Inspection on 10/11/05 for Norwood Trust Limited

This inspection was carried out on 10th November 2005.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Norwood Trust Limited 09/07/07

Norwood Trust Limited 05/10/06

Norwood Trust Limited 27/04/05

Norwood Trust Limited 10/11/04

Norwood Trust Limited 20/07/04

Norwood Trust Limited 04/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Norwood Trust Limited 21 Arkwright Road Marple Stockport Cheshire SK6 7DB Lead Inspector Sylvia Brown Unannounced Inspection 10th November 2005 11:30 Norwood Trust Limited DS0000008570.V263539.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 Trust Limited DS0000008570.V263539.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 Trust Limited DS0000008570.V263539.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Norwood Trust Limited Address 21 Arkwright Road Marple Stockport Cheshire SK6 7DB 0161-449 0391 NO FAX 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 Trust Limited Leslie Horton Care Home 14 Category(ies) of Learning disability (14) registration, with number of places Norwood Trust Limited DS0000008570.V263539.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 14 LD. Date of last inspection 27th April 2005 Brief Description of the Service: The Norwood Trust was established in 1985 and is a registered charity. Norwood is a care home providing personal care and accommodation for 14 adults, between the ages of 32 and 62 years, with a learning disability, ten of whom are accommodated in the main house and four who lead semiindependent lives in a purpose built bungalow in the grounds. Norwood is a large, Victorian, semi-detached house with a purpose-built bungalow at the rear of the property. Both buildings are furnished and maintained in a homely manner and are suitable to meet the needs of the current service users. The main accommodation consists of six single bedrooms, two shared bedrooms, two lounges, dining room, kitchen, laundry and bathrooms. All the bedrooms are located on the two upper floors. There is no lift and the stairs to the second floor are particularly steep. The bungalow consists of four single bedrooms, lounge and separate dining kitchen, two toilets and a bathroom. The home is located in the Marple area of Stockport. The village centre, which is approximately a ten to 15 minute walk away, has a wide variety of shops, banks and a post office, as well as a cinema, restaurants and swimming pool. A regular bus service (with a stop outside the home) is in operation. The train station is a short distance from the property. Norwood Trust Limited DS0000008570.V263539.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of Norwood House was unannounced and commenced at 11:30am. The primary focus of the inspection was to monitor the home’s actions to meet requirements and recommendations issued at the previous inspection in April 2005. Additionally, time was spent evaluating the support provided to two residents accommodated within the ‘Bungalow’. Time was spent sitting with residents and evaluating records. Feedback was provided to the registered manager regarding the outcome of the inspection, particularly where opportunities to develop remain. What the service does well: What has improved since the last inspection? The development of improved bedroom facilities has commenced. The home has converted an office space into a single bedroom. One resident who previously shared a bedroom has moved into the single room, he has benefited greatly from this move and is more happy and contented. Arrangements are in place for the division of a double bedroom into two single rooms which will require some structural alteration. Furthermore, a large room is being redesigned to accommodate a resident who would benefit from semi-independent living. Norwood Trust Limited DS0000008570.V263539.R01.S.doc Version 5.0 Page 6 A replacement external fire escape has been fitted which is less obvious and makes more space available next to the dining room, where future plans may include extending the area. The registered manager continues to develop administration systems and is currently looking at ways in which the home can be adapted to accommodate residents who are approaching retirement age and/or being affected by the ageing process and disabilities. 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 Trust Limited DS0000008570.V263539.R01.S.doc Version 5.0 Page 7 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 Trust Limited DS0000008570.V263539.R01.S.doc Version 5.0 Page 8 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): 1, 2 & 5 Residents receive information prior to being accommodated. EVIDENCE: Information is made available to all prospective residents regarding the home’s services. Individual contracts are issued to residents accommodated. The home has a statement of purpose and service user guide which are provided to all prospective residents upon initial enquiry and re-issued at the point of admission. Contracts and terms and conditions of residency are provided at the point of admission. Signatures of agreement are obtained from the resident and/or their representative. Prior to admission and throughout the placement, assessments of need are completed and recorded. Assessments are kept under review and updated as