Inspection on 19/06/07 for Norwyn House

This inspection was carried out on 19th June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Norwyn House 23/04/08

Norwyn House 08/01/07

Norwyn House 19/10/05

Norwyn House 18/05/05

Norwyn House 20/10/04

Norwyn House 13/04/04

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

CARE HOME ADULTS 18-65 Norwyn House Norwyn Charmouth Road Raymonds Hill Axminster Devon EX13 5ST Lead Inspector Teresa Anderson Unannounced Inspection 19th June 2007 10:00 Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 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 Norwyn House DS0000021991.V335955.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 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. Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norwyn House Address 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) Norwyn Charmouth Road Raymonds Hill Axminster Devon EX13 5ST 01297 35111 Miss Barbara Jill Anning Miss Barbara Jill Anning Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th January 2007 Brief Description of the Service: Norwyn is a detached 3-story property situated on the A35 near Axminster, Devon. The home offers personal care and accommodation for up to 5 service users with learning difficulties. It operates as a small, family home where service users and the owners and their family live together. All service users are able bodied so the home is not equipped with aids or adaptations. The communal space is on the ground floor and is made up of two lounges (the owners and their family tend to use one of these), a large kitchen/dining room and a separate quiet/dining room. Service user bedrooms are on the first floor. These are all single rooms.Ensuite facilities are not available but there are shared bathrooms nearby. Support is provided by the owners, one carer and a cleaner. There are local shops and a pub within walking distance of the home and a bus service to local towns. In addition the owners provide transport in the family cars. The house is surrounded by approximately one and a half acres of garden. Ample parking is available. The current levels of fees range from £321.00 to £486.00 per week. Additional information about the home, together with copies of inspection reports, are available direct from the home. Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place as part of the normal programme of inspection. It started at 10.00am and finished at 2.00pm. During that time we spoke with 3 of the 5 people who live here (2 were out), with the owner and with 1 member of care staff. We looked at all the communal areas and at 2 bedrooms. Records in relation to assessment, care planning, risk assessment, medication, fire safety and staff recruitment were seen. Prior to the visit the owner completed a preinspection questionnaire providing details about the management of the home. Questionnaires asking for feedback about this service were sent to all the people who live here and 3 were returned; to 2 members of staff and none were returned and to 3 health and social care professionals and 1 was returned. Their feedback and comments are included in this report. What the service does well: People who consider coming to live here can be assured that they will have enough information about the home and can visit lots of times before they make a choice. People each have their own bedroom which can be locked and which is considered the private space of the person it belongs to. Toilets and bathrooms are shared. Staff understand the needs of each person who lives here and treat each person as an individual and with respect. Staff understand about equality and diversity issues and work hard to ensure that they treat people equally. People who live here are helped to live the life they choose and are helped to develop skills so that they can take risks such as using buses, going out alone and managing their own medicines and monies. The home is busy and relaxed and there is lots going on. The people who live here live with the owners and their children. Routines are minimal and revolve around making sure everyone gets the attention they need. People go out on day trips with other people who live here and they have one to one time with staff. Activities include going to ‘Magic Carpet’, a community based service specifically for people with learning difficulties, going to the seaside, playing skittles and going out to local amenities. People who live here usually have 2 holidays each year. People living here do not tend to cook but they do help with shopping and choosing meals. The owner balances personal preferences for chips and sweets with healthy menu planning. People usually have their main meal in the evening and a sandwich at lunchtime. They like to eat at the table in the kitchen. Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 6 People are helped to stay healthy through regular health checks and seeing for example the dentist and chiropodist. They are encouraged to make complaints and to air their views. They are kept safe from abuse through training of staff and by staff helping them to have the confidence to speak out. Radiators are covered and upstairs windows have restricted openings to prevent accidents. The home has a small staff team and there is usually one or two people on duty. They are well trained and kind and helpful. They have a good understanding of how to run a home so that the people who live there are supported to make decisions and are treated equally. People who live here say ‘I like it here’, ‘I am really happy’ and ‘I am the happiest I have ever been’. What has improved since the last inspection? What they could do better: People who live here do not have care or life plans that help them to be sure they are getting the support they need to reach their full potential in life. The system for managing medication is not safe as the owner is putting medicines dispensed by the pharmacy into pillboxes. The system of hand washing consists of bar soap and hand towels. The owner needs to check with environmental health to ensure this is adequate to control infection in this care home. Police checks must be carried out on all staff members before they come to work at the home. These checks must be carried out by the current employer to help ensure the protection of the people who live here. The owner must put in place comprehensive quality monitoring systems so that she can be sure that the home is being run in the best interests of the people who live here and to ensure the services offered to people continue to improve. The owner must ensure that any fire drills or fire alarm tests that take place are recorded. Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 7 The radiator covers are not painted. If they were this would enhance the overall décor of the home. 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. Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 8 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 Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. People who come to live here can be assured that they have enough information to make a choice. Staff will have a good understanding of their needs and desires. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The people who come to live here are supported to do so through social services and care managers. An assessment of their needs is provided and the owner tries to get as much additional information as possible from other sources. This includes family and, if the person has lived in another home, from that service. All people who consider coming to live here visit on numerous occasions and at different times so that they can meet with staff and the people who live here to help them make a decision. Since the last inspection one person has been admitted. They sat they visited the home, spoke with staff and met with the other people who live here. They say they had enough information to make a decision. Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is adequate. People who live here make decisions about their lives and are supported to remain independent and to take risks. However, it cannot be guaranteed that they are reaching their full potential due to a lack of care/life planning. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The owner and staff spoken with and observed demonstrate an excellent understanding of each person who lives here, their needs and their preferences. Each person is treated as an individual and each is helped to make decisions about how they live their lives. The people who live here have varying abilities and so freedom of choice is balanced with safety through risk assessments. People who live here talked of the risks they take and the plans they have to develop their skills so they can take more risks. Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 11 However, care plans do not capture this information. Risk assessments, the development of skills, how needs and aspirations are met are not all recorded or reviewed and updated. This was discussed at the last inspection. Each person does have a pen picture relating to him or her but this does not provide the level of detail and depth needed to help people plan how they can reach their full potential. Care plans in place tend to be the property of the home, designed to give basic information to staff, but are not designed to be owned by the person they relate to or to help them to plan how they live their lives. Whilst this is a small home within which verbal communication works well, care plans should be comprehensive, written and agreed with each service user. This is particularly important as the staff team grows. Annual reviews are undertaken with social services for each person living here and these are recorded. Discussions with people who live here indicate that they are supported to make decisions such as what to wear, what to eat and how to spend their time and money. Those people who are able to manage their own monies do so and others are provided with support. Support is offered in a way that promotes involvement whilst offering protection. All accounts were checked and these were in order. All records were complete and all receipts had been kept for audit purposes. Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. People who live here lead a stimulating lifestyle that meets their needs. They benefit from a varied and nutritious diet. Their rights to equality are promoted and protected. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In surveys and in discussions the people who live here say that they can do what they like during the day, evening and weekends. Activities include going to ‘Magic Carpet’, which the owner reports is the only community based activity available specifically for people with learning disabilities. People also go out for example on day trips, to car boot sales and to the seaside. Everyone who lives here, including the owners children, might go out together. One Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 13 person talked about how they had all gone shopping together and what fun this had been. Another person talked of meeting with their family. In a survey a professional said that the introduction of community based activities for one person was enhancing their life. In addition each person living at the home has one to one time, if they wish, with either the owner or a member of staff. During this time the service user chooses what they would like to do. Some people are able to go out alone and go to the local shops and to local towns. On the day of this inspection one person was out working and another had gone out with the male owner and his daughter. The owner reports that very often people who live here choose to join in with short trips such as picking the children up from school and going to the DIY shop. All the service users had recently gone on holiday for a week to Butlins and are currently considering where to go next. Holidays tend to happen twice a year. Routines in the home are the same as in other busy family homes and relate to ensuring that everyone gets what they want. All bedroom doors have locks and each person holds their own key. The home has a policy of not entering people’s rooms without permission or without being asked. Everyone is expected to respect this. Mealtimes are relaxed and informal. The main meal of the day is served in the evening with lunch usually being a snack of people’s choosing. During the day hot and cold drinks and snacks are available. Following discussions at house meetings, the home decided that the table would be moved from the lounge to give more room there. People now eat their meals at the table in the kitchen. They say this suits them and that they prefer not to eat in the dining room. They also say they like chips and pasta, and the owner reports that these preferences are balanced with health menu planning. Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. People are supported to stay healthy and personal assistance is offered in a way that promotes choice and independence. The way medications are managed is presenting some risks to the people who live here. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each person living here is registered with a local GP, dentist and chiropodist and regular preventative checks take place. Specialist referrals are made when needed and appointments, which are usually in Exeter, as used as an opportunity for a day out doing what the service user wants to do when the appointment is over. The owner has worked very hard to find the details of one persons specialist consultant and about appointments and treatments. In a survey a professional said that people’s healthcare needs are always met and that their privacy and dignity is always respected. People who live here need minimal help with their personal care. Discussions with staff and with service users demonstrate that individual choices about personal care are respected. Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 15 Records in relation to medication are kept to a good standard and the owner demonstrates a good understanding of the medicines used. People who live here are supported to look after their own medicines to a level that suits them and their abilities. One person manages their own medication. The system that the owner is currently using to manage medications, dispensing medicines from packs into pillboxes marked with the day and time to be given, is not safe. She uses this system because she believes it is safer than any alternative. She has approached local pharmacies to ask if they would supply medication in a monitored dosage system but this is not possible with the medicines being used. The owner has agreed to ask the local pharmacy if they would dispense the medicines into pillboxes in order to overcome this problem, and to assess if people who live here could be further supported to manage their own medications. Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is excellent. All people living here have their concerns and complaints heard, even when verbal means of communication are not possible, and they are kept safe. This judgement has been made using available evidence including a visit to this service. EVIDENCE: In surveys people who live here say that they know how to make a complaint; that staff treat them well and that staff always listen and act on what they say. One survey indicates that a service user did not know how to make a complaint. However, when we checked this out by talking with the person concerned and checking their understanding of the question, it was clear that this person did know how to make a complaint and had the confidence to do so. This person went on to say that they are happier than they have ever been. The owner talked of encouraging people to air their views, including making complaints, as a way of helping them to increase their confidence and to have more control over their lives. During discussions with service users they say that if they did not like what someone was doing that they would say so. They say they feel safe and secure in their home. One person said they know what bad care is and this does not happen here. Staff report that some people cannot communicate verbally, so they make sure they ‘listen’ to these people in other ways. For example, Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 17 looking at their body language and behaviour. In this way they can determine if someone is not happy. The owner is also learning sign language as a way of supporting one person to be heard. Neither the home nor the commission have received any complaints about this home. Staff receive training in protecting vulnerable adults and demonstrate a good understanding of this. Interactions between the people who live here and staff are relaxed and respectful. Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. The people who live here enjoy a relaxed and homely environment. Improvements to hygiene procedures would better protect everyone who lives here from getting or spreading infection. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Norwyn is a three-storey house with a large kitchen/diner, dining room and two lounges. One lounge tends to be used by the owner-occupiers. The house is very busy with people coming and going and lots happening. Some decoration and replacement of flooring has taken place. People who live here say they like the way the home is and that they feel comfortable being untidy and relaxed. Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 19 One person who was admitted to the home most recently chose the colours of the paint in their bedroom and the new carpet. They say they are very happy with their room. All radiators are covered or have cool touch surfaces to prevent scalding. At the last inspection it was recommended that radiator covers would benefit from painting to enhance the overall décor of the home. One has now been painted. All upstairs windows have window restrictors in place to prevent accidental falling. There are no adaptations or mobility aids in the home as everyone who lives here is able bodied. The laundry equipment is sited in the kitchen, which is unusual in a care home. This has been approved by the Environmental Health Officer. The owner was asked to contact this officer again as the systems in place for controlling infection might be able to be improved. At the moment hand washing facilities are made up of bar soap and towels. It is usual in care homes for liquid soap and paper towels to be used. People who live here have their own bedrooms and all bedroom doors have locks. Service users say that people are not allowed to enter their rooms without permission and this is very important to some people. They say this is always adhered to. Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. People who live here benefit from well-trained staff. However, they are not fully protected because of inadequate recruitment procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Norwyn is owned and managed by Barbara Anning. She lives at the home with her partner and two children, and is very involved in the day-to-day running of the home and the provision of support. Her partner tends to act as the maintenance man and driver. In addition there are two other members of staff who work part time. Care, cleaning and cooking is shared between these people. There are usually one or two people on duty during the day and one or two people (sleeping) at night. Staffing is very flexible to suit what the people who live here are doing and the activities they are taking part in. Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 21 Since February there have been five people living at the home which has increased the overall level of need. In response to this the owner has recruited a new member of staff who will start work soon. In the pre-inspection questionnaire provided by the owner it was noted that the police check of one person was dated prior to their employment at this home. When we checked this, this person had bought their police check with them from a previous employment. This is not good practice and the owner has agreed to carry out a new police check to ensure it is current and to ensure the full protection of the people who live here. All other recruitment checks are in place, including references from previous employers and proof of identity. The pre-inspection questionnaire also identified that the majority of staff hold a National Vocational Qualification in Care to level 2 or above. The member of staff who is due to start work shortly is just about to commence this training. Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. People who live here benefit from a management style that keeps them at the centre of how the home is run. Risks to their safety could be reduced with improved and consistently applied management systems. This judgement has been made using available evidence including a visit to this service. EVIDENCE: This owner/manager has successfully completed the Registered Manager’s Award and there is clear evidence in the home of how she has used this knowledge to benefit the people who live here. She has for example carried out quality audits and has an excellent understanding of equality and diversity issues which she puts into practice to secure equality for the people who live here. Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 23 In the pre-inspection questionnaire the owner reports that appropriate maintenance checks and contracts are in place for systems such as heating and electrics. She also states that fire checks and drills are in place. However, when records were checked in relation to fire drills, they had not been completed since April 2007. The owners say they do take place and the people who live here confirm this but were unable to confirm how often these happen. The pre-inspection questionnaire also identified that many policies used in the home had not been reviewed for some years. However, on discussion the owner reports that they had been reviewed but not changed. All staff receive mandatory training and updating is currently taking place. This includes First Aid, food hygiene, infection control and health and safety. Staff and the people living here meet weekly to discuss any issues and/or plans for the future. In addition the owner has developed a quality audit system which measures overall satisfaction. However, this does not include the views of other people such as care managers, relatives or advocates. There is evidence that the owner is overstretched. With the addition of an additional member of staff it is anticipated that the problems identified in relation to medication, care planning, quality assurance processes and fire safety will be addressed. Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 24 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 Standard No Score 1 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 3 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 x 32 4 33 x 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 x 2 x 2 x x 2 x Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 25 Yes 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 YA6 Regulation 15 (1) (2) Requirement In order to ensure that people living here are reaching their full potential, each person should have a plan of support that identifies their goals and aspirations and how these are to be achieved. This plan should be written in consultation with the person it refers to and must be reviewed so that it is up to date and relevant. Previous timescale of 31/03/07 not met. 2. YA20 13 (2) When medication is administered to people living here it must be done in a way that is safe and which complies with Royal Pharmaceutical guidelines. Secondary dispensing is not allowed unless it has been carried as with a service user as a say of supporting them to look after their own medications. The manager must consult with the environmental health officer DS0000021991.V335955.R01.S.doc Timescale for action 31/08/07 31/07/07 3. YA30 16 (2) (j) 31/07/07 Norwyn House Version 5.2 Page 26 4. YA34 19 (4) (b) Schedule 2 5. YA39 24 (1) 6. YA42 23 (4) to determine the best way to control the spread of infection in relation to hand washing facilities. To ensure that the staff recruited 31/07/07 are appropriate to work with vulnerable people they must have a police check (CRB) undertaken prior to working in the home. This must be undertaken by the employer of that person. The owner must put in place 31/08/07 quality monitoring systems which measure the success of the home based on the aims and objectives identified in the statement of purpose. Views should be sort from different sources to ensure that the people who live here benefit from living in a home that is run in line with best practice and which is open to ideas for improvement. To ensure that people living here 31/07/07 are protected in the event of fire, fire drills or fire alarm test must be carried out and these must be recorded as being done. 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. Refer to Standard YA24 Good Practice Recommendations You should consider painting the radiator covers to enhance the décor of the home. Norwyn House DS0000021991.V335955.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP 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 Norwyn House DS0000021991.V335955.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. 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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