Inspection on 02/01/07 for Norwood House

This inspection was carried out on 2nd January 2007.

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 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

Norwood House 15/11/05

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 Mrs Rosalind Sanderson Unannounced Inspection 2nd January 2007 09:20 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.V325770.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 House DS0000063732.V325770.R01.S.doc Version 5.2 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.V325770.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15/11/2005 Brief Description of the Service: Norwood House is a large adapted and extended property situated in a residential area of the town. There are many local shops within walking distance including a Post Office. There is a regular bus service that provides transport to the town. The service provided is for personal care for up to 21 residents. Service users are accommodated by virtue of age or infirmity and who have failing mental health and suffer from varying degrees of dementia. 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. Accommodation is provided in single and shared bedrooms located on four floors together with suitable bathing and toilet facilities. Some bedrooms have en-suite facilities. There are four lounge areas that also provide service users with dining facilities. There is a passenger lift to all floors. A small garden area is available at the side of the building accessed by some steps. The main building has ramped access. 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. Information about the services provided at Norwood House is given to service users and their relatives in the form of a brochure. The most recent Commission for Social Care Inspection report is available in the home or individual copies are made available on request. The scale of charges made at the date of this visit ranged between £346 and £350 per week. Additional charges are made for hairdressing, chiropody, personal toiletries and newspapers. Norwood House DS0000063732.V325770.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence for this report. These sources include: • • • • Reviewing information that has been received about the home since the last inspection. Information provided by the registered person on a pre inspection questionnaire; Comment cards returned from 1 service user, 6 relatives, 1 care managers and 4 Health and Social Care professionals. A visit to the home carried out by one inspector. A site visit was carried out and lasted for six hours hours. Three service users, four staff and the diversional therapist were spoken with. Records relating to service users, staff and the management activities of the home were inspected. During the visit care practices were observed, where appropriate, and time was also spent watching the general activity within the home. This enabled the inspector to gain an insight of what life is like at Norwood House for the people that live there. The registered manager was available to assist the inspector during the day. Two representatives from the company were also available for part of the day. What the service does well: Norwood House provides a calm and comforting environment for the service users who live there. Comments received include, ‘,‘It’s quiet down here (downstairs lounge) I like that it’s peaceful’ The staff at the home provide a professional service and health care professionals said, ‘The staff are dedicated to the wellbeing of the clients. They are welcoming of enquiries and always give accurate accounts of clients’ conditions’. Another said, ‘First Class in every aspect of care’. Relatives appreciate the care given to their family members. One commented, ‘I have been most impressed by the quality of care and commitment of the carers, I have every confidence they are in good hands’ A diversional therapist provides activities and service users are encouraged to join in if they wish or just to observe. The chef provides nutritionally sound food and caters for special diets and needs. The food is well presented and service users were seen to enjoy it. Norwood House DS0000063732.V325770.R01.S.doc Version 5.2 Page 6 Staff receive sufficient and relevant training to equip them to meet the needs of the service user group. 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 House DS0000063732.V325770.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 House DS0000063732.V325770.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, 6 is not applicable Quality in this outcome area is adequate. Service users needs are not always fully assessed prior to admission. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Although staff try to visit people before they are admitted to the home, pre admission assessments are not always carried out before people are admitted. In some cases care managers or other professionals give information about peoples needs. This information is not always used when planning service users care. An example of this is from a recent admission where previous risk assessments had shown that the service user was at risk from pressure damage and at risk of falls. No care plans had been put in place to address and minimise. Norwood House DS0000063732.V325770.