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Inspection on 23/07/08 for Norwood House Nursing Home

Also see our care home review for Norwood House Nursing Home for more information

This inspection was carried out on 23rd July 2008.

CSCI found this care home to be providing an Adequate service.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Relatives told us they are happy with the care provided by the home. People also told us the staff are friendly and caring. Visitors are encouraged and made welcome and people can invite relatives to have a meal with them. One person told us they enjoyed visiting the home because if has a "lovely atmosphere". The home has received a 5 star rating (the highest) from the environmental health department for its standards of food hygiene.

What has improved since the last inspection?

There were no requirements following the last inspection, a number of good practice recommendations were made. The new acting manager has also identified a number of areas where improvements are needed. These include care planning, staff training, and staff supervision. However, because of theshort time she has been in post she has not yet been able to fully implement these improvements.

What the care home could do better:

The home must make sure that people`s needs are fully assessed either before admission or, in the case of emergency admissions, as soon as possible after they arrive in the home. This is to make sure that all people`s needs are identified and needs are not overlooked. The care records must set out how all people`s needs are to be addressed and whenever possible people or those close to them must be involved in drawing up care plans. This is to make sure that people`s needs are met in a way that takes account of their preferences. The home must improve the way people`s social care needs are met. This is to make sure that people are given the support they need to follow their interests and make the most of the abilities. More attention should be given to the quality of the food so that people can enjoy it and look forward to mealtimes. To make sure that people are protected the home must follow the correct safeguarding procedures when dealing with reports or suspicions of abuse. The arrangements for day-to-day maintenance must be improved to make sure the home is safe and suitably equipped to meet people`s needs. Staff must be given training to make sure they have the skills and knowledge they need to meet the needs of people living in the home.

