Inspection on 04/06/07 for Norwood House Care Home

This inspection was carried out on 4th June 2007.

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

The inspector 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 25/07/06

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

Similar services:

Abbey The

Snydale Care Home

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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 Stephen Robertshaw Unannounced Inspection 4th June 2007 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.V341889.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.V341889.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 Vacant 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.V341889.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th July 2006 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 between £349-£398 per week. This includes the £15 top up fee made by the home to all of the service users. Additional charges include hairdressing, chiropody, holidays and newspapers or magazines. Individual service users pay for these services as and when they require them. Norwood House Care Home DS0000002847.V341889.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The site visit to the service took place on the 04 th June 2007. The visit was unannounced and the inspector was in the home for approximately seven and a half hours. The inspector spoke with seven of the service users, four staff, the management of the service and observed the written documentation in the home. The inspector also observed the interactions between the individual service users and each other and their interactions with the care staff. The inspector would like to thank everyone for making him welcome at the home. What the service does well: What has improved since the last inspection? The medication administered to the service users is recorded better to make sure that they receive the right medication to keep them safe and healthy. One of the downstairs bathrooms have been replaced with a new shower room. The equipment makes it easier for service users who prefer to have a shower to use these facilities. The front lounge in the home has been decorated and new carpets, curtains and chairs have been provided for the service users. This means that a more homely and friendly atmosphere has been provided. Norwood House Care Home DS0000002847.V341889.R01.S.doc Version 5.2 Page 6 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 Care Home DS0000002847.V341889.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 Care Home DS0000002847.V341889.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): 1,2,3,4,5 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that the service user or their representatives are given the opportunity to visit the home before they make a decision to move there. EVIDENCE: At the time of the inspection there were twenty-one service users living at the home. The inspector observed all of the information recorded in the home in relation to the care provided to and received by four of the service users. All of the service users had their care needs fully assessed before they had been admitted in to the home to ensure that the home was able to meet their individual needs and that this was within the homes registration with the Commission. The assessments were a combination of the home’s preadmission information and where appropriate care management assessments of need. Norwood House Care Home DS0000002847.V341889.R01.S.doc Version 5.2 Page 9 Contracts were in position for all of the service users files that were seen by the inspector. Due to the complexities of the needs of the service users the inspector was not able to determine if they understood the terms and conditions of their contracts. In all cases the 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 information in the service user guide and statement of purpose need to include that the manager post is currently vacant. The home has the capacity to meet the needs of the service users. This evidence was supported through direct observations of the interactions between care staff and service users, discussions with service users, interviews with management and staff and observation of staff training records. One service user stated to the inspector ‘the girls are great, you don’t want for anything here’. The home does not offer intermediate care to service users. Norwood House Care Home DS0000002847.V341889.R01.S.doc Version 5.2 Page 10 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 and 11 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that there are care plans for most of the individual needs of the service users however not all of their dementia care needs had been appropriately identified and care planned for. EVIDENCE: The inspector observed the care plans for four of the service user living at the home. Three of these service users had dementia related problems. Their care plans for their other needs were well identified and clearly defined how the needs must be met, however there were no appropriate care plans to support their dementia related needs. All of the remaining care needs as recognised in the service users’ assessments of need had been identified and care plans had been developed to support these needs. This included any moving and handling issues. Norwood House Care Home DS0000002847.V341889.R01.S.doc Version 5.2 Page 11 The daily diary records for the service users that support how the service users needs are being met are usually recorded on the home’s computer system. At the time of the inspection the computer system was not functioning fully and the records were being manually recorded. These records