Inspection on 21/05/08 for Norley Hall Care Home

This is the latest available inspection report for this service, carried out on 21st May 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Norley Hall Care Home Norley Avenue Pemberton Wigan WN5 9PL Lead Inspector Judith Stanley Unannounced Inspection 21st May 2008 09:30 X10015.doc Version 1.40 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 Norley Hall Care Home DS0000069532.V363922.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 Older People. 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. Norley Hall Care Home DS0000069532.V363922.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norley Hall Care Home Address Norley Avenue Pemberton Wigan WN5 9PL 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) 01942 224334 Millennium Care U.K. Ltd Joan Irene Stonehouse Care Home 51 Category(ies) of Dementia (25), Old age, not falling within any registration, with number other category (26) of places Norley Hall Care Home DS0000069532.V363922.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care home only - code PC, to people of either gender whose primary care needs on admission to the home are within the following categories: Older people not falling within any other category - Code OP Dementia - Code DE, maximum number of places 25 The maximum number of people who can be accommodated is 51. Date of last inspection 6th November 2007 Brief Description of the Service: Norley Hall is owned by Millennium Care (UK) Ltd and offers care for 51 residents. It is situated off the main road through Pemberton and is near to shops and other local amenities and public transport runs close by. Norley Hall offers accommodation to older people who need help and support and to people with a dementia related illness. The dementia unit is on the first floor accessible by a passenger lift. Norley Hall is a purpose built two - storey home that offers apart from one shared room all single rooms with en suites facilities with the exception of one room. There are separatel lounges and dining rooms on both floors. There are other communal rooms on both floors and a relative’s kitchen on the ground floor. Bathrooms and toilets are in close proximity to communal areas. There is outside space at the front and rear of the home for residents to sit outside and car parking is available within the grounds. The current scale of fees ranges from £274.00 - £495.00 per week. Extra charges are made for hairdressing, private chiropody and items bought from the tuck shop. Norley Hall Care Home DS0000069532.V363922.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 service is two star. This means the people who use the service experience good quality outcomes. This inspection included a site visit and was unannounced and was conducted over 6¼ hours on one day. The homes manager was available to assist with the inspection and provided the inspector with all the necessary information required. Part of the time was spent in the office looking at some of the resident’s records (care plans) and other information such as staff files and staff training and other records the home is required to keep ensuring that the home is being properly run. For the rest of the time the inspector looked around the home and spoke with residents, staff and visitors. As this was the second inspection at Norley Hall we used the same Annual Quality Assessment (AQAA) form that the home completed and returned to us for the previous inspection in November 2007. The AQAA is completed by the homes manager and tells us what the home does well and what areas they feel they could improve and develop. To gather further information about the home and the services provided we sent comment cards to residents, relatives and staff asking them what they thought about the home and the services provided. Ten residents returned comment cards. It was evident that staff had helped some residents to complete them. It was discussed with the manager, that assistance in completing cards would perhaps be more beneficial if assistance was provided by an independent person. All ten residents expressed their satisfaction about the home and the care provided. No further comments were added. Eight relatives returned comment cards, one said, “ All aspects of care are excellent”, another said, “The home is warm, the food is excellent, a good all round care home”. One relative was complementary about the staff on the dementia unit and said; “I have found the staff very caring and professional. They care for individuals and communicate well”. Fourteen staff comments cards were returned and included comments such as, ‘the care is excellent, good staff induction, staff work well as a team and staff training is good’. The inspector spoke with two visitors at the home and both were very satisfied with the care their relatives received, they had no worries or concerns. There have been no complaints made to the manager of the home and no complaints have been made to CSCI. Norley Hall Care Home DS0000069532.V363922.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Staff confirmed that there had been a lot of training including dementia care and protection of vulnerable adults training for all staff. The care plans are now more organised and contained more information about the residents and the individual care required. There is now a seating area on the corridor on the dementia unit for residents to sit and relax. A separate dining room has been created on the dementia unit away from the lounge. The garden area at the rear of the home; now has a raised flowerbed which staff said has been a great success. The other two garden plots are also to be raised to allow residents to tend to them. Norley Hall Care Home DS0000069532.V363922.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Norley Hall Care Home DS0000069532.V363922.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Norley Hall Care Home DS0000069532.V363922.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 4. Standard 6 does not apply at Norley Hall as the home does not provide an intermediate care service. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides residents and their supporters with up to date information about the home that helps them in making a decision about moving in to the home and the services provided. EVIDENCE: The home has a statement of purpose and a service user guide. This information is available to prospective residents and to residents already living at the home. The home also produces a quarterly magazine that informs residents of what’s going on in the home and any forthcoming events. The last inspection report is available in the foyer for residents and visitors to read if they wish. Norley Hall Care Home DS0000069532.V363922.R01.S.doc Version 5.2 Page 10 We selected four residents care plans for inspection, two off each floor. It was noted that these four residents had a contract in place regardless of how their care was purchased. These were kept separate from the main care plans. There was evidence to show that in the four files a pre admission assessment had been completed prior to admission to ensure the resident’s health, personal and social care needs could be met. The assessments also details and covers the residents well being, any areas of risk such as falls and mobility, bathing, dressing, personal care, medication, etc. Assessments are carried out at the most convenient place for the prospective resident either in their own home or in hospital. Staff had recently undertaking the training ‘Yesterday, Today and Tomorrow’, which is caring for people with dementia ensuring their needs can be fully met. Most of the staff achieved 100 in the examination at the end of the course. Norley Hall Care Home DS0000069532.V363922.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans were complete and concise and provide staff with the information they need to meet the needs of the residents. Personal support is offered in such a way as to promote and protect resident’s privacy and dignity. EVIDENCE: We continued to work with the same four care plans. The information contained in the care plans gave staff detailed information about the care each resident required. The information written is person centred for example, under the section on well being it says, “I am happy at the moment, I am enjoying my life”. Under mobility it states, “ I am able to get in and out of bed on my own”. Other information covers all aspects of personal care required, nutrition (all four residents had gain weight since admission), medication, records of bathing, and a social profile. Norley Hall Care Home DS0000069532.V363922.R01.S.doc Version 5.2 Page 12 Other information includes risk assessment, for example the risk of falls and mobility, pressure care, and moving and handling. There was evidence to demonstrate that outside agencies, such as doctors, district nurses, and the chiropodist are contacted and visit the home as required. The daily progress notes had been completed and showed that checks during the night are carried out every two hours, (unless someone is ill when these will be more frequent). The time of the checks was documented and information added as required. Observation throughout the inspection showed that the personal care needs of the residents were being met. Attention was given to all residents personal grooming, resident’s were seen to be clean and clothes nicely laundered, and coordinated. Ladies had had their hair done by the hairdresser and the gentlemen were clean-shaven. Staff were observed and heard speaking with the residents in a respectful and friendly manner. It was evident that good relationships had been formed. Staff were seen offering assistance to residents as necessary in a discreet and sensitive manner. All medication is administered by a person who is trained to do so. The MAR sheets (drug sheet) were checked for the four people whose care plans we were looking at and these had been completed as required. Norley Hall Care Home DS0000069532.V363922.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are offered a wide and varied range of activities to meet their capabilities and expectations. EVIDENCE: The homes deputy manager and a member of the care team oversee the activities and with the help of the residents plan a wide range of indoor and outdoor activities. During the inspection one lady was knitting, another gentleman was reading, a group of residents were enjoying a game of dominoes. Some of the residents and their relatives were joining in some gentle armchair exercise. One of the carers who set up the Karaoke machine was involving the residents who were singing and dancing and appeared to be enjoying themselves. In the garden at the rear of the home a raised flowerbed has been built, this allows staff and residents to work outside weeding and planting without having to bend down. There are another two garden plots, which staff hopes can be Norley Hall Care Home DS0000069532.V363922.R01.S.doc Version 5.2 Page 14 raised to allow more residents to be involved. The raised garden was colourful and had lots of different smells such as lavender and mint. Staff spoken with said it had been a great success and got the residents involved and outside in the fresh air. Residents of both floors are encouraged to join in the activities. The home has also a computer and some staff and residents are having a go to master their IT skills. The home welcomes visits from the local clergy who visit the home on a regular basis and offer a short service and communion for those residents who wish to partake. Visitors are welcome to at any time; there are no restrictions as to when people can visit. Some visitors were chatting with their relatives in the lounge whilst another went to the resident’s room. There is a relative’s kitchen on the ground floor so visitors can help themselves to refreshments. The inspector spoke with one visitor who said, “The home and staff are wonderful, I have no complaints about anything”. The menus were looked at in the kitchen and it was noted that there was an ample and varied selection of food available. A choice of breakfast dishes was available including cereals, porridge, toast and preserves and tea or coffee. A cooked breakfast is available if requested. A lighter lunch was served of soup and rolls and a choice of sandwiches, followed by a dessert of apple crumble and custard or fresh fruit. A roast pork dinner with trimmings was to be served at dinnertime. The chef confirmed that there were always plenty of alternatives if residents fancied something else. A range of drinks and snacks was available during the day. Suppers are available including toast, crumpets, teacakes, Horlicks, hot chocolate etc. Norley Hall Care Home DS0000069532.V363922.