Inspection on 15/11/05 for Norwood House

This inspection was carried out on 15th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Norwood House 02/01/07

Norwood House 28/04/05

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

CARE HOMES FOR OLDER PEOPLE Norwood House 12 Westbourne Grove Scarborough North Yorkshire YO11 2DJ Lead Inspector Brian Hallgate Unannounced Inspection 15th November 2005 09:30 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 House DS0000063732.V264525.R01.S.doc Version 5.0 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 House DS0000063732.V264525.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Norwood House Address 12 Westbourne Grove Scarborough North Yorkshire YO11 2DJ 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) 01723 360360 Comfy Care Homes Ltd Mrs Catherine Ellwood Care Home 21 Category(ies) of Dementia - over 65 years of age (21) registration, with number of places Norwood House DS0000063732.V264525.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th April 2005 Brief Description of the Service: Norwood House is a large adapted and extended property situated in a residential area of the town. The staff at the home provide personal care and services for a maximum of 21 residents who are accommodated by virtue of age or infirmity. Some may have failing mental health and suffer from varying degrees of dementia. Accommodation is provided in single and shared bedrooms located on all floors together with suitable bathing and toilet facilities. Some bedrooms have an en-suite facility. There are a number of sitting and dining areas. Gardens are available to three sides with suitable ramped access. There is a passenger lift to all floors. The staff offer personal care, a catering service, laundry facilities and domestic and cleaning services. Leisure and recreational activities are offered in-house through the services of a diversional therapist on three afternoons each week and by staff at other times. Residents are offered excursions out either individually or in groups. Those able to go out unaided are encouraged to do so though suitable and appropriate risk assessments are carried out. Residents are registered with local doctors who provide access to other health services. The staff also offer day care to a maximum of five people each day. Adequate space, facilities and staffing have been provided to cope with the needs of day care users. Norwood House DS0000063732.V264525.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was an unannounced inspection that took place on the 15th November 2005 and took four hours, including preparation time. A tour of the home was made with the registered provider and a number of records were inspected. Five service users, a group of eleven service users undertaking activities and 5 members of staff were spoken to. What the service does well: 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 House DS0000063732.V264525.R01.S.doc Version 5.0 Page 6 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 House DS0000063732.V264525.R01.S.doc Version 5.0 Page 7 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 The Statement of Purpose still needs updating to show the changes in ownership and management of the home. EVIDENCE: The Service Users Guide to the home has been amended as required at the previous inspection. The Statement of Purpose was in the process of being up dated but no amended copy was available for inspection. Norwood House DS0000063732.V264525.R01.S.doc Version 5.0 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 and 10 The staff have a good understanding of the service users’ support needs EVIDENCE: The relatives of service users are involved in the development of the care plans and they are now asked to sign the plans on completion. Staff administer medication for all service users. The records inspected were up to date and in order. Staff were observed interacting with service users. Staff were seen to treat service users with respect and offer them choices. Relatives are involved with service users and would inform staff if they had any concerns. The registered persons and the registered manager work alongside staff on a regular basis and observe how they treat service users. Norwood House DS0000063732.V264525.R01.S.doc Version 5.0 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 14. Social activities are well organised, creative and provide stimulation and interest for people living in the home. EVIDENCE: There is a planned list of activities that service users are invited to undertake throughout each day. One member of staff has responsibility for organising the day care and a diversional therapist organises activities for service users and day care attenders on three days each week. Activities include games, aromatherapy, quizzes, ball games and chair exercises. The therapist was working with a group of eleven service users at the time of this inspection. Some service users did not wish to take part in the actual activity but preferred to watch others. Those service users who wish, go out to a local hotel and join in sing-a-longs. Some service users are taken out into the local community by relatives on a regular basis. A local vicar visits the home and one service users goes out to a local church. Family and friends are welcome at anytime. Relatives bring people in for day care and the staff were observed to support these relatives. Relatives also help out when service users go into the community. Staff were observed to give service users choice in the activities that they took part in. Norwood House DS0000063732.V264525.R01.S.doc Version 5.0 Page 10 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The home has satisfactory complaints and abuse policies in place and staff were aware of the action to take if a complaint or a suspected abuse situation was reported. EVIDENCE: The complaint information is now recorded at the time the complaint in made as required at the previous inspection. One complaint had been received since the last inspection. This had been correctly dealt with. There was an in-house abuse policy but the home did not have a copy of the York and North Yorkshire Vulnerable Adults Policy. Staff were however fully aware of what action to take in the event of a suspected abuse situation occurring. Norwood House DS0000063732.V264525.R01.S.doc Version 5.0 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): NONE EVIDENCE: Norwood House DS0000063732.V264525.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28 and 30 The service users receive a good standard of care from the well-prepared and experienced staff. EVIDENCE: A number of staff have been working at the home for many years and are very experienced in caring for people with varying degrees of dementia. The duty rota for the week was inspected. It showed that there are usually five staff on duty in a morning, three in an afternoon and evening and 2 waking night staff. The number of staff on duty meets the needs of the present service users who are all mobile. Staff are undertaking NVQ training at Levels 2, 3 and 4. In addition staff stated that they had received training during the past twelve months in dementia awareness, medication, infection control, supervision skills, manual handling, fire prevention, food safety and health and safety. Norwood House DS0000063732.V264525.R01.S.doc Version 5.0 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 The home is managed in an open and inclusive manner by the registered manager who enjoys the support of the staff. EVIDENCE: The registered manager is undertaking the Registered Managers Award and NVQ Level 4 in care. She has over 20 years experience in care and four years management experience. The home is run in the best interests of the service users. Staff are not involved in the administration of residents finances. One service user deals with his own finance and relatives assist the other residents with all their financial affairs. The pipework exposed at the previous inspection has been replaced with a new radiator. Norwood House DS0000063732.V264525.R01.S.doc Version 5.0 Page 14 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 1 x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 x x x x x x x x STAFFING Standard No Score 27 3 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Norwood House DS0000063732.V264525.R01.S.doc Version 5.0 Page 15 Are there any outstanding requirements from the last inspection? YES 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 OP1 Regulation 6 Requirement The Statement of Purpose must be reviewed and updated to reflect the changes in ownership and management. (Previous timescale of 31/05/05 not met) Timescale for action 30/11/05 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 18 Good Practice Recommendations The registered manager should obtain a copy of the York and North Yorkshire Vulnerable Adults Policy Norwood House DS0000063732.V264525.R01.S.doc Version 5.0 Page 16 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 House DS0000063732.V264525.R01.S.doc Version 5.0 Page 17 - 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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