needs change. Norwood Trust Limited DS0000008570.V263539.R01.S.doc Version 5.0 Page 9 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, 7, 8, 9 & 10 Residents are supported to make their own decisions and choices. They are able to take risks and live their preferred lifestyle. EVIDENCE: Two residents confirmed they were aware that records concerning their care and support were held by the home. One resident stated he was able to see written information and that the home consulted with him regarding his day to day living arrangements. Evaluation of two residents’ files identified that care plans were brief and lacked sufficient information to demonstrate the good work undertaken by staff to meet care needs and support residents to reach stated aims and objectives and long term goals.. Norwood Trust Limited DS0000008570.V263539.R01.S.doc Version 5.0 Page 10 The outcomes of risk assessments were recorded, enabling residents to take everyday acceptable risks. However, the inspector could not identify the process undertaken to assess risk and who was involved in the decision making process. Risk assessments should also be kept under review and systems introduced to periodically re-evaluate risk assessments and residents’ abilities and safety when taking risks. Norwood Trust Limited DS0000008570.V263539.R01.S.doc Version 5.0 Page 11 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): 11, 12, 13, 14, 15, 16 & 17 Residents at Norwood are supported to live fulfilled lives and are enabled to have everyday experiences. EVIDENCE: The majority of residents have regular family contact; some spend time away from the home visiting their families, whilst other families visit the residents at the home. Residents confirmed written information which stated they have the opportunity to joined in a wide selection of leisure activities as a group and individually. Most residents have daytime occupation, including employment. One resident has recently received an award and substantial gift from his employer for accomplishing ten years’ service. Norwood Trust Limited DS0000008570.V263539.R01.S.doc Version 5.0 Page 12 It is recognised that some residents are approaching older age and prefer to live less active lifestyles. Staff are aware of the ageing process and support residents to appropriately occupy themselves during the day. The home continues to provide a healthy diet which includes a good variety of fresh food, including fruit and vegetables. Residents’ weights are monitored and those on reduction diets are successfully losing weight. The inspector noted that some residents’ aims and objectives were to learn to cook and prepare main meals, however due to the manner in which routines are devised, particularly within the bungalow, main meals are generally prepared by staff. Norwood Trust Limited DS0000008570.V263539.R01.S.doc Version 5.0 Page 13 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): 18, 19 & 20 Residents are supported, as far as possible, to maintain good health. EVIDENCE: Residents’ health is kept under review. Medical appointments and visits are recorded, as are treatments. The home consults with professionals regarding the effects of ageing and the care of older people. One the day of the inspection one resident was taken to visit the dentist. Podiatry treatments are in place and annual checks are provided regarding optical and dental care. Some residents have hearing difficulties and receive specialist support. Aids and adaptations have been provided and the registered manager continues to look at ways in which those who are hard of hearing can be further supported. Medication administration procedures continue to be of the required standard, however risk assessments in place to support those residents who self medicate need updating and, as with other risk assessments, the process undertaken to determine the level of risk was not evident. Norwood Trust Limited DS0000008570.V263539.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): 22 & 23 Systems are in place to protect residents from abuse. Complaints are recorded and investigated. EVIDENCE: Since the last inspection the registered manager has ensured that all residents, visitors, relatives and professionals are aware of the home’s complaint procedure and how to raise any concerns regarding service provision. One complaint has been received since the last inspection. Records detailed the nature of the complaint and the action taken to find a positive resolution. The majority of staff have completed adult protection training since the previous inspection. They are aware of their responsibility to report any suspicions of abuse and poor practice. Arrangements are in place to ensure all staff receive adult protection training in the near future. Norwood Trust Limited DS0000008570.V263539.