were very brief and did not clearly identify how the service user had responded to any interventions form other people including care staff and other service users. It is important that these aspects are clearly recorded in particular in relation to the service users with dementia related problems as this may help to identify any patterns of behaviour. The medication practices in the home have improved since the previous inspection. All of the records were up to date and had been accurately maintained. The controlled drugs in the home were all accounted for and had been appropriately recorded. The only difficulty with the medication was the fridge used to store certain medication including eye drops. The temperature of the fridge was recording -15°C. The eye drops needed to be stored between 2°C and - 8°C. The manager of the home was advised to contact the pharmacy to see if the eye drops could be continued to be used or needed to be replaced. A recommendation was also given to obtain alternative arrangements to store refrigerated medicines. The administration of medication was observed at two separate times by the inspector and all appropriate legislation and good practice guidelines were followed. Training records and interviews with care staff identified that only staff that have received appropriate medication training can administer prescribed medication to the service users. A service user with dementia was observed holding their medication in their mouth and not swallowing it. The member of staff was very patient with them and after some time managed to communicate with the service user that they need to swallow their medication. The inspector’s observations also supported that the service users privacy and dignity is upheld at all times in n the home. One service user told the inspector ‘ when I see my family or the doctor I can do this in my room …if I need help the care staff will help me’. The home meets the health and personal care needs of the service users. Clear records are kept of all health appointments attended in the home or in the community. Service users confirmed to the inspector that they are able to see a GP whenever they wish or when staff felt they needed to because they thought that their health was not as good as it usually was. Care managers contacted by the inspector were confident that the service users that they were responsible for had all of the health and personal care needs met through the services provided by the home. All of the care files observed by the inspector included their last wishes in the event of their deaths. Norwood House Care Home DS0000002847.V341889.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This meant that the service users are supported to maintain and develop the interests that they had before they were admitted in to the home. EVIDENCE: The daily lives and activities provided for the service users are very flexible and varied and are targeted to meet the individual needs of the service users. On the day of the site visit several of the service users were observed with two of the care staff playing ‘photo bingo’ this is a game supplied by a specialist games company for service users with dementia related problems. The service users seemed to thoroughly enjoy this game and showed good interest in it. The acting manager of the home stated that the home had gained several different indoor and outdoor games that had been provided through the same supplier. The publication of when individual activities are available in the home is more difficult than at previous times. This is due to the increasing dementia care Norwood House Care Home DS0000002847.V341889.R01.S.doc Version 5.2 Page 13 needs of service users in the home. Due to certain individuals’ problems, when messages are placed on notice boards or walls they are taken down by individual service users and therefore are not available for all of the other service users and visitors to see. One half of the registration certificate was also missing. The manager of the home stated that due to these concerns a lockable unit would be placed in the entrance to the home and all modifiable information would be displayed inside the unit. Previously the home’s insurance certificate had ‘gone missing’ however it was later ‘recovered’. The home has a social fund which service users are consulted with around its usage. One service user is signatory to this fund. However their capacity to continue as a signatory appears to have deteriorated significantly. This fund will be responded to later in the management section of the report. Care staff confirmed to the inspector through their interviews that they were positive about being able to spend regular time with service users and enjoyed providing activities to them. The atmosphere in the home was very relaxed. Not all service users have equal access to the outside of the building due to the uneven paths at the rear of the home that could cause them to fall due to their restricted mobility. One service user said that she was religious and would like to attend church in the community. They stated that they had done this until recently until they had ‘been unwell’ and wanted to do this again. This was mentioned by the inspector to the acting manager who stated that this would be followed up as soon as possible. 