Inspection on 28/04/05 for Norwood House

This inspection was carried out on 28th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 02/01/07

Norwood House 15/11/05

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 David Blackburn Unannounced 28 April 2005 09:00 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 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 J53-J04 S63732 Norwood House V223926 280405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Norwood House Address 12 Westbourne Grove, Scarborough, North Yorkshire, YO11 2DJ Telephone number Fax number Email 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 01723 360360 Comfy Care Homes Ltd Mrs Catherine Ellwood Care home only 21 Category(ies) of DE(E) Dementia -over 65 (21) registration, with number of places Norwood House J53-J04 S63732 Norwood House V223926 280405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 02/12/2004 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 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 diverional therapist on three afternnons 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 J53-J04 S63732 Norwood House V223926 280405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection on which this report is based was the first to be undertaken in the inspection year April 2005 to March 2006. It was carried out over 6 hours including preparation time. The focus was on a number of the key standards together with those subject to requirements and recommendations at the last inspection. An inspection of some of the premises, including a small number of bedrooms, was undertaken. A number of records and other documents were examined. Discussions were held with the registered manager, six residents, four staff including the cook, day care worker and the administrative assistant and a visiting health professional. A telephone conversation was held with a relative. What the service does well: What has improved since the last inspection? New washing machines had been installed that minimised the risk of cross infection and contamination. The passenger lift had been refurbished making it safer and easier for residents to use. Norwood House J53-J04 S63732 Norwood House V223926 280405 Stage 4.doc Version 1.30 Page 6 Selective redecoration, re-carpeting and new furniture had been provided to some bedrooms giving residents a more comfortable and homely room. An administrative assistant had been employed to enable the registered manager spend more time on the supervision of staff and residents. 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 J53-J04 S63732 Norwood House V223926 280405 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Norwood House J53-J04 S63732 Norwood House V223926 280405 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 and 6. Information available from the home together with the pre-admission assessment procedure was very good providing residents and prospective residents with the details of the care, services and facilities on offer and assuring them that their needs could be met. EVIDENCE: A Statement of Purpose and Service User Guide were seen. They made good use of photographs and graphic illustrations most in colour and large clear print. The documents were extremely informative and provided an excellent source of information for any prospective resident. Both publications, however, need to be revised to reflect the changes in ownership and management of the home. Pre-admission assessment forms were seen on the files examined. For those privately funded these had been completed by the responsible individual of the owners (a qualified social worker) or the registered manager (who held a National Vocational Qualification in care to level 3). For residents publicly funded the assessment had been carried out by a care manager from the placing authority. The information gained provided the basis for care needs to be identified and care plans developed. The registered manager said intermediate care was not offered in the home. Norwood House J53-J04 S63732 Norwood House V223926 280405 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 and 9. The physical and health care needs of residents were well recorded and acted upon by staff promoting good health. Medication administration record sheets must be completed at the time medicines are administered to ensure all staff are aware they have been given. EVIDENCE: Four care plans were examined. All were up-to-date and informative in detailing strengths and needs and how they were to be met by staff. Risk assessments were on the files seen. All care plans showed evidence of a monthly review. A number, but not all, had been signed by the resident or their representative. Personal and health care needs were fully recorded. A health-check report form gave reasons for any referral to a health specialist, the outcomes and the need, if any, for further visits. Specialist areas of care, for example pressure area and continence were promoted with the input of health workers. Nutritional needs and weight gain or loss were recorded where necessary. A visiting health worker was complimentary towards the staff and care provided. “Residents are always well cared for. I have no concerns when I visit. Staff are helpful and conscientious.” A relative said “I have no concerns the care they offer is very good.” Norwood House J53-J04 S63732 Norwood House V223926 280405 Stage 4.doc Version 1.30 Page 10 Proper procedures were in place for the ordering, receipt, storage, administration, recording and return of medication. The correct procedures were being followed. However on scrutiny of the medication administration sheets it was noted that there were gaps in a small number of recordings for the previous day. Recording must be carried out at the time medication is administered to ensure all staff are aware that medicines have been given. The registered manager agreed to immediately reinstate her system of daily checks. Only staff who had completed a recognised course in medication training could take responsibility for administration. Norwood House J53-J04 S63732 Norwood House V223926 280405 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 15. The dietary needs of residents were well met with a varied menu of food being served that satisfied their tastes and choices. EVIDENCE: The present menu had been based on the choices, preferences and wishes of residents. Choice was available at all meals. Residents were asked to state their preference. This was confirmed by observation in the kitchen of the food being prepared and in discussion with the cook. Food was well presented and properly served. Tables were well set in the dining areas. Each area offered residents and staff ease of movement and