CARE HOMES FOR OLDER PEOPLE Norwood House Nursing Home Greenthwaite Close High Spring Gardens Keighley West Yorkshire BD20 6DZ Lead Inspector Mary Bentley Key Unannounced Inspection 23rd & 30th July 2008 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 Nursing Home DS0000019884.V369288.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 Nursing Home DS0000019884.V369288.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norwood House Nursing Home Address Greenthwaite Close High Spring Gardens Keighley West Yorkshire BD20 6DZ 01535 602137 01535 692017 care@norwoodhouse.co.uk 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) Norwood House Nursing Home Limited Care Home 31 Category(ies) of Dementia (15), Old age, not falling within any registration, with number other category (31), Physical disability (31) of places Norwood House Nursing Home DS0000019884.V369288.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home with nursing - Code N To service users of the following gender: Either. Whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Physical disability - Code PD Dementia - Code DE (maximum number of places: 15) The maximum number of service users who can be accommodated is 31. 24th January 2008 2. Date of last inspection Brief Description of the Service: Norwood House is a large period property, which has been extended. It is in a residential area about a mile from Keighley town centre. There are gardens and a patio for people to use. Car parking is available. The home is registered to provide personal care with nursing to older people, people with physical disabilities and up to 15 people with dementia. Accommodation is provided mainly in single rooms, many of which have ensuite facilities. There are some shared rooms without en-suites. Communal lounges and a dining room are provided on the ground floor, with a large conservatory at the front of the house, overlooking the gardens. Copies of inspection reports are available from the home. The weekly fees in February 2008 ranged from £505.66 to £605.64. Items not covered by the fee include newspapers, hairdressing, and chiropody. Norwood House Nursing Home DS0000019884.V369288.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. This inspection was done over 2 days by one inspector. The first day of the visit was unannounced; over the two days we spent approximately 12 hours in the home. Since the last inspection in January 2008 we have received information, which included concerns about the management of the home and the welfare of the people living there. The purpose of this inspection was to assess how well the service is meeting people’s needs. During the visit we spoke to people living in the home, visitors, staff and management. We looked at various records including care records and looked at some parts of the home. On this occasion we did not send surveys to people using the service or ask the home to complete a self-assessment form. The home appointed a new acting manager in May this year, she told us she has started the process of application for registration with the Commission. What the service does well: What has improved since the last inspection? There were no requirements following the last inspection, a number of good practice recommendations were made. The new acting manager has also identified a number of areas where improvements are needed. These include care planning, staff training, and staff supervision. However, because of the Norwood House Nursing Home DS0000019884.V369288.R01.S.doc Version 5.2 Page 6 short time she has been in post she has not yet been able to fully implement these improvements. 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 Nursing Home DS0000019884.V369288.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 Nursing Home DS0000019884.V369288.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 5. Standard 6 does not apply. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People’s needs are not always fully assessed and people or those close to them are not always involved in choosing the home. This means that some of people’s needs could be overlooked. EVIDENCE: We looked at the care records of 8 people admitted to the home since our last visit in January 2008. We saw that the home had done pre-admission assessments for three people who moved in between January and March. For the remaining 5 people we could not find any records to show that a preadmission had been done before people moved in. The acting manager said most of them had been emergency admissions. The relatives of two people told us they had not looked at the home before making a decision about admission. However, they said they are satisfied that the home is meeting Norwood House Nursing Home DS0000019884.V369288.R01.S.doc Version 5.2 Page 9 their relatives’ needs. One person told us they had looked around the home before choosing it for their relative. In one case a relative told us a pre-admission assessment visit had taken place but we could not find a record of it. The acting manager told us it had been filed incorrectly. The assessment information that was available was incomplete and this could lead to some of this person’s needs being overlooked. Another person’s records also showed that the assessment done at the time of admission had only been partially completed, again this could result in needs being overlooked. Norwood House Nursing Home DS0000019884.V369288.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 and 10. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. For the most part people’s needs are met. However, because of shortfalls in the care records and because people are not involved in planning their care there is a risk that people’s needs may be overlooked and care may not always be delivered in a way that takes account of people’s preferences and abilities. EVIDENCE: The care records for one person recently admitted to the home were incomplete. The assessment of needs was not fully completed and there were no care plans. For example there was no nutritional assessment and no care plan for eating and drinking although the person was nutritionally at risk because of a low weight and poor appetite. There was a risk assessment showing this person had a pressure sore at the time of admission and was at risk of developing further pressure sores. However, there was no care plan showing how this risk would be dealt with. There was a wound care management plan but it wasn’t clear if the tissue viability nurse had been involved. Norwood House Nursing Home DS0000019884.V369288.R01.S.doc Version 5.2 Page 11 The records of another person with a pressure sore were also unclear about the involvement of the tissue viability nurse. The acting manager said the wound was being managed and a referral to the tissue viability nurse was not required. The care records for another person who had been in the home for approximately four months showed that the only information about how to meet their needs was in an initial care plan. Initial care plans are drawn up, usually from the information obtained in the pre admission assessment, to provide basic information on people’s care needs in the first few days after admission. By then more detailed care plans should be in place setting out how all the person’s assessed needs are to be met. If care plans are not in place then there is a risk that people’s needs may be overlooked. For example, the records showed that the person is sometimes aggressive but there was no information for staff on how to deal with this. The acting manager told us she is going to replace the nutritional risk assessment because it is not a nationally recognised assessment. We saw that dietary supplements are prescribed for people if needed. There are charts in place for some people to record their dietary intake, however they were not always fully completed. The cook has a list of people that need dietary supplements and special diets for example soft food. However, she was unsure about how to add extra nutritional value to people’s food to help them gain weight. There are forms to record personal care and people’s participation in social activities every day but they are not being completed consistently. The acting manager said she would follow this up. She also told us the home was in the process of updating and reviewing all the care records. She has provided training for nursing staff on care planning. Some of the care plans we looked at had an advanced care planning agreement, which provides information about people’s wishes for end of life care. We saw that some people’s relatives had been consulted about this. However, there was no other evidence that people or their representatives are involved in the care planning process. The record showed that people have access to NHS services such as GPs, district nurses, and dentists. We saw evidence of involvement by speech and language therapists and one visitor told us their relative was receiving physiotherapy. Overall the way the home deals with medicines is satisfactory. However, on both occasions when we visited the medicine trolleys in the dining room were not secured to the wall. We told the acting manager about this and she dealt with it. Norwood House Nursing Home DS0000019884.V369288.