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. This also included supporting appropriate service users to vote in local and national elections. The inspector observed two meal times at the home and had lunch with several of the service users. The meal times were unhurried and where needed care staff offered appropriate levels of support to individual service users whilst at the same time upholding their dignity. Service users were not offered a choice at the lunchtime meal. The manager stated to the inspector that previously choices had been included for all meal times at the home however, choices were picked by the individual service users in the morning for the lunchtime meal. Due to the complexities of many of the service users dementia care needs at lunchtime they could not remember what they had ordered and this caused problems when the meals were served. Service users would argue with other service users wanting their meals. The manager stated that due to this the menus were provided to give an option of a healthy diet and were discussed at service user and family meetings to make sure that they service users received the meals that they liked. It was observed that the cook had a list of service users likes and dislikes and if they did not like the meal Norwood House Care Home DS0000002847.V341889.R01.S.doc Version 5.2 Page 14 provided then an alternative meal would be offered. One service user stated to the inspector that ‘the meals are always tasty, and I like them all’. Another service user confirmed this by saying ‘the meals here are very good’. Norwood House Care Home DS0000002847.V341889.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This means that there is a clear complaints procedure in the home and the service users are protected from possible abuse. EVIDENCE: The home has a clear and easy to follow complaints procedures. There had been no formal complaints recorded at the home, or with the Commission since the last inspection. A service user said to the inspector that if they had any concerns or complaints then they would ‘speak to the staff or the manager’ and they appeared confident that they would deal with their concerns appropriately. One of the care files observed by the inspector confirmed that their finances were controlled through the court of protection and all of their records were up to date and had been accurately recorded. There had been no safeguarding adult issues since the last inspection. All of the staff personnel and training files confirmed that the staff receive training in relation to the protection of vulnerable adults. Staff interviewed by the inspector were also aware of safeguarding adults issues and how to alert the appropriate authorities if they had any concerns or and had received any allegations of abuse. Norwood House Care Home DS0000002847.V341889.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,22,24,25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the environment provided for the service users can generally meet their needs however there are some areas of the home that require improvement to improve the quality of life for the service users. EVIDENCE: The inspector made a tour of the premises. Since the last inspection of the service there have been several improvements made to the environment of the home. This includes a new key safe that has been fitted close to the main entrance to the home as a result of a fire service recommendation, they also stated that the doors in the home needed to be fitted with fire and smoke seals. A programme has begun to put these in place, however it had not yet been completed. The bathroom mentioned in the last report has been replaced with a new wet room. This has made showers available to more of the service Norwood House Care Home DS0000002847.V341889.R01.S.doc Version 5.2 Page 17 users New carpets and chairs have been introduced to the main lounge in the home and the windows down the side of the building have been replaced with double glazing. Rooms five and thirteen had also been fitted with new windows. In line with current legislation smoking had been restricted to one room in the home and all entertainment equipment has been moved out of this room to discourage service users from staying in the room for considerable lengths of time. The outside of the home is well maintained, however not all of the service users have equal access to the garden area. The paths at the rear of the home around the garden are not level and could easily cause a service user to trip or fall if there were any problems with their mobility. One service user said to the inspector that they ‘would like to go outside more’ but they were ‘frightened of falling. The office door needs to be secured to ensure that all records are held in accordance with the Data Protection act 1998. The shower room in the corridor near the dining room needs to have a new floor covering provided, as the present floor is badly marked and damaged. In a downstairs shower room there was a loose rack that could fall over on the service users and staff. This must be secured to the wall. The general decoration for the home is looking tardy. The acting manager stated that all of the corridors in the home were identified for decorating and this should be completed in the next six weeks. There was not a refurbishment and replacement plan available to support this information. The manager stated that there was a refurbishment plan in place however the painter had the plan and therefore it was not available. The window above the door of room 9 is transparent had been obscured to ensure that privacy and dignity is maintained and upheld for the service user living in the room. The towel rail in room 5 was broken at the last inspection it was obvious that it had been refitted to the wall but had become loose again The home has a laundry, which is suitable to meet the needs of service users. Two service users spoken to by the inspector stated that they always receive their own clothes back from the laundry. There is only one manual hoist used in the home and the service and maintenance records were