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 Quality in this outcome area is good. Service users receive good care but would benefit from a more consistent approach to the planning of the care This judgement has been made using available evidence including a visit to this service. EVIDENCE: Service users were observed to be calm and free to wander around the home safely. Staff spoke to them respectfully and gave them ample opportunity to express their feelings and make individual choices. They were well dressed and appeared to have their personal hygiene needs met. The registered manager works alongside the staff team and supervises and supports them to deliver the good care. A healthcare professional had commented, ‘The staff are dedicated to the wellbeing of the clients. They are welcoming of enquiries and always give accurate accounts of clients’ conditions’. Another said, ‘First Class in every aspect of care’. A relative commented, ‘I have been most impressed by the quality of care and commitment of the carers, I have every confidence they are in good hands’ Norwood House DS0000063732.V325770.R01.S.doc Version 5.2 Page 10 Although staff were knowledgeable about service users wishes and needs care records were very basic. There were no risk assessments in place to look at the risk of falls, pressure damage or nutritional needs. These would assist staff to plan and monitor service users care better. Where care needs had changed due to illness the care plans had not been updated to reflect this and direct staff as to how best the needs could be met. The care records did not show if service users or their relatives had had any input into the care plans. Service users care records were kept communally with others and in one case the records had got replaced in the wrong section. Medications records showed that there had been some gaps in recording. This means that it is unclear whether service users had received their medications at the correct time. These included pain relief, sedation and heart medications. However the records showed that the manager had highlighted some errors during an informal audit. Norwood House DS0000063732.V325770.R01.S.doc Version 5.2 Page 11 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. Service users appear to be satisfied with their daily routines and are appreciative of the nutritious food they receive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is a planned list of activities that service users are able to take part in throughout each day. A member of staff has responsibility for organising the day care and activities that the service users are free to join in. A diversional therapist organises activities for service users on three days each week. Activities include games, aromatherapy, quizzes, ball games and chair exercises. On the day of this visit a group were taking part in a game of quoits and later a sing a long. Some service users did not wish to take part in the actual activity but preferred to watch others. Some service users are taken for rides out by relatives on a regular basis. Service users have access to a visiting clergy should they wish to participate in worship. Family and friends are welcome at anytime. Staff were observed to give service users choice in the activities that they took part in and where they spent their days. One service user said, ‘Its quiet down here (downstairs lounge) I like that it’s peaceful’ Norwood House DS0000063732.V325770.R01.S.doc Version 5.2 Page 12 The food provided offer a nutritious well balanced diet for the service users. For those service users who find it easier finger foods are offered. The chef was able to describe how he enriches diets when service users appetites are not good. All service users are given a choice of food at each mealtime and are able to change their mind at anytime. Special diets are catered for including diabetic and vegetarian. The vegetarian option on the day of the inspection was puy lentil and roast red pepper casserole. Norwood House DS0000063732.V325770.R01.S.doc Version 5.2 Page 13 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. Service users are listened to and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints procedure is available within the brochure given to service users and their representatives. The procedure is clear and those relatives that provided comments all indicated they knew how to make a complaint. There had been no complaints since the last inspection. There is an in-house adult protection policy and the home has a copy of the City of York and North Yorkshire Multi Agency policy for the Protection of Vulnerable Adults. Staff are aware of what action to take in the event of suspected abuse or a disclosure being made. Norwood House DS0000063732.V325770.R01.S.doc Version 5.2 Page 14 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 adequate. Service users live in a comfortable environment but would benefit from additional laundry and domestic staff. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The premises are in good structural order. There is a rolling programme of redecoration for the home. Recently bathrooms have been refurbished and wet shower rooms provided in two shared rooms. Communal bathrooms and toilets were conveniently located on all floors accessed by residents. Some rooms had an en-suite facility. Shared rooms have the use of screening to provide privacy for service users that occupy these rooms. There was a passenger lift to all floors. Equipment, crockery and cutlery, bed linen, towels and other furnishings were of a good quality and in a serviceable condition. There is a secure garden with seating that the service users can enjoy weather permitting. One resident said ‘I like living here.’ Norwood House DS0000063732.V325770.R01.S.doc Version 5.2 Page 15 A fire door leading to the outside garden area did not have an alarm fitted. This meant that service users might wander outside unobserved. The door leads to the garden that is accessible down a flight of steps. There was no risk assessment in place. Looking around the premises there was an odour of urine in some areas. At 10.30 some commodes that had been used were not emptied and bedrooms where service users had been assisted to get up earlier still had not had their beds made and the curtains remained drawn. A soiled pad had been left in a bathroom. The care staff have responsibility for the domestic arrangements within the home and also for the laundering of the bedding and service users clothing. On the day of the inspection the home was short staffed due to a service user requiring an escort and a member of staff’s absence following an incident that morning. Norwood House also provides a valuable day care service for up to five people. Some of these people are able to have a bath when they visit. There are three communal bathing facilities in the home situated on floors where service users private accommodation is. Norwood House DS0000063732.V325770.R01.S.doc Version 5.2 Page 16 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 adequate. Service users are not fully protected by the homes recruitment procedures. This judgement has been made using available evidence including a visit to this service. 