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives can have confidence that any complaints or concerns will be listen to and appropriately dealt with. EVIDENCE: A complaints procedure exists within the home and any complaints would be properly recorded along with the outcome. There has been no complaints made to the manager of the home and none have been forwarded to CSCI. There has been one adult safeguarding issue since the last inspection this was suitably dealt with by the manager. Staff have received training in the protection of vulnerable adults and the staff have access to the local councils adult safeguarding procedure. Norley Hall Care Home DS0000069532.V363922.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Norley Hall is maintained to a good standard making it a homely, comfortable, clean and pleasant home for residents to live in. EVIDENCE: From a tour of the premises, it was evident that the home is maintained to a good standard both internally and externally. The lounges are comfortable and bright and are well equipped with TVs and music centres. The conservatory at the front of the home is well furnished and provides residents with a quieter area away from the hub of the home. Norley Hall Care Home DS0000069532.V363922.R01.S.doc Version 5.2 Page 17 Several bedrooms were looked, these were seen to be clean and tidy and well furnished with colour coordinated bedding, curtains and carpets. The rooms are of a good size and offers space for residents to personalise them with their own belongings brought with them from home. The bathrooms are decorated in a domestic style so as to offer a relaxed atmosphere when bathing. The outside of the home is well maintained and the grounds were neat and tidy. Systems are in place to control the risk of cross infection. Staff were seen wearing different protective clothing for different tasks. Staff do enter the kitchen area without wearing an overall over their uniforms. The laundry is sited away from food preparation and food storage areas and does not intrude on the residents. The home was clean and no offensive odours were detected. Norley Hall Care Home DS0000069532.V363922.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be sure that their needs can be met by good staffing levels and with a competent, committed, experienced and a well-trained staff team. EVIDENCE: The staff rotas showed that there are sufficient numbers of staff on duty each day and through the night. The ratios of care staff to residents takes into account the needs of the residents. Neither staff nor residents expressed concerns about staffing levels within the home. Domestic and kitchen staff are employed in sufficient numbers to cater for the residents and to support care staff. From the inspectors’ observations, staff morale appeared to be good and the staff team genuinely appeared happy to be working at the home. A full copy of each members of staff’s employment file is kept in the home in a secure location. The file of the last most recently recruited member of staff was looked and was complete and up to date. We looked at another two staff Norley Hall Care Home DS0000069532.V363922.R01.S.doc Version 5.2 Page 19 files and there was evidence of an application form, a Criminal Records Bureau check, two references and other forms of identification. All staff undertakes a full induction programme on commencement of work. Other staff have undertaken training in dementia, protection of vulnerable adults, fire safety, COSHH, and basic food hygiene. Staff were able to describe the training as good and relevant to their roles. Norley Hall Care Home DS0000069532.V363922.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can be sure that their best interests will be the central focus, with a positive and inclusive approach to making the service better. EVIDENCE: The homes manager has been registered in post for seven months and appears to have settled well in her role. Staff spoken with was complementary about the manager, one member of staff said, “She is great and very supportive”, another said, “ We have a really good manager in charge here”. Norley Hall Care Home DS0000069532.V363922.R01.S.doc Version 5.2 Page 21 The manager is suitably qualified and has a number of years experience in working with elderly people. The home’s manager is committed to her own training and that of her staff and sees this an essential element to delivering good quality care for residents. The way in, which the home is managed, is open and transparent. The homes manager operates an ‘open door’ policy so that she may be approached at any time by staff, residents or their families. The office was well organised so that staff have access to all the paperwork and contact information they need during a shift. Systems are in place for continuous monitoring in the home, which includes, satisfaction questionnaires, staff and residents meetings, and regular audits. The owner of the home spends a lot of time on site, and as required by regulation completes a monthly report of his findings. These were not available for inspection as they were locked away in the administrator’s office. The administrator was off site but did offer to come back to the home with a key. The inspector deemed this not necessary and the reports will be examined at the next inspection. The manager, for some residents holds small amounts of money for safekeeping. Using the same four residents whose care plans we had looked at, checked any money held. All transactions had been recorded and the balance sheets were correct. As this is a new home all the necessary safety equipment, gas and electric certificates, fire detection systems and certificates for the lift and hoists are still valid. The manager keeps the CSCI informed of any significant events that occur within the home and inform us any accidents, injures or incidents that affect the well-being of the residents. Norley Hall Care Home DS0000069532.V363922.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x 3 x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Norley Hall Care Home DS0000069532.V363922.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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 Norley Hall Care Home DS0000069532.V363922.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU 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 Norley Hall Care Home DS0000069532.V363922.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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