up to date for this equipment. Several service users also invited the inspector to look around their own rooms. These all included their personal tastes and preferences. Norwood House Care Home DS0000002847.V341889.R01.S.doc Version 5.2 Page 18 The manager of the home also stated she hoped that the existing conservatory that is in need of attention will soon be replaced by a new and larger conservatory if it is decided that it is not viable to repair. The acting manager stated to the inspector that several different quotes had been requested from different companies to replace the conservatory. The home also has two cats that live in and wander around the home. Service users spoken to by the inspector appeared to be very happy with the cats. Due to the deteriorating mobilise of many of the service users the manager of the home should consider how much of a trip hazard that the cats may provide for the individual service users and possibly limit them to certain areas of the home or find alternative accommodation for them to reduce the risks to the service users. Norwood House Care Home DS0000002847.V341889.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the staff have most of the skills and knowledge to care for the service users, however specialist straining such as dementia care needs to be improved. EVIDENCE: The home is staffed appropriately in accordance with the residential forum. However due to the design of the building and the nature of the service users dementia care needs the proprietor should consider the current staffing arrangements. On two occasions during the site visit the inspector observed up to four service users sitting in the entrance area to the home for considerable lengths of time without any staff being present or offering services to them. Three staff are on duty throughout the day, which includes a senior member of staff at all times. A further member of staff has been recruited to provide additional cover during the mornings to enable phone calls etc to be made without impacting on staff numbers available to the service users. The home employs domestic and catering staff. Two care staff are on duty at night. The manager is supernumerary to the rota. The management and care staff are very positive towards NVQ training (National Vocational Qualifications) and are currently working towards their Norwood House Care Home DS0000002847.V341889.R01.S.doc Version 5.2 Page 20 commitment to a minimum of 50 of the care staff to have achieved a minimum of NVQ 2 or equivalent in care. The recruitment practices in the home are appropriate to ensure that the residents are protected and are appropriately cared for. This included CRB applications being completed before the new staff are employed to work at the home and two written references are also obtained prior to staff being employed. The proprietor must develop a training and development plan/matrix so that the mandatory and specialist training needs of the care staff are identified with dates for completion and renewal of awards. The inspector interviewed three of the care staff working at the home and they all confirmed that they receive in excess of the required three days paid training per year. They also confirmed that if the have to attend training on their off duties then they are paid for attending this training. The homes induction and foundation booklets also included the requirements and specifications of the national training organisation. The inspector observed the personnel and training files for three of the care staff working at the home and all of these had the appropriate information recorded. The staff working at the home included other nationalities and the service users confirmed to the inspector that all of the staff understood their needs and could speak ‘very good English’. Norwood House Care Home DS0000002847.V341889.R01.S.doc Version 5.2 Page 21 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): 31,32,33,34,35,36,37 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. This means that the management is generally supportive of the needs of the service, however the current manager has been in position since last August and still has not made an application to the Commission. EVIDENCE: Since the last inspection of the service the registered manger of the home has left to move on to other employment. The proprietors of the home promoted one of the care workers to the acting manager of the home in August 2006. The acting manager has not submitted an application to the Commission to be recognised as a ‘fit person’ and as the registered manager of the home. Norwood House Care Home DS0000002847.V341889.R01.S.doc Version 5.2 Page 22 The acting manager has begun the Registered Managers Award. She stated to the inspector that since she has been in her current position she has received a great deal of support from the outside management of the home. The record of the homes regulation 26 visits would support this. The homes registration certificate needs to be replaced to recognise that the registered manager is no longer in position in the home. Service users and staff spoken to by the inspector supported the evidence that the management of the home is open, positive and inclusive. One member of staff stated ‘I can always speak to the manager whenever I want or need to’’ and service users also confirmed that they have open access to the acting manager. The home has an effective quality assurance system that seeks the views of service users and staff on a regular basis. The system now also includes other health and social care professionals. There is a monthly audit system in place that looks at key areas aimed at improving standards. Staff supervision appears to