Inspection on 29/09/05 for Norwood Road 227

This inspection was carried out on 29th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Norwood Road 227 05/01/06

Norwood Road 227 22/02/05

Norwood Road 227 09/11/04

Norwood Road 227 30/03/04

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

CARE HOME ADULTS 18-65 Norwood Road, 227 West Norwood London SE24 9AG Lead Inspector Ms Rehema Russell Unannounced Inspection 29th September 2005 12:00 Norwood Road, 227 DS0000022745.V256408.R01.S.doc Version 5.0 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 Road, 227 DS0000022745.V256408.R01.S.doc Version 5.0 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 Adults 18-65. 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 Road, 227 DS0000022745.V256408.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Norwood Road, 227 Address West Norwood London SE24 9AG 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) 0207-498-2533 Southside Partnership Ms Tawa Olaloko Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Norwood Road, 227 DS0000022745.V256408.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd February 2005 Brief Description of the Service: 227, Norwood Road is a large three storey house on a busy main road in a residential area. It is one of a number of homes where the care is provided by Southside Partnership and the building is owned and maintained by Hyde Housing Association. Car parking is not possible on the road outside the home, but is available in nearby side streets. The home is on a bus route and is walking distance from a rail station. There is a small parade of local shops opposite the home and a large park a few minutes walk away. The home has a front garden with steps to the front door and a rear garden with patio and steps leading to a larger lawned area. Communal sitting, dining and utility areas are on the ground floor. The first floor has three single bedrooms and a bathroom with toilet and there are two further single bedrooms, toilet, shower room and office/sleeping-in room on the second floor. The home would not admit service users with mobility problems/wheelchair needs as it is not suitable for people with physical disabilities. The home describes itself as a ‘Teaching Project’ which service users should regard as their own home while developing their independence and potential and where appropriate, working towards more independent living. It is registered for five people. Norwood Road, 227 DS0000022745.V256408.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the afternoon of 29th September 2005. There were two vacancies at the home, and of the three current service users one was temporarily in hospital. The inspector spoke with the manager, two support workers, one of the two service users currently at the home, toured the premises and looked at documentation and records. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Norwood Road, 227 DS0000022745.V256408.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Norwood Road, 227 DS0000022745.V256408.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The home implements a thorough assessment procedure which ensures that prospective service users’ individual aspirations and needs are assessed. EVIDENCE: Two assessments by the home for prospective service users were examined. Both were found to be very thorough, covering all relevant areas needed to assess the suitability of the home for the needs and aspirations of service users. Areas such as cooking, budgeting, cleaning, use of public services, mental health, medication, activities, personal hygiene, and relationships with family and friends were assessed by speaking with the service user. In addition other documentation is obtained from relevant specialists and professionals, such as Care Programme Approach, nursing reports, consultant psychologist reports and full histories, care manager referrals and care plan, risk assessments and community psychiatric nurse reports. It was explained that the home always assures potential service users that they can have someone of their choice with them at the assessment. An example was given of one person currently being assessed choosing to have her favourite nurse accompany her. Norwood Road, 227 DS0000022745.V256408.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 7 Care plans are detailed and thorough and reflect service users’ assessed and changing needs and personal goals. Service users are encouraged and enabled to make decisions about their lives, with appropriate assistance and support. EVIDENCE: Three care files were seen and found to be thorough, clearly written, well laid out and containing all necessary information. A very detailed initial assessment is carried out with the service user within 72 hours of admission, each section of the assessment having identified strengths and identified problems/needs. These assessments are signed by the service user and dated. There is then a Person Centred Plan outlining the service user’s aspirations and dreams and the support needed to achieve this. It is reviewed monthly and there evidence was seen of the resulting action plan being implemented and achieved. The care plans themselves addressed individual needs, with short and long-term goals evaluated by the key worker and service user together. They were regularly evaluated/reviewed, with each evaluation containing feedback from the service user, dated and signed. Care plans also contained evidence of reviews led by social workers which were attended by the service user and appropriate professionals/significant others, daily progress reports, monthly Norwood Road, 227 