Inspection on 25/07/06 for Norwood House Care Home

This inspection was carried out on 25th July 2006.

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 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 Care Home 19/09/08

Norwood House Care Home 04/06/07

Norwood House Care Home 27/10/05

Norwood House Care Home 25/11/04

Norwood House Care Home 18/06/04

Norwood House Care Home 25/03/04

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

CARE HOMES FOR OLDER PEOPLE Norwood House Care Home 1-3 Vicarage Gardens Scunthorpe North Lincs DN15 7BA Lead Inspector Sarah Urding Unannounced Inspection 25th July 2006 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 Care Home DS0000002847.V305969.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 Care Home DS0000002847.V305969.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norwood House Care Home Address 1-3 Vicarage Gardens Scunthorpe North Lincs DN15 7BA 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) 01724 850321 North Lincolnshire Care Limited Miss Nicola J McDonagh Care Home 23 Category(ies) of Dementia - over 65 years of age (23), Old age, registration, with number not falling within any other category (23) of places Norwood House Care Home DS0000002847.V305969.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th October 2005 Brief Description of the Service: Norwood House is in the centre of Scunthorpe and close to all of the local shops and amenities. It is registered for 23 service users in the category of older people and older people with dementia. The home has 4 bathrooms, a shower room and nine toilets for the service users to share. These are all in close proximity to service users’ bedrooms. Three bedrooms also have en-suite facilities. The accommodation is provided over two floors. There are two staircases and two passenger lifts to aid accessibility. There are pleasant gardens to the front and rear of the property. The current scale of charges are £348-£377 per week. Additional charges include hairdressing, chiropody, holidays and newspapers or magazines. Norwood House Care Home DS0000002847.V305969.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection and the visit to the home was unannounced, taking place over a period of six hours. The inspector received comments prior to the inspection from three GP’s, thirteen members of staff and sixteen service users. This information was used in the inspection and will be reflected in this report. On arrival at the home the building was looked around and a number of records and policies were inspected. The manager and four members of staff were spoken to. Eleven service users and a visitor to the home were also spoken to. What the service does well: The home undertakes thorough assessments of service users needs before they are admitted in to the home. The care plans of service users are clearly presented and completed in detail. This means that staff can clearly see how to meet the needs of service users. Good records are kept of service users daily lives and of all medical appointments. Service users are well cared for and their needs are well met by staff in the home. Service users spoken to said that they are happy with the care that they are receiving. One service user said that staff are very good and they try hard to please everyone. A visitor to the home said that she is made to feel welcome when she visits and that staff keep her informed of events. Staff are well trained and recruited safely. Staff were observed to treat service users with respect and were sensitive to their needs. Staff were seen to consult with service users giving them choices about how to run their lives. Service users and a visitor to the home said that staff are always polite to them and treat them with respect. There is a varied programme of activities on offer in the home which service users are satisfied with. Service users cultural and religious needs are well met by the home. The food in the home is nutritious and menus are well planned and recorded. Choices are given at every mealtime. The home protects and listens to service users well. This means that service users are safely looked after and can contribute to changing things in the home if they wish. The home is well managed. Service users said that they are happy with their rooms. The home reviews the quality of care it provides on a regular basis and seeks the views of service users so that standards are maintained. Norwood House Care Home DS0000002847.V305969.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The recording of the administration of medication has improved. However it was not possible to account for some of the medication held in the home. The home needs to record the date when some medication is started so that the numbers of tablets held can be monitored. This will enable staff to know if the system is being misused. The home keeps a diary for every service user of one to one time spent and activities enjoyed. It would be good practice if this diary were maintained regularly as it is a good way of evidencing that people’s interests are met. Some aspects of the environment really let the home down. The living areas of the home are well presented and comfortable for service users. However some of the bedrooms and bathrooms are in urgent need of re-decoration. The manager said that a programme of re-decoration has been devised although this was not available for me to see during the visit. Without this I am not confident that the issues will be addressed. The home must send CSCI a copy of this plan with timescales for the intended works to be carried out. Of particular concern is the standard of the downstairs bathroom. The bath looks filthy, is covered in lime scale and surrounding tiles are chipped or broken. The manager assured me that this bath is not in use at the present time. However the toilet in the room is still in use. This room must be decorated and cleaned or the statement of purpose must be revised to reflect that this room is not available as a facility for service users. Other areas for improvement will be mentioned within this report. Staff induction and training is good but the home does not yet meet the standard with regards to 50 of staff being trained to NVQ level 2. There is a receipt for £150 missing from the resident’s fund. The manager said that the money had been used to pay for a bus trip to Cleethorpes. A copy of this receipt must be requested so that the fund is accountable. Please contact the provider for advice of actions taken in response to this Norwood House Care Home DS0000002847.V305969.