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 rotas for the previous two weeks were inspected. It showed that there is usually sufficient staff on duty to meet the needs of the present service users. However care staff are also responsible for domestic and laundry provision within the home. A dedicated staff member is usually employed to attend the day care clients but was not in attendance on the day of the inspection due to illness. Staff are undertaking NVQ training. Currently 50 of staff hold an NVQ qualification in care at level 2 or above. In addition staff have received training in dementia awareness, medication, infection control, manual handling, fire prevention, food safety and health and safety. Further training is planned for this year. Polish staff are provided with health and safety information in their own language as well as in English. Norwood House DS0000063732.V325770.R01.S.doc Version 5.2 Page 17 The recruitment records looked at showed that not all staff have two written references in place. Some have only one and one person had none. The manager stated that verbal references had been obtained in two cases. In one case no written or verbal references were in place. The registered manager agreed to put in place supervision for this staff member until a reference was obtained. Some staff had started work before a full CRB had been received. The recruitment records did not show whether a POVA 1st check had been obtained for these members of staff. The registered manager was unable to produce these records at the inspection. Norwood House DS0000063732.V325770.R01.S.doc Version 5.2 Page 18 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. The home is managed well. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection the registered manager has gained qualification in care at NVQ level 4. She has also been awarded her Registered Managers Award. She has many years experience in care. She manages the home in an open and inclusive manner and staff feel well supported by her. Relatives or representatives deal with all service users personal monies. If service users wish to keep some money at the home they are provided with safe lockable facilities to do so. Norwood House DS0000063732.V325770.R01.S.doc Version 5.2 Page 19 The manager carries out quality assurance audits on medications, care plans and health and safety within the home. Staff meetings are held on a regular basis and all staff receive supervision and appraisal. The home holds the ‘Investors in People’ Award. Some safety records were not available at the inspection. These include the Portable Appliance Testing, The Gas Safety certificate and the Electrical Wiring certificate. Norwood House DS0000063732.V325770.R01.S.doc Version 5.2 Page 20 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 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Norwood House DS0000063732.V325770.R01.S.doc Version 5.2 Page 21 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 OP3 Regulation 14 Requirement Timescale for action 02/02/07 2. OP8 12,13 3. OP9 13 The registered person must make sure that sufficient information is obtained about service user’s needs before they are admitted to the home. Information received from other health and social care professionals must be used to form the basis for service user’s plans of care. The registered person must carry 02/02/07 out an assessment of risk for each service user in relation to: • Falls • Nutrition • Risk of pressure damage • Moving and Handling. These must be kept under review and updated as needed to ensure that current needs are addressed. The registered person must 02/02/07 ensure that medication systems are formally audited and a record kept of this. Any errors identified are addressed with the person responsible during supervision sessions. Norwood House DS0000063732.V325770.R01.S.doc Version 5.2 Page 22 4. OP19 13 5. OP26 OP27 16(k) 6. OP29 19 7. OP38 13 A risk assessment must be carried out to assess the possible risk to service users should they access the garden area via the fire exit door in the lounge and down the flight of steps. The registered person must keep the staffing provision under review to ensure that at all times there are sufficient staff on to: • Meet the service user’s needs. • Make adequate provision for domestic and laundry duties • Ensure that the home is free from odours and kept clean at all times.. The registered person must ensure that: • All staff members have two written references in place before they are deployed to work at the home. • Where POVA 1st checks are sought, evidence that these have been received is kept on the staff members file. The registered person must forward to the Commission for Social Care Inspection copies of the following certificates when obtained: • Gas Safety Certificate • Electrical Wiring Certificate • Portable Appliance Testing certificate. 02/02/07 02/02/07 10/01/07 14/03/07 Norwood House DS0000063732.V325770.R01.S.doc Version 5.2 Page 23 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. 2.. Refer to Standard OP7 OP33 Good Practice Recommendations Service users personal records should be kept securely and individually. This will ensure compliance with the Data Protection Act 1998 It is recommended that the quality assurance system is further developed to ensure that the views of all stakeholders are sought and acted upon. Norwood House DS0000063732.V325770.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 House DS0000063732.V325770.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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