Inspection on 23/04/08 for Norwyn House

This inspection was carried out on 23rd April 2008.

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

Norwyn House 19/06/07

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 Vivien Stephens Unannounced Inspection 23rd April 2008 10:30 Norwyn House DS0000021991.V362446.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.V362446.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.V362446.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.V362446.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th June 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 £271.00 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.V362446.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 home is 1 star (adequate). This unannounced inspection took place as part of our regular inspection routine. It began at 10.30am and finished at 3.30pm. During this visit we talked to the owner, Barbara Anning, her mother (who helps out when needed) and three people who live at the home (two were out for the day). We looked at all the communal areas and at four bedrooms. Records in relation to assessment, care planning, risk assessment, medication, fire safety and staff recruitment were seen. The Commission normally sends out a quality assurance assessment form to services before an inspection is carried out. However, in this instance the form was not sent out until after the inspection and therefore some information was not available to the inspector. The completed form will be checked and any issues arising will be discussed with the home at a later date. What the service does well: What has improved since the last inspection? New care plans have been drawn up by sitting and talking to each person and agreeing what they need help with, and how. The plans are clear and straightforward. People either hold their own care plan in their room, or they have agreed where the file is kept and understand that they can look at it whenever they want. Norwyn House DS0000021991.V362446.R01.S.doc Version 5.2 Page 6 Systems of storing and administering medicines have improved significantly. Each person now has a locked medicine cabinet in their room and Barbara Anning provides assistance with this task where necessary. Some people are now able to administer their own medicines, while others can take greater responsibility for their own medicines with support and guidance as needed. Good recording systems are in place. The systems for dispensing medicines when people are going away from the home has also improved. Safety and risk have been considered for each person, and this has been balanced against independence and choice. Fire drills and fire alarm test are now carried out regularly. 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 Norwyn House DS0000021991.V362446.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Norwyn House DS0000021991.V362446.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.V362446.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 may be considering moving in can feel confident they will have enough information and opportunity to get to know the home and make to make an informed choice. The home has good assessment procedures in place that ensure they have a clear understanding of people’s needs and desires. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection no new people have moved into the home, and there was no likelihood of anyone moving out in the near future. The people currently living at Norwyn received help from social services and care managers before they moved into the home. An assessment of their needs was provided by social services and, in addition, the owner gathered as much additional information as possible from other sources, including family and previous accommodation. We were given assurances from Barbara Anning that she would follow similar admission procedures in the future, giving people as much time and opportunity to get to know the home as necessary. Norwyn House DS0000021991.V362446.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, 9 Quality in this outcome area is good. People who live at Norwyn are supported to make decisions about their lives and to enable them to remain as independent as possible. People are able to take risks if they wish, although some potential risks may not have been fully documented. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection Barbara Anning has worked closely with each person living in the home to draw up a clear and straightforward agreement about the things they want assistance with. The new plans set out the person’s preferred morning and evening routines, and explained what they can do themselves and what they want help with. The plans also showed what each person’s normal daily/weekly activities were. There was a section that set out what the person’s aims and hopes for the future are, and how the owner and staff can help them to achieve these. Four people hold their care plan in their rooms. Norwyn House DS0000021991.V362446.R01.S.doc Version 5.2 Page 11 The fifth person has agreed with Barbara Anning that their care plan is held elsewhere, but they can have access to it at any time. The plans provided evidence of how Barbara Anning has discussed with each person some of the risks they might encounter in their daily lives. The assessments showed that they have considered ways in which the home can support people to lead their lives as they wish, and any support or guidance the home can provide to help the person avoid or minimise any anticipated risks. However, some aspects of risks had not been covered, for example, nutrition, health risks, or medication. We talked to Barbara Anning about how the assessment and review procedure could be improved by devising a form/checklist that could help to prompt her to look at every potential area of need and risk and to make sure these are fully documented. We talked to three people living in the home about their care plans. They agreed that the information in the care plans was correct, and that they had been fully involved and consulted over the content of the care plans. We also talked to people about how they make decisions over their daily lives. People told us about how they choose the food they eat, what they wear, where they go each day, holidays, and the way their bedrooms have been decorated. Residents’ meetings are held every week and this gives people opportunities to speak out about things that affect them, and things they want to do. We heard how people hold their own money for day-to-day expenses. Barbara Anning told us she does not hold any cash on behalf of people. She said she will liaise with individuals and/or their representatives for larger expenses such as holidays or clothing. Norwyn House DS0000021991.V362446.