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Norwood House Care Home DS0000002847.V305969.R01.S.doc Version 5.2 Page 8 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 Care Home DS0000002847.V305969.R01.S.doc Version 5.2 Page 9 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): 2, 3, 6 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home undertakes a thorough assessment prior to admission and issues clear contracts, which ensure that service users needs and expectations of the home are met and understood. EVIDENCE: The standard relating to service users contracts was looked at during the inspection because one service user said that she was not sure whether she had been issued with a contract and terms and conditions of the home. Three service users records were assessed during the inspection and it was found that the home has issued clear contracts. In all cases service users or their representatives had signed the contracts. The contracts and terms and conditions of the home were clearly set out and informed service users and relatives of expectations of service. The home undertakes a thorough pre-admission assessment of service users needs in all cases. This takes place for those service users experiencing Norwood House Care Home DS0000002847.V305969.R01.S.doc Version 5.2 Page 10 periods of respite in the home also. The assessments are well presented and link clearly to the care plans of those service users. The home ensures that it is able to meet the needs of service users prior to looking after them. Standards 3.3 is met for all service users. Service users, their representatives and health professionals have contributed to the formation of the assessment. This evidences that the home works in partnership to glean full information about service users lives. The home does not offer intermediate care. Norwood House Care Home DS0000002847.V305969.R01.S.doc Version 5.2 Page 11 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, 8, 9, 10 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users health and personal care needs are well met by staff who understand the importance of treating service users with dignity and respect. A minor shortfall in the standard relating to medication needs to be addressed. EVIDENCE: The home has comprehensive care plans in place that link clearly to the preadmission assessment. The care plans are clearly documented and easy to follow. They give staff a clear picture of the needs of service users and how to meet these needs. All aspects of service users lives are incorporated in to the care plan. Consultation takes place and service users and their representatives have signed their agreement with the plan. The home meets the health care needs of service users well. Clear records are kept of all health appointments attended. Service users said that they were able to see a GP when they wished or when staff felt they needed to. GP’s were positive about the home being able to meet the health care needs of service users. Norwood House Care Home DS0000002847.V305969.R01.S.doc Version 5.2 Page 12 Service users are administered medication safely and there were improvements in the record keeping since the last inspection. Medication is stored appropriately, which includes the storage of controlled drugs. The system is regularly audited to ensure that staff administering medication are doing so safely. This is good practice. The home operates within a monitored dosage system and unused medication is returned to the chemist. There was a minor shortfall for those drugs held that were not part of the monitored dosage system. The home was unable to account for the number of tablets held in some cases. The start date of this Medication must be recorded so that staff are able to monitor whether the system is being misused. The overall system is well managed and the manager said that this would be addressed. Service users and visitors said that they were treated with respect by staff. Interaction between staff and service users was observed to be positive and polite. Service users said that their privacy was upheld and staff recognised the need for sensitivity when carrying out personal care tasks. Norwood House Care Home DS0000002847.V305969.R01.S.doc Version 5.2 Page 13 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, 14, 15 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Good facilities are provided for service users to experience activities, community and religious involvement of their choosing and maintain contact with their relatives. Meals are nutritious and balanced, offering a healthy and varied diet for service users. EVIDENCE: Service users lifestyle in the home satisfies their social, cultural religious and recreational needs. This was evidenced in care plans and in talking to service users and staff. A range of weekly activities is offered in the home including bingo, reminiscence, board games and arts and craft. Activities diaries are kept to record one to one time spent with service users. It would be good practice if these were completed on a more regular basis as they evidence that individual needs are being met. Religious services are regularly held in the home and service users are able to attend church services in the community. The home has an equality and diversity management plan in place which looks at all aspects of service users Norwood House Care Home DS0000002847.V305969.R01.S.doc Version 5.2 Page 14 lives and plans how to ensure all needs are met in this area. This is good practice. The home has a social fund which service users are consulted with around its usage. One service user is signatory to this fund. The accountability of the residents fund will be referred to in the management section of this report. Staff were positive about being able to spend regular time with service users enjoying activities. During the inspection service users were observed to be enjoying a singing and dancing activity with staff. It was a particularly hot day and service users were offered choc-ices and lollies, which they said they had on a regular basis. The atmosphere was relaxed and good fun. Contact with family and friends is promoted by the home. Service users were positive about being able to see their friends and family when they wish. One relative said that she is made to feel welcome by staff and is kept informed of events. Service users are encouraged to maintain choice and control over their lives on a daily basis. Advocacy services are made available to residents. Staff spoken