DS0000022745.V256408.R01.S.doc Version 5.0 Page 9 key worker meetings, risk assessments, weekly activity programmes and individual behaviour agreements where appropriate. The service user spoken with understood the purpose of her care plan and was familiar its contents. Service users are encouraged and supported to make decisions about their own care and matters of daily living both inside and outside the home. Four different examples of this were evidenced by speaking with staff and service users. Each example demonstrated information and support being given by staff in a tactful and sensitive manner, with service users making their own decision and relevant information recorded in key worker meeting minutes or elsewhere as appropriate. The service user spoken with confirmed that she was encouraged and supported to make her own decisions, saying that staff treated her “with respect, dignity and as an adult” and that she “can make my own decisions”. No service user currently has an appointee and all are able to handle their own finances. Norwood Road, 227 DS0000022745.V256408.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the 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 and 15 Service users are supported to take part in age, peer and culturally appropriate activities according to their choice. They are part of the local community and have appropriate personal and family relationships. EVIDENCE: Service users are encouraged and supported by staff to continue their education or training, to find and keep appropriate employment and to take part in fulfilling activities, including culturally appropriate activities, according to their wishes and inclinations. One service user attends a local authority agency which provides paid skills teaching and future employment. She also attends a day centre which concentrates on furthering educational and employment skills and staff from the home have assisted her to sign up for a course at college which is appropriate for the career she wishes to take up. Staff are also in the process of offering to train service users in use of the internet. The service user who is temporarily in hospital attended a day centre designed specifically for people with his cultural background. The third service user attended a local health course run by social services but chooses not to attend any regular day centres or prepare for paid work. Norwood Road, 227 DS0000022745.V256408.R01.S.doc Version 5.0 Page 11 Service users are fully integrated into the local community, participating in local colleges, public transport, cinemas, shopping facilities, cafes, public houses and local events. Two examples were given of staff supporting service users to explore religions they were interested in and to attend church or meetings, and staff ensured that all service users received a postal vote and understood their rights and choices in this regard. All current service users have contact with either family or friends. Staff demonstrated sensitivity and perception in their support of service users’ relationships. They offer support and encouragement if service users wish to keep in contact with relatives or friends but are very clear that this is the service user’s choice, and will also support them if they wish to break off or have no contact with relatives/friends. Appropriate sexual guidance is offered as necessary, including consultation with specialist teams in regard to specific issues. Norwood Road, 227 DS0000022745.V256408.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 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 and 20 Service users’ physical and emotional health needs are met. The home has thorough polices and procedures for dealing with medicines and its practices ensure service users’ safety. EVIDENCE: Verbal and documentary evidence indicated that the home ensures that service users are supported and facilitated to take control of and manage their own healthcare as appropriate. Each service user has a health action plan which documents the health issues, name and date of practitioner seen and the date of the next planned visit. Health action plans evidenced that service users are facilitated to see the GP, CPN and/or Consultant Psychiatrist regularly or as needed, and are supported to make optician/dental/chiropody appointments as they choose. The service user spoken with confirmed that staff ensure that her health care needs are met, and was appreciative of this. Medication systems at the home had been thoroughly checked by the Pharmacist inspector in February 2005. Two recommendations had been made at that time and these had been implemented within a month. At this inspection, the recording, storage and administration of medication was checked, including random tablet counts, and was found to be in very good order. Recording systems are strictly adhered to by staff and regular and random checks are conducted and recorded by the manager and deputy. The Norwood Road, 227 DS0000022745.V256408.R01.S.doc Version 5.0 Page 13 medication file, which is kept on hand near the medication cabinet, has very clear and detailed guidelines for missing and refused medication, for medication monitoring, for overnight stays outside of the home and for “as needed” medication. There is also a list of bank and agency staff sample signatures, clear instructions for the filling of dossette boxes, and full guidelines for reviewing, handling and ordering medication. Norwood Road, 227 DS0000022745.V256408.