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, 25, 26, 27, 28 & 30 Residents live in a homely and inviting environment, which is maintained to a good standard. EVIDENCE: Norwood House provides residents with a warm, comfortable, homely environment which is maintained to a high standard. Since the previous inspection a single bedroom has been created to provide residents who shared with single accommodation. Plans are underway to divide another double room into two single rooms which, after structural changes, will provide residents with a good standard of accommodation suitable to meet their individual needs. Furthermore, another larger bedroom is to be developed to meet the needs of a resident who is semi-independent and would benefit from having a bed sitting room with facilities to prepare and eat light snacks. Fixtures and fittings throughout the home are in keeping with a homely environment and offer comfort to all residents. The home is kept in good repair and hygiene standards are high. Norwood Trust Limited DS0000008570.V263539.R01.S.doc Version 5.0 Page 16 Consideration is still being given to the future development of the home to meet the needs of residents who are ageing and who may require more accessible bedroom accommodation. However, due to the financial investment undertaken in the previous year and for the next year, such alterations are not expected prior to 2007. Norwood Trust Limited DS0000008570.V263539.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): 31, 32, 33, 34, 35 & 36 Residents are supported by a stable, competent and experienced staff team. EVIDENCE: The current staff are, in the main, long serving and the majority have NVQ level 2 training and above. Training programmes continue and consideration is being given to training staff in supporting older people, as some residents are reaching older age. One new staff member has been recruited since the last inspection. Improved recording systems ensure required documentation is retained and statutory checks undertaken. The staff team attend regular team meetings, the minutes of which are supplied to the CSCI. Formal supervision is undertaken as required and staff work alongside senior managers, including the registered manager. Residents were able to explain the support they received from staff, and good friendships were evident. Norwood Trust Limited DS0000008570.V263539.R01.S.doc Version 5.0 Page 18 Staffing levels within the main house appear adequate, however after talking with residents and staff, it would seem staffing arrangements within the bungalow require reviewing to ensure residents are fully supported to reach their maximum potential and identified aims and objectives within their care plans. Norwood Trust Limited DS0000008570.V263539.R01.S.doc Version 5.0 Page 19 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): 37, 38, 40, 41 & 42 Norwood House is a well managed and well run home. EVIDENCE: The registered manager has been in post approximately one year. During that time, he has developed administration systems and improved the overall running of the home and his leadership style has enhanced the already stable staff team. Staff spoke positively regarding the registered manager’s abilities and routines to support them to complete the work required. Positive relationships were evident between staff members and between residents and staff. The views of residents and staff are sought, respected and acted upon, and the inclusive atmosphere provides residents with a warm, caring and friendly environment. Norwood Trust Limited DS0000008570.V263539.R01.S.doc Version 5.0 Page 20 Systems are in place for health and safety monitoring, including fire safety, accidents, infection control and maintenance of the home and grounds. Regulation 26 visits are completed each month and a report submitted to the CSCI. Residents’ health, wellbeing and safety is, as far as possible, protected. They stated they felt safe, had someone to talk to and enjoyed living at the home. Norwood Trust Limited DS0000008570.V263539.R01.S.doc Version 5.0 Page 21 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 3 3 X X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 2 2 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 2 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Norwood Trust Limited Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X 3 X DS0000008570.V263539.R01.S.doc Version 5.0 Page 22 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 YA9 Regulation 17(1)(a) Requirement The registered person must ensure that the process of assessing risks is recorded and that the outcomes are kept under review and up to date. The registered person must review staffing levels and ensure that staff are in sufficient numbers to provide the support services to meet the homes aims and objectives, both in the main house and the bungalow. (Previous timescale of 15/06/05 not met). Timescale for action 01/02/06 2. YA33 18(1)(a) 01/02/06 Norwood Trust Limited DS0000008570.V263539.R01.S.doc Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA6 YA6 Good Practice Recommendations The registered person should ensure that care plans are sufficiently detailed to identify the care needs of residents and the support required. The registered person should ensure that residents’ longterm goals are identified and recorded. Details should include arrangements of support to be provided to enable the resident to, as far as possible, achieve their goal. Norwood Trust Limited DS0000008570.V263539.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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 Trust Limited DS0000008570.V263539.R01.S.doc Version 5.0 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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