to described how they ensure that residents are consulted with and empowered to make their own decisions. This ensures that residents maintain their independence for as long as possible and that staff are aware of treating people in a positive and inclusive manner. The positive interaction between staff and service users was observed during the inspection. A number of people in the home commented about the food and how good it is. A number of service users said that the food is “very good”. One service user said that there were too many root vegetables on the menu and not enough pasta and rice. Menus were found to be well balanced and varied. However they did demonstrate that potatoes were served every day. The manager said that a lot of the service users did not like pasta and rice but these were always available at their request. Service users should be reminded of this fact on a regular basis. It was observed that staff offered choice at lunchtime and the menus indicated that a choice is available at every meal. Meals are well presented and organised. Norwood House Care Home DS0000002847.V305969.R01.S.doc Version 5.2 Page 15 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, 18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The arrangements for complaints and protection are handled well and practice ensures that service users are listened to. EVIDENCE: The home has a clear complaints procedure in place. Service users spoken to said that they have no complaints about the home and feel confident to raise issues of concern if they arise. The relationships between staff and service users were observed to be open and inclusive. This is encouraging and evidences that service users concerns will be dealt with appropriately. Complaints are recorded appropriately in a complaints log and addressed by the manager. There have been no complaints since the last inspection. The home has an appropriate policy in place for the protection of vulnerable adults. Staff spoken to were clear about reporting procedures should a service user make an allegation and around the indicators of abuse. There has been an improvement in staff understanding of protecting vulnerable adults since the last inspection. The manager said that all staff have received training in this area. A recent vulnerable adults issue has been dealt with appropriately by staff and has been fully documented. CSCI have been kept fully informed of events and the matter has now been resolved to the satisfaction of all parties. Service users spoken to said that they felt safe when being looked after by staff. Norwood House Care Home DS0000002847.V305969.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 26 Quality in this outcome area is poor. This judgement has been made from evidence gathered both during and before the visit to this service. Lack of upkeep and attention to detail in some parts of the building mean that the comfort, hygiene and safety of service users is compromised. EVIDENCE: Some aspects of the environment let the home down. The entrance hall, dining room and lounges are well maintained, clean and comfortable for service users. Some service users’ bedrooms are well decorated and homely. Other areas of the home however need redecoration and maintenance. It is unclear what further development to the home is planned as the maintenance and development plan has not yet been completed. Areas requiring immediate attention include: Re-decoration and repair to the downstairs bathroom, which looks shabby and is unhygienic. There are cracked and broken floor and wall tiles and there is no seal between the bath and the floor. The bath is filthy and covered in lime Norwood House Care Home DS0000002847.V305969.R01.S.doc Version 5.2 Page 17 scale. The manager said that the bath is not in use at the present time but service users are still using the toilet in this room. The standard of decoration in the bathroom is poor and makes the room look dirty and cold. This is not conducive to ensuring a comfortable or hygienic experience for service users. The home’s statement of purpose offers the bathroom as a facility for service users but in its present condition this is not acceptable. The works must be carried out as a matter of priority or the room be withdrawn as a stated facility of the home. Requirements of the fire and environmental health department are being met by the home although the door to bedroom 4 will not close without force. This must be repaired. A cupboard in one of the upstairs bathrooms was very full and presents a risk of items falling on service users if they open the door. The registered manager must ensure that the cupboard is cleared and can be safely opened. There were also a number of items being stored in this bathroom, including a commode in the bath. This is hazardous and unhygienic. The manager was asked to clear the room of all obstacles. This was carried out during the inspection. Not all of the service users rooms assured comfort and privacy. The window above the door of room 9 is transparent and must be covered so that privacy is ensured. The towel rail in room 5 is broken and the service user’s towel was placed on a bin for storage. This must be addressed. There were a number of cobwebs on the wall of one service user’s bedroom and these must be cleaned. The responsible individual is required to produce a maintenance and redecoration plan for the home and include a schedule for the above works to take place. A copy of this plan must be sent to CSCI. Policies for the control of infection are in place and followed in practice. Staff were observed to practice appropriately to avoid the risk of cross contamination. Staff were aware of the need to wear protective clothing when undertaking certain tasks. The home has a laundry, which is suitable to meet the needs of service users although a comment from one member of staff implied that a new washer/dryer would be useful. This should be looked in to. Service users and a relative were satisfied with the laundry service that the home provides. Norwood House Care Home DS0000002847.V305969.