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Archived: Southside Partnership - 227 Norwood Road Good


Inspection carried out on 12 May 2016

During a routine inspection

This inspection was carried out on 12 May 2016 and was unannounced. 227 Norwood Road provides accommodation and support for up to five adults with mental health needs. The service assists people to develop their independence and daily living skills. At the time of our inspection five people were using the service.

At our previous inspection, on 23 January 2015 the service had not met all the regulations we inspected. We found breaches which relate to premises and equipment and the registered manager conditions. We issued two requirement notices for these breaches.

At the inspection on 29 July 2015, we followed up on the outstanding breaches of the regulations. We found that action had been taken to address the breach regarding the premises and equipment. However, the provider had not made sufficient improvements in relation to the registered manager conditions.

At this inspection, we found that actions had been taken by the provider to address the breach related to the registered manager conditions. At the time of inspection, the service had a registered manager in post. The registered manager was also managing other services for the provider. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. The service had a deputy manager who was responsible for managing the day-to-day running of the service.

Staff recognised signs of potential abuse to people and supported them to stay safe from harm. People’s individual risk assessments were in place and addressed the support required for people in crisis. There were enough staff at the service to support people in their home and in the community. Staff assessed people’s ability to manage their own medicines and supported them to understand what medicines they were taking.

Staff were knowledgeable about the support people required with their care needs. They received regular supervision and appraisal, which provided them with opportunities to discuss their professional goals and develop in their role. Staff had support with their training needs and attended refresher courses as required.

We found that the staff team had limited understanding about the Mental Capacity Act (MCA) 2005 principles as they had not attended the MCA training. We recommended the service to seek advice and guidance from a reputable source, in relation to the requirements of the MCA training for social care staff.

People had a signed agreement with the provider consenting to some restrictions at the service. Staff monitored people’s food intake to ensure that their nutritional needs were being met. People had access to health professionals and staff reminded them about the medical appointments they needed to attend.

People told us that staff were kind and respectful. People had good relationships with staff that attended to their needs with care. Staff respected people’s privacy and asked them when they wanted to be supported. The service supported people to increase their social contacts and develop relationships in the community. Staff provided people with information about the group activities available and people chose if they wanted to attend them.

People were involved in the assessment and planning of their care. Regular review meetings were held for people to monitor their progress and agree on future goals to increase their independence. People raised their concerns to the staff team that provided them with opportunities to question practice as necessary. The organisation had asked people and their relatives for feedback about the services provided for people to ensure their involvement in developing the service.

The management team had supported staff to carry out their responsibilities as required. Staff to

Inspection carried out on 29 July 2015

During an inspection looking at part of the service

We carried out an unannounced comprehensive inspection of this service on 23 January 2015. A breach of legal requirements was found. After the comprehensive inspection, the provider wrote to us to say what they would do to meet legal requirements in relation to; safety and suitability of premises and their registration condition requiring a registered manager. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We undertook this focused inspection on 29 July 2015 to check that they had followed their plan and to check that they now met the legal requirements inspected. This report only covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Southside Partnership – 227 Norwood Road on our website at

At our previous inspection we found that suitable premises were not provided for people. There were stains and spills throughout the building, and damage to paintwork. There were cracks in the walls and water damage in the bathroom.

Since our comprehensive inspection the service had been deep cleaned and the majority of rooms had been freshly painted. The service had agreed with the housing provider to have the kitchen and main bathroom renovated. The service was now meeting the regulation relating to safe and suitable premises.

At our previous inspection we found the service did not have a registered manager. This inspection confirmed the service still had no registered manager and continued to be in breach of this condition of their registration. The service was in the process of recruiting a new permanent manager. This breach will be followed up during our next comprehensive inspection of the service.

Inspection carried out on 23 January 2015

During a routine inspection

The service at 227 Norwood Road provides accommodation, care and support to up to five people with mental ill-health. At the time of our inspection four people were using the service.

At our previous inspection on 11 June 2013 the service was meeting the regulations inspected.

At the time of our inspection there was no registered manager at the service. The manager had started the process of becoming registered with the Care Quality Commission as required by the service’s registration. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

The staff liaised with people’s care co-ordinator from the Community Mental Health Team (CMHT) about people’s care and support needs. This information, together with discussions with the person using the service, was used to develop individualised recovery and support plans. These plans were reviewed regularly and staff supported people to work towards their goals. If there were any concerns about a person’s health or the support provided, this was discussed with the person’s care co-ordinator to identify what additional support could be provided.

Staff were friendly and polite, and respected people’s individuality. Staff supported people in line with their preferences.

Information was gathered about any risks to people’s safety and staff supported people to manage those risks. Some restrictions were in place at the service to protect people’s safety and maintain their welfare.

Staff received regular training and had the knowledge and skills to support people using the service. Staff met with their manager regularly to discuss their performance and identify any areas for improvement and development. Staff told us they felt well supported by their manager and felt comfortable speaking to them if they wanted any further advice about how to support people.

Staff supported people with their medicines, and safe medicine management practices were in place. Staff supported some people to manage their finances and processes were in place to protect people from financial abuse.

The manager of the service and their line manager undertook regular checks to review the quality of care provided. Any areas for improvement were identified and where possible actioned. The manager had identified that improvements were required to the environment but had been unsuccessful in getting the required maintenance undertaken. We found the service provided an unsuitable environment for people living there. General maintenance was required and the bathrooms required renovation.

We found the service was in breach of the regulation relating to the suitability of premises and the condition of their registration to have a registered manager. You can see what action we told the provider to take at the back of the full version of the report.

Inspection carried out on 12 June 2013

During a routine inspection

We were unable to speak to people using the service in detail as many of them were out accessing services in the community, but through brief discussions people seemed happy with the service they received. Other health professionals visiting the service on the day of our inspection reported that there were good joint working arrangements.

People using the service were given the opportunity to consent to their placement before moving to the service and were involved in developing their support plans so they could consent to the support provided. For those that were unable to consent the provider acted in accordance with legal requirements.

People were provided with support plans tailored to their needs, and there were regular meetings to discuss the progress they had made. There was evidence that people were involved in all decisions regarding the support they received.

Medicines were safely stored and safely administered. Administration of medicines was recorded on a medicines administration record and we saw evidence that these had been completed appropriately.

The building provided a safe and secure premise for people to stay at, and at the time of our inspection there were no outstanding maintenance requests.

At the time of our inspection there had been no complaints received in the last year. There was a complaints process in place and staff were able to demonstrate how they would support an individual to complain if they so wished.

Inspection carried out on 3 January 2013

During a routine inspection

227 Norwood Road focuses on promoting the independence of the people who use the service, and this was evidenced through the activities on offer, the emphasis on daily living skills and the delivery of person centred care. One person using the service told us about the support provided by the staff to enable them to go back into the community and said "I couldn't do it without them."

We spoke with three out of the four people who were using the service. All three told us they were aware of their care plans and associated review processes, and had been involved in the development of them.

Staff spoken to on the day felt well supported by their manager. Records showed that all staff members were up to date with their mandatory training, and staff had a good working knowledge of the service's policies and procedures. There was evidence of staff being supported to continue with their professional development.

Records on the day showed the quality of service provision was regularly monitored, and learning from incidents was incorporated into service delivery.

Inspection carried out on 8 March 2011

During a routine inspection

People who live at the home told us that they are happy there and find the staff �nice and friendly� and �helpful�. They said that they are well supported with the things that are important to them.

People told us that the house is clean and they like the communal spaces, their bedrooms and the garden. They said that they can choose what to do and enjoy a range of social and educational activities.