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Service users are protected from abuse, neglect and self-harm. EVIDENCE: Staff were fully conversant with the home’s policy regarding abuse and with the many different forms abuse may take. Training is given both during induction and on subsequent training courses. The support worker spoken with demonstrated a clear understanding of the procedures to be followed should abuse be suspected, including the local authority’s vulnerable adult procedures. He also demonstrated a good understanding of how to deal with verbal or physical aggression. Norwood Road, 227 DS0000022745.V256408.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 29 and 30 The environment is pleasant, well maintained, clean and comfortable. EVIDENCE: The home is suitable for its stated purpose. The premises are accessible, safe and well maintained throughout. The décor, furniture, fixtures and fittings are of good quality and the whole home is attractive, non-institutional and homely. The premises are in keeping with the local community and blends in with the other residential premises alongside it. Bedrooms were seen and those occupied reflected the choices, preferences and lifestyles of the individual occupants. A handle was missing from the wardrobe of the service user who was currently in hospital, leaving a nail protruding. The manager said that this would be fixed as a matter of urgency. The home has a suitable number of bathrooms and toilets and offers service users the choice of bath or shower. There is a toilet on the ground floor which is conveniently located for the communal areas. The shared spaces in the home are of particularly high quality. The living room has leather sofas, video, television, DVD player, freeview box, library, plants, mirrors, framed pictures, magazines such as the Time Out London Guide and Norwood Road, 227 DS0000022745.V256408.R01.S.doc Version 5.0 Page 16 good quality carpet and curtains. It is comfortable and homely and a very pleasant area to sit in. There is also a conservatory where residents may smoke. This is also an attractive room, with television and a music system, a view of the back garden and ceiling blinds in order to control the temperature on sunny days. The home does not admit service users with physical disabilities as it is not suitable. Residents do not therefore require any specialist equipment or aids. On the day of the inspection the home was found to be in an excellent state of cleanliness and hygiene. The carpets appeared new but were not – the manager explained that they are cleaned every six months. The kitchen, which is used by all service users for drinks and food preparation, was clean, hygienic and well maintained. Norwood Road, 227 DS0000022745.V256408.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 A broad range of training is provided for staff which ensures that service users’ individual and joint needs are met. EVIDENCE: All staff joining the home have an initial induction which covers all of the basic policies and procedures at the home, including medication and health and safety. Within their first six months of employment all staff then take the TOPPS training which includes manual handling, food hygiene, fire safety, medication, risk assessment, health and safety and equal opportunities. They also attend a one day external training course on mental health issues. From then on training and development needs are raised in supervision for individuals and in team meetings for the staff group as a whole. The Registered Provider runs a very well organised and comprehensive training programme, and provides individual training profiles for staff and regular reminders to homes when refresher courses are due. The Manager of the home also ensures that any information/training needs arising from the particular mental health problems of service users at the home are provided for. For example, factsheets and information were obtained regarding autism and these were discussed in team meetings, specialist teams are accessed as appropriate, and the manager cascades any relevant external training she has accessed to other members of staff. Norwood Road, 227 DS0000022745.V256408.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 The health, safety and welfare of service users are promoted and protected. EVIDENCE: The following certificates and recorded checks were seen and were all found to be up to date and in good order: gas, portable electrical appliances, heating, water risk assessments including legionella, health and safety, fire inspection, fire extinguishers, fire alarm installation, electricity, fire drills and call points, sanitary removal, accident book. Fire risk assessments for each service user’s room, and for the conservatory where service users smoke, were seen and were of a high standard. The home will update these annually. Hazardous substances are kept in a locked cupboard in the kitchen. Norwood Road, 227 DS0000022745.V256408.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 4 x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 4 x 2 3 4 N/A 4 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score X X X X 4 X CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Norwood Road, 227 Score x 3 4 x Standard No 37 38 39 40 41 42 43 Score X X X X X 3 x DS0000022745.V256408.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA26 Regulation 23(2)(b) Requirement The protruding nail should be removed and the handle fixed on the wardrobe of the top floor bedroom. Timescale for action 01/12/05 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 Road, 227 DS0000022745.V256408.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Norwood Road, 227 DS0000022745.V256408.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!