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. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home provides some activities and supports people in keeping in touch with their family and friends. However, more needs to be done to make sure that in their daily lives people are given opportunities for social interaction and supported in following their personal interests. EVIDENCE: There is an activities programme displayed in the hallway. The programme states that an aroma therapist visits on Tuesdays however the aroma therapist has not been able to visit for several months. The programme should be updated to reflect this. On the day we visited there was a visiting musician and several people seemed to enjoy singing along. This is a regular Wednesday morning event. The home has a weekly communion service, also on Wednesday mornings. We were told someone comes in on Mondays to do chair exercises with people. A Nintendo wii games console has been provided but we didn’t see anyone using it while we were in the home. Norwood House Nursing Home DS0000019884.V369288.R01.S.doc Version 5.2 Page 13 For the remainder of the week it is up to care staff to organise activities for people such as games and quizzes but it wasn’t clear if these actually take place. On the afternoon of our first visit some people had visitors but for other people there didn’t seem to be anything to do other than watch television. Staff didn’t spend much time with people unless it was for a specific reason such as giving out drinks or helping with personal care. There are not many opportunities for people to go out unless they do so with family and/or friends. The acting manager confirmed there have not been any organised outings since she started in May this year. The home fund raises for activities and was planning a garden party on the weekend following our visit. The home has an open visiting policy and visitors told us they are always made welcome. One visitor told us they had joined their relative for lunch at the home, they said they enjoyed visiting because the home has a “lovely atmosphere”. Most people said the food is “ok” or “reasonable”. At lunchtime on the first day we visited people said the meat was tough. We discussed this with the cook. She said she had used a different supplier and would not use them again. The home has a menu and people are asked what they want to eat one day in advance. The cook said the meals served are usually but not always those on the menu. The acting manager said they are planning to revise the menus and people living in the home would be consulted about this. The food records showed that people are offered a choice of two hot meals at lunchtime and a hot meal at teatime. People we spoke to confirmed this. We observed the lunchtime meal in the dining room on the first day we visited. The tables were nicely set, people were offered a cold drink with their meal and aids such as plate guards were provided to help people eat independently. There were some staff around to help but mostly it was the laundry assistant who helped people. She said she enjoyed helping people with their meals. However, it was not clear what, if any, training she has had for this role. This was discussed with the management. The kitchen stores were adequately stocked and the cook said there was no problem with supplies. There were fresh vegetables. We asked people if fresh fruit is available. They said they are sometimes offered bananas and could have other fruit if they asked but said they had never asked. Norwood House Nursing Home DS0000019884.V369288.R01.S.doc Version 5.2 Page 14 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 and 18. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. People are given information about the complaints procedures and complaints are taken seriously and acted on. The procedures for safeguarding people are not always followed and this could put people at risk. EVIDENCE: The home has a complaints procedure that is clear and easy to follow. A copy is included in the home’s brochure and displayed on the home’s notice board. The home’s questionnaire asks people if they are aware of the complaints procedures. We saw that in one case when someone said they were not aware of the procedure the home followed this up and made sure they were given the information. The home told us they have not had any complaints since our last visit in January. In February this year we received a complaint about the service, we sent it to the home and they dealt with it. The home has procedures in place to protect people from abuse. However, the records showed that an incident, which was reported earlier this year, had not been dealt with in accordance with these procedures. This was discussed with the management team. Norwood House Nursing Home DS0000019884.V369288.R01.S.doc Version 5.2 Page 15 The staff we spoke to had not received adult protection (safeguarding) training. They had some understanding of their responsibilities in safeguarding the well being of people living in the home. The acting manager has provided training for the majority of staff and more training is planned. Norwood House Nursing Home DS0000019884.V369288.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, 24 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The home provides a pleasant place for people to live. More attention is needed to day to day maintenance to make sure the home continues to provide an environment that is safe and suitably equipped to meet people’s needs. EVIDENCE: Generally the home was clean, there were some slight odours in places, but the home is managing them. The home has a maintenance book where staff should record anything that needs attention and the owners then arrange for the work to be done. However, this does not always seem to work. For example on the first day of our visit staff told us that the bath on the ground floor was not working because the mixer tap was broken. The owners said they were not aware of this, however the tap was replaced before our second visit. The owners told us they are planning to employ a maintenance person. Norwood House Nursing Home DS0000019884.V369288.R01.S.doc Version 5.2 Page 17 The communal rooms are suitably furnished and sufficiently well lit for example if people want to read. One of the lounges opens onto a small patio at the front of the home. On the day we visited the doors were open but although the weather was pleasant people did not go outside. One person said they could not get out to the patio because they could not get their wheelchair over the step (door frame). There is a well-kept garden at the front which is accessible to people. The fire officer visited the home in July this year. There is some work to be done in order for the building to fully meet current fire safety regulations. The owners have agreed to provide the fire officer with an action plan and timescales for completion of this work. The home has 2 assisted bathrooms and a shower room. A new shower chair has recently been purchased to make it easier for people to use the shower. The bathroom on the first floor did not appear to be in use, it was being used for storage, and staff confirmed it is not used. Staff also told us that many people do not like the Parker bath, which is on the ground floor. This means that people are limited to using the shower room. The owners told us they are aware of this and planning to replace the Parker bath with a different type of assisted bath and an overhead track hoist. The communal toilets on the ground floor are close to the living areas. They are clearly signed and this helps people, particularly those with dementia, to find them. In the bedrooms we looked at we saw that people have some of their personal belongings around them such as pictures and ornaments. In some rooms the bed linen and towels were thin and frayed. The owners said they had plenty of new bedding and towels in stock and would replace the worn items. We saw some evidence that communal toiletries are used this is not good practice. It does not promote people’s dignity and increases the risk of cross infection. The home received 5 stars (the maximum) from environmental health for its kitchen hygiene standards. Norwood House Nursing Home DS0000019884.V369288.