Inspection on 13/07/06 for Norfolk Lodge

This is the latest available inspection report for this service, carried out on 13th July 2006.

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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Norfolk Lodge 10/05/05

Norfolk Lodge 19/03/05

Norfolk Lodge 23/11/04

Norfolk Lodge 23/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

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Seabourne House

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Lyncol House

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

CARE HOME ADULTS 18-65 Norfolk Lodge 9 Norfolk Road Horsham West Sussex RH12 1BZ Lead Inspector Ms A Campbell-Currie Unannounced Inspection 13th July 2006 02:30 Norfolk Lodge DS0000014640.V295328.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 Norfolk Lodge DS0000014640.V295328.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. Norfolk Lodge DS0000014640.V295328.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norfolk Lodge Address 9 Norfolk Road Horsham West Sussex RH12 1BZ 01403 218876 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) Dr Shafik Hussien Sachedina Mr Shiraz Boghani Post Vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Norfolk Lodge DS0000014640.V295328.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st September 2005 Brief Description of the Service: Norfolk Lodge is registered to provide personal care for up to eight service users between the ages of eighteen and sixty-five years who have a learning disability (LD). Norfolk Lodge is a semi-detached building in a residential road in the town of Horsham. Service users are accommodated in rooms on the ground and first floors. The laundry room and staff office are on the second floor. There are three rooms on the ground floor that are set aside for communal use including the dining room. There is a communal room on the first floor that is used for staff on sleeping in duties; this room is also used for meetings and other events. There is a secluded garden at the back of the building. Sussex Health Care owns the service; Mr Boghani and Dr Sachedina are the registered providers. There is an acting manager in post. The fees range from £600 to £1,200 per week. Norfolk Lodge DS0000014640.V295328.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during an afternoon and early evening. The manager designate was on duty and assisted with the inspection. There were two care staff on duty; both of whom were spoken with. One service user was out during the afternoon. Seven service users were seen and time spent with two of them. One service user took pride in showing me the work he had been doing in the garden, with staff support. The manager designate has been in post since February and moved from a post in another care home within the Sussex Health Care group. The outcomes for service users were assessed in relation to the key National Minimum Standards. What the service does well: What has improved since the last inspection? What they could do better: The manager designate should ensure that all staff have completed training in adult protection and that everyone who works in the home understands the West Sussex policy and procedure for the protection of vulnerable adults. The manager designate should ensure that the recruitment process fully protects the welfare of service users and that the required records of staff employed are made available. Norfolk Lodge DS0000014640.V295328.R01.S.doc Version 5.2 Page 6 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. Norfolk Lodge DS0000014640.V295328.R01.S.doc Version 5.2 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 Norfolk Lodge DS0000014640.V295328.R01.S.doc Version 5.2 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): 2 Quality in this outcome area is good. It was evident that service users’ needs and aspirations had been assessed prior to them making a decision about moving to Norfolk Lodge. EVIDENCE: The case records of three service users were read. These documents showed that a thorough assessment of need had been carried out prior to a service user moving to Norfolk Lodge. The physical and emotional needs and aspirations had been clearly documented. Information from relatives and health and social care professionals had been taken into account to ensure that people’s individual needs could be met at Norfolk Lodge. The person who had most recently moved to Norfolk Lodge had been given the opportunity to visit the home before a decision was made about the move. The staff who were on duty were clear about the needs of those living in the home. Norfolk Lodge DS0000014640.V295328.R01.S.doc Version 5.2 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 and 9 Quality in this outcome area is good. Service users know that their assessed and changing needs and personal goals are reflected in their individual Plan. Service users are supported to make decisions about their lives. People are supported to take risks as part of an independent lifestyle however it was not clear that all aspects of risk had been assessed for the protection of service users. EVIDENCE: The care plans for three service users were looked at in detail. A personcentred approach has been taken to care planning. The personal goals and aspirations of service users were clearly noted with detailed guidance for staff about the way people prefer their care to be provided. The guidance is based on service user’s wishes and also professional advice to ensure that behaviours are managed and service user’s individual needs are met. It had been noted that care plans had been reviewed by the manager designate every month. Risk assessments in many aspects of people’s lives had been carried out. Two additional areas of risk were noted during the inspection however there was no evidence to show that these risks had been Norfolk Lodge DS0000014640.V295328.R01.S.doc Version 5.2 Page 10 noted and assessed. Service users are encouraged to make choices and decisions about their lives with assistance from