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, 17 Quality in this outcome area is good People generally lead varied and stimulating lifestyles that meet their needs, although some people are limited due to the lack of community activities in the Axminster area. People receive a varied diet to meet their individual preferences. Equality, privacy and dignity are promoted and protected at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The owners and their two young children live on the premises. The house is very busy with people coming and going and lots happening, giving it a lively and happy family atmosphere. Norwyn House DS0000021991.V362446.R01.S.doc Version 5.2 Page 13 We looked at the care plan files and saw that each person had an individual plan of their regular chosen weekly activities. There was also an overview of all of the activities for everyone. Barbara Anning said that the people living in the home liked to know what everyone was doing, and sometimes people could choose to join the others in an activity if they wanted. The care plans include sections on people’s aims and hopes for the future and we could see that the home had considered ways these could be achieved, including regular activities that might provide opportunity to learn new skills. An example was given – they are in the process of setting up an area in the garden where they will keep chickens. One person has said he would enjoy looking after them. Some of the things people did each week included helping with household tasks such as hoovering, washing, laundry and gardening. Some people regularly attended a group called ‘Magic Carpet’ which Barbara Anning told us is the only community based activity available locally specifically for people with learning disabilities. We discussed the possibility of looking at what is available in other parts of East Devon. Barbara Anning said she has approached another local care home to see if they are willing to let people join them in some of their organised activities. One person works in a local pub at lunchtimes. He told us about his job and how much he enjoys the work. He told us about his friends, his hobbies and interests. We were assured that he leads a very full and satisfying life. He showed us his room where he has a television and music equipment, photos and books. Another person we talked to enjoyed helping around the home each day and joining in with family activities such as shopping, outings and going out for coffee. Two people were out at the time of our inspection. We heard that they are able to go out independently, and enjoy visiting different places. Weekly residents’ meetings are held, and one of the main topics recently discussed has been where people want to go on holiday this year. One person is particularly interested in maps and castles and Barbara Anning talked about how they have taken this into consideration when planning the next holiday. People talked about their families and friends and how they are able to keep in touch. There was a very open atmosphere within the home with visitors and friends clearly being made to feel welcome. There is a great deal of emphasis on privacy and dignity within the home. Everyone has a lock on their bedroom door and other people are not allowed to enter a person’s room without their permission. Barbara Anning gave us Norwyn House DS0000021991.V362446.R01.S.doc Version 5.2 Page 14 examples of how people are supported in an individual and personalised way, including the introduction of locked medicine cabinets in each room that have resulted in much greater privacy and dignity and independence over medicine administration. We looked at the arrangements for meals. We were told that everyone is able to choose what they want to eat each day. Each care plan contains a form for people to make suggestions about the meals they would like to eat. There are no written menus and no records of the meals people have received. There was no information in the care plans about nutrition needs or about likes and dislikes, although we received assurances that Barbara Anning has a very clear knowledge of these. We talked to her about the benefits of keeping a record of people’s weight, any special dietary needs, and a record of what people have eaten each day. Norwyn House DS0000021991.V362446.R01.S.doc Version 5.2 Page 15 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, 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. Medications are stored and administered safely, although staff would benefit from more comprehensive training on this subject and the home’s policy on safe administration of medicines is incomplete. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans set out very clearly exactly how people want to be helped with all personal care tasks. They gave good detail about each task and demonstrated that the home has a very clear understanding about each person’s daily routines and how the person wants to be supported. They also gave details about how to respect people’s privacy and dignity when supporting them with personal care tasks. The plans explain the normal times each person wakes up/gets up and goes to bed. They set out how people want to be supported to wash, get dressed, and their appearance generally. Norwyn House DS0000021991.V362446.R01.S.doc Version 5.2 Page 16 Records of health care needs and all medical appointments have been maintained and we were able to see evidence of specialist health input and regular check ups. People told us about visits to health professionals. We could see that the home has sought advice appropriately and have worked closely with professionals to achieve positive results. In the last year the home has provided a locked medicine cabinet in each bedroom. Barbara Anning said she felt this has been a great success. In some cases people are now able to hold and administer their own medicines, and good systems are in place to ensure they are carrying this out safely. In other cases the staff provide guidance and support appropriate to each person to help them take their medication safely. Good recording systems are in place that show exactly how much medication has been administered, how much is left, and when new medication must be ordered. Barbara Anning said she had received some training on the safe administration when she carried out the registered manager’s award. However, this training only provided a brief overview and cover all of the areas recommended in the nationally recognised training standards on the safe administration