, service user plans and health & safety are carried out periodically by the Registered Manager and other staff within the home. Regulation 26 unannounced visits on behalf of the Responsible Individual are carried out and copies of the report are available at the home. Results collated from customer satisfaction surveys have been discussed at the relatives and residents meeting. An action plan is generated to address any shortfalls identified by the surveys. Residents and relatives meetings take place and minutes are published. Staff meetings are carried out with each unit and department. Small amounts of personal monies are managed by the home. Records of income and expenditure viewed were up to date and receipts were available. Weekly and monthly reconciliations are undertaken. A sample of servicing and maintenance records were viewed and those viewed were up to date. The home employs one full time maintenance person. Fire drills were taking place for both day and night staff. The fire risk assessment had been reviewed in April 2007. Risk assessments for equipment and safe working practices were in place, with relevant copies in the kitchen and laundry areas. The Registered Manager has also developed a health and safety committee, which meets on a periodic basis to discuss any health and safety issues. The training matrix evidenced that staff had received health & safety training to include moving & handling, fire awareness, food safety, first aid, COSHH and infection control. Staff spoken with said that they receive training in all health & safety topics. Norwood Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 4 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 3 X 3 X X 3 Norwood Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? NO 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 OP7 Regulation 15 Requirement Service user plans must be reviewed monthly and whenever the service users condition changes, to ensure the information is always accurate and up to date. The hot trolley provision must be reviewed to ensure all residents receive their meals hot and at the time of the meal have a choice of food and portion size, in order to meet their individual preferences. Timescale for action 12/10/07 2. OP15 16(2)(i) 01/11/07 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 Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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 Green Care Home DS0000068283.V343149.R01.S.doc Version 5.2 Page 25 - 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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