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. There are usually enough staff available to meet people’s needs and people are protected because staff are properly checked before they start work in the home. More training is needed to make sure that the staff team have the knowledge and skills they need to meet the needs of people living in the home. EVIDENCE: There were 31 people in the home when we visited. There are usually 5 care staff in the morning, until 2.30pm, 4 in the afternoon and 2 overnight. In addition there is always one nurse on duty. The manager is supernumerary and separate staff are employed for housekeeping and catering. Staff told us they are sometimes short but most of the time the right number of staff are on duty. People we spoke to did not raise any concerns about the availability of staff. A lot of staff have left recently and some of the staff we spoke to had only been working in the home for a short time. Care staff told us they had done induction training and this was recorded. We were unable to find a record of induction training for two new nursing staff. Norwood House Nursing Home DS0000019884.V369288.R01.S.doc Version 5.2 Page 19 The turnover in staff has meant that although the home was providing training many of the current staff have not had training on dementia care. However, the acting manager has put a training plan in place. Some staff are booked on training in dementia care in September. Since January two of the nurses have attended training on wound care and most have done training on palliative care. Moving & handling training is scheduled to take place in early August. Three assistants have achieved an NVQ (National Vocational Qualification) level 2 in care. None of the remaining care staff are doing NVQ training at present. Approximately half of the care staff team is made up of oversees nurses who are working as carers while working towards getting their nursing registration in this country. This adds to the knowledge and skills of the care staff team. We looked at three staff files and they showed that the home had completed all the required checks before new staff started work. Norwood House Nursing Home DS0000019884.V369288.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to the service. The management team are clearly committed to providing a good service to people. However, at present there are a number of areas where the home is not providing good outcomes for people. EVIDENCE: The acting manager who was in post when we visited in January this year has since left. A new acting manager was appointed in May, she has many years experience and told us she has started the process of applying for registration. Since the registered manager left at the end of last year the home has been going through a period of uncertainty. It is hoped that the appointment of this manager will bring that to an end and that the management team will be able Norwood House Nursing Home DS0000019884.V369288.R01.S.doc Version 5.2 Page 21 to move forward with planned improvements, which will benefit people living in the home. The home has also appointed a senior nurse and she provides clinical support when the acting manager is not available. The owners are in the home everyday and are very involved in the day-to-day management of the service. The home sent questionnaire to people using the service in December last year. The results have yet to be analysed but any individual issues that required action have been dealt with. The home leaves questionnaires in the reception area so that people who are visiting can pick one up at any time. When the new acting manager was appointed the home organised a social event to introduce her to people and gave out questionnaire to people who attended. We looked at some of the completed questionnaires and they showed that people are generally satisfied with the service. One person said the “staff are very helpful and caring” and another said they had, “seen a lot of improvements in the last 18 months”. There are meetings for people living in the home; the most recent was in April this year. There are also staff meetings; the most recent one was in June. The home told us they also have meetings at the end of shifts but these are not recorded. The home does not hold any personal money for people, any additional services, such as hairdressing, are charged on the invoices. The acting manager said that staff supervision and appraisals are not up to date because of the recent management changes. She is aware this needs to be addressed. We looked at a selection of maintenance records and they showed that most installations and equipment are serviced and maintained at the required intervals. The home does not have a current electrical hard wiring certificate. The owners have arranged for the work to be done. A copy of the certificate must be sent to the Commission when the work is completed. Norwood House Nursing Home DS0000019884.V369288.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 X 2 X 2 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 3 X X 2 X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 2 X 2 Norwood House Nursing Home DS0000019884.V369288.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 14 Requirement People’s needs must be fully assessed either before admission or in the case of emergency admissions as soon as possible after admission and people or those close to them must, whenever possible, be involved in the assessment process. This is to make sure that all people’s needs are identified and that people can be confident that the home will be able to meet their needs. The care plans must set out in detail how people’s personal, health, and social care needs are to be met. Whenever possible people or those close to them must be involved in drawing up and reviewing plans of care. This is to make sure that care is given consistently and that care needs are not overlooked. And to make sure that care is given in a way that takes account of people’s preferences. People living in the home must be supported in taking part in a DS0000019884.V369288.R01.S.doc Timescale for action 31/10/08 2 OP7 15 31/10/08 3 OP12 16(2)(n) 31/10/08 Page 24 Norwood House Nursing Home Version 5.2 4 OP30 18 range of social and leisure activities that take account of their interests and abilities and this includes providing opportunities to take part in activities outside of the home. Staff must be given the training they need to help them acquire the knowledge and skills they need to meet the needs of people living in the home. This is to make sure that people are cared for properly. 31/10/08 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 Standard Good Practice Recommendations Norwood House Nursing Home DS0000019884.V369288.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Nursing Home DS0000019884.V369288.R01.S.doc Version 5.2 Page 26 - 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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