of medicines. We also looked at the home’s policy on the safe administration of medicines and found that this was very brief and did not cover all of the areas set out in guidance provided by the Commission, or by the Royal Pharmaceutical Society. Norwyn House DS0000021991.V362446.R01.S.doc Version 5.2 Page 17 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, 23 Quality in this outcome area is good. People are confident that their concerns and complaints will listened to and addressed, although staff would benefit from further training on adult abuse and protection issues. This judgement has been made using available evidence including a visit to this service. EVIDENCE: No complaints or concerns about the home have been received by the Commission in the last year. We talked to Barbara Anning about the way the home tells people about their right to complain, and how they respond to this. They have no recorded complaints in the last year. They do, however, have forms in each care plan encouraging people to speak out if they have any moans, grumbles or concerns. These have been explained and discussed with each person. The people we talked to said they had no concerns about the home. They said if they had any concerns they would talk to Barbara or her partner, or to their relatives. They said they were confident any issues would be sorted out satisfactorily. Barbara Anning told us she regularly talks to people individually and in the resident’s meeting to encourage them to let her know if they had any concerns or problems. The home has recently purchased a training pack on adult abuse and we were told they home to start this training in the next six months. We talked to Norwyn House DS0000021991.V362446.R01.S.doc Version 5.2 Page 18 Barbara Anning about the importance of fully understanding local procedures for reporting suspected incidents of abuse, and suggested that she and her staff enrol on a local training course provided by Social Services, in addition to the in-house training she is planning to provide. Norwyn House DS0000021991.V362446.R01.S.doc Version 5.2 Page 19 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, 30 Quality in this outcome area is adequate. People live in a comfortable and homely environment, although the overall standard could be improved by regular maintenance checks and repairs. 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, two lounges and two bathrooms. One lounge tends to be used by the owneroccupiers. The gardens are large, well fenced, and provide a safe area for everyone to use. We looked in four bedrooms. Each person has their own bedroom. There are locks on each door to promote privacy and dignity. Norwyn House DS0000021991.V362446.R01.S.doc Version 5.2 Page 20 We found that most rooms were spacious and appeared comfortable and homely. People told us they liked their rooms and had helped to choose the decoration. However, some aspects of the decoration and furnishings needed attention. While these were not immediately obvious, they did detract from the overall look of the rooms. We noticed few areas of chipped and scratched paintwork, some curtains hanging down, some furniture that appeared old or worn, and some radiator covers that were broken. We talked to Barbara Anning about the need to carry out regular checks and maintenance on bedrooms to ensure that good standards are always maintained. We were told that plans have been drawn up to extend the house, creating a new kitchen and larger bedroom accommodation for the owners’ family. When this work has been completed they hope to create a small kitchen area for people to make their own drinks and snacks. They also plan to decorate and improve other parts of the home. At the time of this inspection there were no definite timescales for this work. 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 there 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. At the last inspection the owner was asked to contact this officer again as the systems in place for controlling infection might be able to be improved. At this inspection we saw evidence to show that she has taken advice and has implemented new facilities and procedures to promote safe infection control measures. These included paper towels and liquid soap dispensers. Norwyn House DS0000021991.V362446.R01.S.doc Version 5.2 Page 21 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, 33, 34, 35 Quality in this outcome area is adequate. People needs are met within a family environment by experienced and competent owners, and some limited input from additional staff, although staffing levels could be improved at busy times of the day. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Norwyn is owned and managed by Barbara Anning. Barbara and her family live on the premises. She 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. At the time of this inspection Barbara Anning and two of the people living there were at home during the day, and a third person arrived home at around 3pm. Norwyn House DS0000021991.V362446.R01.S.doc Version 5.2 Page 22 We discussed the difficulties of juggling the responsibilities of running a family home while at the same time caring for five people with learning disabilities. Barbara Anning assured us that she copes well and that usually people receive the attention they need. At the moment only one person is employed two day a week as a care assistant, and Barbara Anning’s mother also helps out as and when needed. A second member of staff has been employed but, due to a six month delay in obtaining a criminal records check this person is currently working in the home as a cleaner. The intention is to employ this person as a care worker as soon as the criminal records check has been received. While we accepted that this person does not work directly with vulnerable people we were concerned that a criminal records check should still be obtained. We advised that this should be followed up as soon as possible. We looked at the criminal records checks carried out on the care staff (this was a requirement at the last inspection) and found this was satisfactory. However, a cleaner has been employed and, although this person does not work directly with vulnerable people living in the home, we would still expect that a Criminal Records Bureau check is taken up. This was applied for six months ago but has still not been returned. We advised Barbara Anning that this must be followed up as a priority. A range of training has either been provided in the last year, or is planned for the coming months. This includes first aid, infection control, and basic food hygiene. They plan to provide training on adult abuse in the next six months (see also Concerns, Complaints and Protection). One member of staff holds a relevant qualification in care. The owner and one member of staff are currently undertaking training on sign language in order to increase the level of communication with one person living at the home. The people we talked to said they felt they were well cared for, and enjoyed living in a lively family atmosphere. Norwyn House DS0000021991.V362446.R01.S.doc Version 5.2 Page 23 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, 40, 42 Quality in this outcome area is adequate. While people are contented and happy in this home, there are some weaknesses in the management that need to be addressed. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Barbara Anning has successfully completed the Registered Manager’s Award and holds a nationally recognised qualification known as NVQ level 4. In our discussions with her she demonstrated a clear understanding of equality and diversity issues and modern principles of supporting people to lead fulfilling lives. Norwyn House DS0000021991.V362446.R01.S.doc Version 5.2 Page 24 This inspection took place on an unannounced basis. It gave us an insight into the normal daily routines in the house and found that Barbara Anning and her partner have demands placed on them by their family life, her partner’s employment, as well as the needs of the 5 people living in the home. While most needs are met, there were some aspects of the management of the home that had been given low priority. This included some aspects of the maintenance of the home (see Environment), quality assurance, and updating policies and procedures in line with national legislation and good practice advice. We considered that additional staff would provide Barbara Anning with the additional time she needs to carry out these management tasks. We were also concerned that a criminal records check had not been rigorously followed up for a cleaning member of staff (see staffing section). We looked at the systems used in the home to check the quality of the services provided and how these are improved where necessary. We found that little progress has been made since the last inspection. Some aspects of quality monitoring are in place, including care plan reviews, residents’ meetings and informal discussions with people every day. The home doesn’t use survey forms or structured questions to seek the views of the people living in the home, their relatives or advocates, or of health and social care professionals who are involved in the home – this was discussed. We also talked about how they can ensure that they regularly review all aspects of the National Minimum Standards to ensure they are met, or where they need to take actions and make improvements. The home has a policy and procedures manual and Barbara Anning said she checks each year to make sure the policies are still correct. However, the policy on the safe administration of medicines was very brief and did not cover any of the areas set out in guidance by the Commission or the Royal Pharmaceutical Society. We talked to Barbara Anning about how she reviews all of the policies and procedures to make sure they are up-to-date and in line with local and national legislation and she admitted she hasn’t done this. We talked to her about ways she could do this, for example, by using the internet. We checked the health and safety procedures within the home. Records showed that fire drills have been carried out regularly. The home was last visited by a Fire safety officer on 9/7/06. The owners and staff have received, or are about to undertake training on food hygiene, infection control and first aid. Norwyn House DS0000021991.V362446.R01.S.doc Version 5.2 Page 25 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 3 23 2 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 2 34 3 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 x 12 2 13 3 14 x 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 x 2 3 x 3 x Norwyn House DS0000021991.V362446.R01.S.doc Version 5.2 Page 26 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 YA33 Regulation 18 (1) (a) Requirement You must ensure there are sufficient suitably qualified, competent and experienced staff to meet the needs of the people living in the home. You must put in place 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. [Previous timescales 31/8/07 and 30/11/07] Timescale for action 31/08/08 2 YA39 24 (1) 31/08/08 Norwyn House DS0000021991.V362446.R01.S.doc Version 5.2 Page 27 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 YA9 Good Practice Recommendations The home should draw up an assessment and review format that helps them to look at all potential areas of needs and where there may be potential risks, for example, nutrition, medication, or possible health risks. All potential risks should be fully documented and any action or support needed by the home should be set out in the daily plan of care. The home should explore the possibility of finding a wider range of activities that people may like to participate in elsewhere in the East Devon area. The home should assess and record all aspects of people’s dietary needs, including special dietary needs, likes and dislikes, and any support people may need with weight problems. The manager and staff should undertake training on the safe administration of medicines that meets nationally recognised standards. The homes policy on medicine administration should be expanded to cover all aspects of receipt, storage, administration, disposal and potential risks of medication. The manager and staff should undertake training on adult abuse, and should be fully aware of local reporting procedures. There should be a programme of regular maintenance checks on all aspects of the accommodation, and action should be taken promptly to address any defects. This should include repairs to damaged paintwork, attention to curtains that are hanging down, repairs and painting of radiator covers, and replacement of damaged furniture. Criminal records checks should be completed on the prospective new staff member to complete the employment process. This will increase the number of staff available to provide direct support to people living in the home. There should be sufficient time dedicated to management tasks to ensure the home runs smoothly and to ensure that people living in the home are safe. 2 3 YA12 YA17 4 YA20 5 6 YA23 YA24 7 YA33 8 YA37 Norwyn House DS0000021991.V362446.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA 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. 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