service. Apart from breakfast mealtimes were set. None of the residents expressed any concerns about this. Special diets and foods were readily available. A discussion about a resident’s particular needs in this area was overheard. The registered manager had attended a course about the nutritional needs of persons with dementia. The ideas gained from this course were being put into action. Residents made very favourable comments including “The food is always nice” and “I enjoyed my dinner. They feed us well.” Norwood House J53-J04 S63732 Norwood House V223926 280405 Stage 4.doc Version 1.30 Page 12 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 standard(s) 16. A complaints procedure was in place with some evidence residents’ concerns and views were listened to and acted upon. It is important that all complaints are recorded to maintain residents’ and relatives’ trust in the published procedure. EVIDENCE: A satisfactory complaints procedure was in place. This showed how to complain, to whom and gave timescales for response. Clear reference was made to the regulatory authority. Complaints were recorded in a book. This was examined. Complaints and how they had been resolved were recorded. A recent complaint was not shown. A relative said she had recently drawn the attention of the responsible individual to a specific matter through the complaints procedure. This had been properly and quickly addressed and resolved. Residents said they were happy but knew how to complain. “If I’m not happy I see G (responsible individual).” Norwood House J53-J04 S63732 Norwood House V223926 280405 Stage 4.doc Version 1.30 Page 13 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 standard(s) 19 and 26. Environmental standards were good providing residents with a homely, clean, comfortable and safe place to live. EVIDENCE: The premises were in good structural order. Remedial work had been carried out to the exterior. Of the 18 bedrooms three could be occupied on a shared basis. Some rooms had an en-suite facility. Communal bathrooms and toilets were conveniently located on all floors accessed by residents. 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. A secure garden with ramped access was provided with seating. The last reports from the Fire Officer and Environmental Health Officer were seen. No recommendations had been made in either report. One resident said “I like my room.” Those parts of the premises seen were warm, clean and free from offensive odours. Appropriate arrangements had been made for the proper laundering of bedding, linen and personal clothing. A visiting health worker commented “It’s always clean and never smells.” Norwood House J53-J04 S63732 Norwood House V223926 280405 Stage 4.doc Version 1.30 Page 14 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28 and 29. Good recruitment and vetting methods meant the employment of proper staff ensuring residents were protected from harm. EVIDENCE: Thirteen staff were employed as care assistants and two as cooks. Two staff had a National Vocational Qualification in care to level 2. A number of other staff continued their work towards this award at level 2 and 3. The files of the last two staff to be appointed were examined. One staff had commenced her duties and her file showed completed application form, written references, POVA/first check, an enhanced Criminal Records Bureau (CRB) disclosure, and a terms and conditions of employment. The second file of a person yet to commence duties revealed a completed application form, written references and a POVA/first check. The registered manager was aware of the need for close supervision of the second person until a full CRB disclosure had been received. The diversional therapist employed on three afternoons each week had obtained an enhanced disclosure from the CRB. Norwood House J53-J04 S63732 Norwood House V223926 280405 Stage 4.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38. Proper attention appeared to be given to matters of health and safety to promote a safe and secure place for residents to live. Two minor matters were noted for attention to ensure residents’ safety did not become compromised. EVIDENCE: The registered provider employed a specialist company to give advice on health and safety matters. A regular report was presented to the providers. Their advice was acted upon. One member of staff acted as health and safety representative for the home. A number of reports and certificates were available relating to the safety of the premises. Two minor matters were brought to the attention of the registered manager. A small area of hot water pipe work was exposed and could pose a risk of scalding. A filing cabinet used for storage of medical requisites and kept in the disabled toilet could limit the room staff had to assist residents. Norwood House J53-J04 S63732 Norwood House V223926 280405 Stage 4.doc Version 1.30 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 1 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 x 28 2 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 1 x x 2 x x x x x x 1 Norwood House J53-J04 S63732 Norwood House V223926 280405 Stage 4.doc Version 1.30 Page 17 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 1 Regulation 6 Requirement The Satement of Purpose and Service User Guide must be reviewed and updated to reflect the changes in ownership and management. Medication administration record sheets must be completed at the time medicines are given out. All complaints must be recorded at the time of receipt. Timescale for action 31/05/05 2. 3. 4. 5. 9 16 38 38 13(2) 17(2) Schedule 4.11 13(4) 13(4) Immediate From next complaint All exposed hot water pipes must 05/05/05 be properly guarded. The filing cabinet kept in the 05/05/05 ground floor disabled toilet must be removed. 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 7 28 Good Practice Recommendations Residents or their representatives should be encouraged to sign the care plans. The registered provider is reminded of the need for 50 of the care staff to have achieved a National Vocational Qualification (NVQ) in care to at least level 2 by 2005. J53-J04 S63732 Norwood House V223926 280405 Stage 4.doc Version 1.30 Page 18 Norwood House 3. 31 The registered providers are reminded of the need for any manager to have a National Vocational Qualification in care and management to at least level 4 by 2005. Norwood House J53-J04 S63732 Norwood House V223926 280405 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection 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 J53-J04 S63732 Norwood House V223926 280405 Stage 4.doc Version 1.30 Page 20 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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