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 at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service. Service users are looked after by safely recruited and well trained staff. EVIDENCE: The home is staffed appropriately. Three staff are on duty throughout the day, which includes a senior member of staff at all times. A further member of staff is being recruited to provide additional cover during the mornings to enable phone calls etc to be made without impacting on staff numbers. The home employs two domestics and a cook. Two staff are on duty at night. The manager is supernumerary to the rota. On the whole staff are positive about the levels of staffing in the home. Although one member of staff feels that there are not always enough staff to meet the needs of service users. This should be looked in to. Five out of the twenty care staff employed by the home are qualified to NVQ level 2 or above in care. Six staff have applied to or are currently undertaking this course. This does not yet meet the 50 recommended level but will do so if staff successfully complete the course. Recruitment practice in the home has improved since the last inspection and is adequate to ensure that residents are protected. Application forms are fully completed and gaps in employment explored. CRB/POVA first checks are in place for all staff and two written references are sought prior to staff being employed. Norwood House Care Home DS0000002847.V305969.R01.S.doc Version 5.2 Page 19 Four staff files were looked at during the inspection. Statement of terms and conditions are in place for these staff. It is not clear whether all staff have been issued with a contract however as indicated within some questionnaires. This must be looked in to and up to date contracts provided for all staff. Staff are inducted appropriately to their role. The home has recently devised a new programme of induction for staff, which is comprehensive. Staff spoken to feel supported well by colleagues and senior members of staff. They spoke of a family atmosphere and said that they enjoy coming to work. A record of training received by staff in the home was available for inspection and appropriate for the work that staff undertake. Training in working with people with dementia is provided although comments in some of the staff questionnaires indicated that not all staff have received this training. It is recommended that this be provided to everyone. Norwood House Care Home DS0000002847.V305969.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 at least once during a 12 month period. 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 from evidence gathered both during and before the visit to this service. Service users live in a well managed home. EVIDENCE: The registered manager has four years experience in running the home. She has completed the Registered Manager’s Award and has a Diploma in social work. Staff spoken to said they feel supported by the manager and they are clear about their roles and responsibilities. The staff team are supportive of each other. High levels of consultation and regular reviews by the manager ensure that service users are looked after in an environment that is both safe and inclusive. The home operates an effective quality assurance system that seeks the views of service users and staff on a regular basis. It would be good Norwood House Care Home DS0000002847.V305969.R01.S.doc Version 5.2 Page 21 practice if the views of health professionals and other stakeholders were also sought. There is a monthly audit system in place that looks at key areas aimed at improving standards. This is good practice. Service users are protected by the financial procedures of the home. The home does not act as appointee for any residents and looks after monies for service users appropriately. Written records of all transactions are accurately maintained. As mentioned previously in this report there is a receipt for £150 missing from the resident’s fund. The manager said that the money had been used to pay for a bus trip to Cleethorpes for the service users. A copy of this receipt must be requested so that the fund is accountable. The home operates in the best interests of the health and safety of service users and staff. All safety checks are carried out within the specified time frame and policies are in place for safe working practice. Health and safety training is available for staff. Norwood House Care Home DS0000002847.V305969.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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 X X X X 2 X 3 STAFFING Standard No Score 27 3 28 2 29 3 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 Care Home DS0000002847.V305969.R01.S.doc Version 5.2 Page 23 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 OP9 Regulation 12, 13 Requirement Timescale for action 31/08/06 2 OP19 3. OP19 4. OP19 The registered manager must ensure that all medication held within the home can be accounted for. Dates when all medication is started should be recorded. 12, 16, 23 The responsible individual must 14/08/06 produce and implement a programme of routine maintenance and renewal of the fabric and decoration of the premises. Copies of this must be sent to CSCI for information. Previous timescale of 30/11/05 was not met. 30/09/06 12, 16, 23 The responsible individual must make arrangements for the redecoration and repair of the downstairs bathroom in the home. To include repair to cracked and broken wall and floor tiles; repair to seal between bath and floor; cleaning or replacement of bath. The bath must not be used until the works are carried out. 12, 23 The registered manager must 14/08/06 ensure that fire regulations are followed. To include repairing the door to room 4. DS0000002847.V305969.R01.S.doc Version 5.2 Norwood House Care Home Page 24 5. OP19 12, 23 6. OP24 The registered manager must ensure that the cupboard in the upstairs bathroom can be safely opened. 12, 16, 23 The registered manager must ensure that service users rooms assure comfort and privacy. 1. The window above the door of room 9 must be covered. Previous timescale of 30/11/05 was not met. 2. The towel rail in room 5 must be replaced. 3. The cobwebs in room 13 must be cleaned. 14/08/06 14/08/06 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. 3. 3. 4. 5. Refer to Standard OP12 OP28 OP29 OP30 OP33 OP35 Good Practice Recommendations Activity diaries should be completed on a regular basis. 50 of care staff should be qualified to NVQ level 2. All staff should be issued with up to date contracts. All staff should receive training on how to work with people with dementia. The views of health professionals and GP’s should be sought when reviewing the quality of care in the home. A copy of the receipt for £150 from the resident’s fund should be sent to CSCI. Norwood House Care Home DS0000002847.V305969.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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. 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