be more appropriate and the frequency has improved from later mid to late 2006. All staff should receive the recommended minimum of six formal recorded supervision (pro-rata) in a twelve-month period. The home does not act as appointee for any resident, however it does look after ‘pocket money accounts’ and the inspector observed three of these. Two of the accounts were inappropriately stored in cigarette/tobacco tins. Written records of all transactions are accurately maintained. The resident’s fund monies did not correlate with the monies held in the home and the monies recorded in the funds records. The funds in the home were £66.83 above what was recorded in the accounts. At the last inspection their was an account error in the residents fund and a requirement to ensure that the fund was accountable. This must be achieved as a priority and the accounting system for the fund must be improved. 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. The managers door needs to include a look to ensure that all information is stored in accordance with the Data Protection Act 19998 when the room is not occupied. As stated earlier in the report the full registration certificate was not available and was also out of date due to the position of the manager. Norwood House Care Home DS0000002847.V341889.R01.S.doc Version 5.2 Page 23 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 1 2 2 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 3 3 3 3 3 2 3 Norwood House Care Home DS0000002847.V341889.R01.S.doc Version 5.2 Page 24 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 OP7 Regulation 15 Requirement Timescale for action 01/07/07 2 OP12 OP19 2. OP19 3. OP19 OP21 The responsible individual must make sure that service users with dementia care needs have this clearly identified in their individual care plans. 16.2m The responsible individual must 30/06/07 23.2b,o make sure that the access to the grounds of the home are made available to all of the service users. This includes levelling the paths and ramps being included where the steps are. 12, 16, 23 The responsible individual must 14/07/07 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 and 14/08/06 were not met. Enforcement may be considered if this requirement is not met by the current timescale 12, 16, 23 The responsible individual must 30/08/07 make arrangements for the repair or replacement of the shower room floor that is DS0000002847.V341889.R01.S.doc Version 5.2 Norwood House Care Home Page 25 4. OP27 18.1a 5. OP31 8, 9 6. OP37 20.1b 24.3a 7. OP37 17 situated in the corridor near to the dining room. This needs to be completed to uphold the health and safety of the service users. The responsible individual must make sure that there are appropriate numbers of staff in all areas of the home that the service users choose to use. The responsible individual must make sure that the acting manager of the home completes an application to the Commission to be considered a fit person to manage the home. The registered person must make sure that the accounts for the service users fund are appropriately recorded and managed. The current accounting system must be replaced with a more accurate record. The Commission must be informed of the outcome of the homes investigation in to the discrepancies in the current records and update the Commission of any new practices that are implemented to safeguard the service users monies. The registered person must make sure that a complete and appropriate registration certificate is displayed in the home. 30/06/07 30/06/07 14/07/07 30/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000002847.V341889.R01.S.doc Version 5.2 Page 26 Norwood House Care Home 1. Standard OP7 2. 3. 4. 5. OP9 OP12 OP19 OP19 OP37 6. OP19 7. 8. OP19 OP19 9. OP27 10. OP28 The responsible individual should make sure that the service users daily diary records are comprehensive and support that the daily care plans for the individual service users are fulfilled. The responsible individual should make sure that the temperature of the medication refrigeration is safely and appropriately maintained. The responsible individual should make sure that where activities are advertised, they remain available for all of the service users to see. The responsible individual should make sure that the programme for fitting fire and smoke seals to all of the doors is completed. The responsible individual should make sure that the managers office is secure when there is no one in it to maintain that the service users and staff red=cords are maintained in accordance with the Data protection act 1998. The registered person should continue with the programme of decoration at the service to ensure that the home provides a homely and comfortable environment for the service users. The registered person should make sure that the towel rail in the en-suite in room 5 is safely secured to the wall. The registered person should make sure that having the pet cats in the home is fully risk assessed in relation to all of the individual mobility needs of the service users and to ensure their health and safety The responsible individual should develop a clear staff training matrix that will help to identify what training staff have received and identifies when refresher training is due. The responsible individual should continue with the homes commitment towards NVQ training and a minimum of 50 of the care staff need to achieve NVQ 2 in care or equivalent. Norwood House Care Home DS0000002847.V341889.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 Care Home DS0000002847.V341889.R01.S.doc Version 5.2 Page 28 - 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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