staff. People’s wishes with regard to their independence were noted in their care plans. Where people’s choices were restricted for their own safety this was documented and guidance to staff provided. The service users seen and spoken with indicated that they receive the care that they need. The staff on duty were clear about the care needs of each individual. A recently appointed member of staff said that he had been given details and guidance about the care plans of service users when he began work. Norfolk Lodge DS0000014640.V295328.R01.S.doc Version 5.2 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): 12, 13, 15, 16 and 17 Quality in this outcome area is good. People are supported to take part in activities of their choice and use the services available in the community. People are supported to maintain contact with their families and friends. Service users’ rights are respected and their responsibilities recognised in their daily lives. People are offered a healthy diet. EVIDENCE: Service users are supported to take part in some activities of their choice. One person was out during the afternoon of the inspection. One person was working in the garden and took great pride in showing me the plants that he was tending. It is clear that he is supported in this area of activity. The other service users were watching television or had chosen to sit in their rooms. The case records showed that some activities had been documented. The activity programmes seen in case records and on the board in the dining room were not up to date. The manager said that service users are taken out in the minibus several times a week if they choose to go. Two holidays to Hayling Island had taken place earlier in the year and four people had had the opportunity to go. The manager designate said that two people who had attended college courses had now chosen not to continue their studies. Norfolk Lodge DS0000014640.V295328.R01.S.doc Version 5.2 Page 12 People are supported to maintain contact with their families. Several people visit their families at weekends. It was not clear whether people have developed any friendships outside the home. It was noted in some care plans that some service users choose to go into town for coffee or shopping trips; risk assessments were on file. Service users are able to make use of two communal lounges and the garden. The kitchen and dining room are kept locked as the manager designate said that some service users would be at risk of harm. A sample of menus were seen and showed that people are provided with a nutritious diet. It was not clear whether any service users are involved in the planning of the meals although it is clear that they are given a choice of food. The manager designate said that none of the service users help with meal preparation although it appeared from discussion that some people might be able to be involved in the preparation of food with staff support if they chose to do this. Norfolk Lodge DS0000014640.V295328.R01.S.doc Version 5.2 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 and 20 Quality in this outcome area is good. Service users receive care in the way they prefer and require. Service users’ physical and emotional needs are met. People are protected by the home’s policies and procedures regarding the administration of medication. EVIDENCE: The sample of case records seen showed that the personal and healthcare needs of service users are documented and guidance provided to staff. There were details about the way that people prefer their care to be provided. The member of staff recently appointed said that he had been provided with the knowledge and guidance he needed when he started work. The healthcare needs of service users were noted and it was evident that people are supported to see the GP or other specialist health care professional when necessary. Detailed records were being kept for one person whose health had given staff cause for concern. People spoken with indicated that they were happy with the care provided. There are policies in place to provide staff with guidance regarding medication. None of the service users have been assessed as able to safely administer their Norfolk Lodge DS0000014640.V295328.R01.S.doc Version 5.2 Page 14 own medication. The storage facilities for medication and the records were seen to be suitable, up to date and in good order. Norfolk Lodge DS0000014640.V295328.R01.S.doc Version 5.2 Page 15 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 and 23 The quality in this outcome area is adequate. There is a complaints policy so that service users feel their views and concerns would be listened to. There are policies regarding adult protection however it was not clear that people are fully protected from harm through staff training and understanding of the investigation procedure. EVIDENCE: There is a complaints policy in place. This has been provided in symbol format to help people who have difficulties with communication. There is a system for recording complaints; none had been recorded since the last inspection. The manager designate was advised to find ways to ensure that service users feel that their concerns and complaints are listened to and acted on. There is an adult protection policy in place and staff have access to the West Sussex policy and procedure for the protection of vulnerable adults. Staff are provided with training regarding adult protection however it was not clear from the records seen that all staff had undertaken this training. The staff spoken with were clear about the reporting and investigation procedure. The manager was advised to ensure that she is familiar with the investigation process to ensure that service users are fully protected in the event of a concern or allegation that abuse may have occurred. Norfolk Lodge DS0000014640.V295328.R01.S.doc Version 5.2 Page 16 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 and 30 The quality in this outcome area is good. Service users live in a comfortable and safe environment. The home was clean at the time of the inspection. EVIDENCE: There is a maintenance programme for the house and garden. Service users who are able to are encouraged to help in cleaning their room and maintaining the garden. Care staff are responsible for making sure that the home is clean. There is a programme of maintenance and redecoration as required. Service users were making use of the lounge areas. The dining room was kept locked for a period of time during the inspection; this restricts the amount of communal space available to service users. The laundry facilities are suitable for the needs of people living at Norfolk Lodge. Those who are able to are encouraged to take their washing upstairs however the manager designate said that service users do not operate the machines. Norfolk Lodge DS0000014640.V295328.R01.S.doc Version 5.2 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): 34 and 35 Quality in this outcome area is adequate. It was not clear that service users are fully protected by the recruitment process at Norfolk Lodge. It was not clear that service users’ individual and joint needs are fully met by appropriately trained staff. EVIDENCE: There is a recruitment policy in place and the staff at the head office of Sussex Health Care are involved in the recruitment process. The manager designate said that she had not been involved in appointments of any new staff since her own appointment in February. There were no records to show the interview process for a member of staff transferred from another home run by Sussex Health Care. The records of three members of staff were seen; these records did not include all the required information. The manager said that staff begin work after the POVA first checks are carried out and before the full, enhanced CRB and POVA checks. The manager was not clear about the measures that should be put in place before the full CRB check is received to ensure the safety and wellbeing of service users. The member of staff recently appointed confirmed that he had been through a thorough recruitment when he first began work with Sussex Health Care. It was not clear how service users are involved in the recruitment process. Norfolk Lodge DS0000014640.V295328.R01.S.doc Version 5.2 Page 18 Staff are provided with an induction and training programme. The members of staff spoken with both said that they are supported to attend training. One person has just completed the NVQ level two award and has applied for the NVQ level 3. There was evidence to show that some people have recently attended moving and handling and fire training. It was not clear that training records are kept for all staff to ensure that everyone has completed the mandatory training and that any new training needs are responded to. Norfolk Lodge DS0000014640.V295328.R01.S.doc Version 5.2 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, 39 and 42 The quality in this outcome area is adequate. The manager designate is not yet fully qualified and experienced to ensure that service users benefit from a well run home. It was not clear that service users could be confident that their views underpin all self-monitoring, review and development of the home. It was not clear that the health, safety and welfare of service users are promoted and fully protected by the training and procedures in place. EVIDENCE: The manager designate has been in post since February; she is a registered nurse and is has begun studying for the registered managers award course which she plans to complete in a year’s time. The manager designate is not yet registered with the Commission. Service users are provided with a survey that the manager designate said care staff help them to complete once a year. An example of this form was seen. The manager said that any issues would be responded to. It was not clear how service users’ views are taken into account in the development of the home. Sussex Health Care staff send out questionnaires to relatives from time to Norfolk Lodge DS0000014640.V295328.R01.S.doc Version 5.2 Page 20 time. It was not clear that the information from quality monitoring systems has been collated or published. The health and safety records were seen. It was not clear that all staff have undertaken mandatory health and safety training. The risk assessment of the building is carried out every week and the fire alarms tested on a regular basis; these records were seen. The accident book was available. The manager designate was advised to ensure that accidents and incidents are monitored to ensure that service users are fully protected. Norfolk Lodge DS0000014640.V295328.R01.S.doc Version 5.2 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 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 2 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 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 2 X Norfolk Lodge DS0000014640.V295328.R01.S.doc Version 5.2 Page 22 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 YA34 Regulation Reg 19 Requirement The Registered persons should ensure if care workers start work without full CRB disclosure having been received that the home follows the guidance provided under the Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004. The Registered persons should obtain and make available the information for all staff required under the Substituted Schedule 2 of The Care Standards Act 2000 (Establishments and Agencies)(Miscellaneous Amendments) Regulations 2004. The Registered persons shall make arrangements, by training staff or by other measures, to prevent service users being harmed or suffering abuse or being placed at risk of harm or abuse. Timescale for action 31/08/06 2 YA34 Reg 19 31/08/06 3 YA23 Reg 13 (6) 31/08/06 Norfolk Lodge DS0000014640.V295328.R01.S.doc Version 5.2 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. Refer to Standard Good Practice Recommendations Norfolk Lodge DS0000014640.V295328.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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. 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