CARE HOMES FOR OLDER PEOPLE
Norbury Hall 55 Craignish Avenue Norbury London SW16 4RW Lead Inspector
Michael Williams Key Unannounced Inspection 09:30 10th January 2008 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 Norbury Hall DS0000025819.V355180.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. Norbury Hall DS0000025819.V355180.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Norbury Hall Address 55 Craignish Avenue Norbury London SW16 4RW 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) 020 8764 9164 020 8679 9636 Norbury Hall Residential Care Home Limited Mr Vijay Kumar Dhir Care Home 47 Category(ies) of Dementia - over 65 years of age (27), Old age, registration, with number not falling within any other category (20) of places Norbury Hall DS0000025819.V355180.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. A variation has been granted to allow two specified service users in the Learning disability - over 65 (LD(E)) category and one specified service user in the Mental disorder (MD) category to be accommodated. 2nd November 2006 Date of last inspection Brief Description of the Service: Norbury Hall is sited within the grounds of a public park, which was part of the old Norbury Hall estate. It is a short distance from the town centre. The home is a residential care home registered to provide personal care (not nursing care) for up to 47 elderly persons. It has changed its original registration to cater for up to 27 older residents with Dementia and they are cared for within the older part of the premises whilst the newer wing caters for residents who do not have dementia - in this way both groups of residents can be looked after without one group impinging upon the other. Each group of residents has their own facilities including separate lounges, dining rooms and bathing facilities. In practice most residents use the main lounge and dining room as matter of choice. There are also conditions of registration in respect of other specific service users. Accommodation in the home includes bedrooms on the ground floor and the first floor; 33 places single and 7 double bedrooms and some bedrooms are ensuite. Fees as at January 2008 are from £400 to £600 each week. Norbury Hall DS0000025819.V355180.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 1 star. This means the people who use this service experience adequate quality outcomes.
This visit was conducted on 10th January 2008 and included the distribution of questionnaires to residents, their relatives, and professional visitors and to staff in the home. The visit lasted from 9:30 am until 7 pm and residents were given the opportunity to talk to the inspector; several relatives were visiting on this day and they most helpfully commented on the services provided in this care home. Comments were also received from a Community Nurse who was on site during our inspection. In addition to speaking to the various people on site we also toured the building and checked the documentation required to be maintained by care homes. What the service does well: What has improved since the last inspection?
The home has been addressing the 4 requirements that arose in the previous inspection in November 2006. The Statement of Purpose details the new arrangements for admitting service users under the revised registration
Norbury Hall DS0000025819.V355180.R01.S.doc Version 5.2 Page 6 category of dementia care. The home no longer has the small lounge on the first floor, instead the home is divided for the purposes of care into two areas; the main, older part of the home is for people with dementia whilst the newer wing is for those who do not have dementia. This is so that residents with dementia may be cared for in a more private setting to preserve their dignity and for the comfort of other service users who may choose not to spend the day with those residents with greater dependency. A programme of gradual refurbishment is underway, so that for example the corridor has been repainted and the owners intend replacing the old lino’ in the dining area with a more modern wooden style flooring - but this work had not been started at the time of our inspection. A senior member of staff, related to the owners, had introduced training packs for areas of work that include catering, dementia and challenging behaviour. If they are followed-through as consistently as we are told they are, they look very helpful training aids. What they could do better:
Four items of safety were identified on the day of our visit and we issued ‘immediate requirements, which require the home to make things safer for residents without delay, that is within 48 hours. Bath-water in one of the bathrooms was 48oC (above 43oC regarded as the safe temperature) and a radiator close to another bath was also 48oC. Other radiators were cooler but they remain uncovered and this is a risk because it is possible they too may become too hot; particularly as many of the thermostatic valves on the radiators were broken. We also found a bedroom door, a fire resistant door, was not closing fully and the integrity of the door was compromised by having a hole in it so these two points comprise the second two immediate requirements. We checked standards of catering and note that an Environmental Health Officer [EHO] visited last year and their recommendations are being followed up, for example, by using a nationally accepted form for recording food and hygiene readings. Only two matters of concern were identified when we checked the kitchen in January; there were two tins of food past their safe use-by date - indicating that not enough attention was being given to stock rotation and secondly, the large fridge in the kitchen has a broken handle and the broken area was dirty. This has the potential to contaminate food. In other respects the kitchen appeared to be operating smoothly and safely and residents commended the meals. In respect of the environment; in 2006 we noted that commodes were being cleaned in the laundry area. The sluice machine was not at that time working properly we were told. Since then the owners have chosen to remove the enclosed mechanical sluice and replace it with an open sluicing sink. Whilst there is no requirement to have an enclosed mechanical sluicing machine (to ensure commodes are thoroughly and effectively cleansed to avoid crosscontaminate and infection), this does seem to be a retrograde step. We are
Norbury Hall DS0000025819.V355180.R01.S.doc Version 5.2 Page 7 told that sluicing of commodes no longer takes place in the home’s laundry area. Although the owners are replacing old and worn furniture there are still some damaged items that need to be removed including chair, chest drawer, wardrobe and so forth. Some items are the property of residents. Other details have been overlooked such as torn curtain and an over-bed light not working. It is suggested the home use a maintenance book and that staff are encouraged to use their initiative and report any shortcomings in the rooms where they support residents. Record keeping in the home was generally to an acceptable standard but care plans were rather limited in scope; repeatedly they refer to plan 1, “person hygiene” and care plan 2 reads, “motivation and stimulation”. There were other care plans but this was common. Not surprisingly with this very limited care planning the outcomes for residents were also recorded as being very limited; for example, “she [the resident] had a bath today” with no indication that any other activity or ‘stimulation’ had taken place for the resident. We also note a lack of detailed information about end-of-life care. There were 12 death reported to the Commission in 2007 and so we would expect greater attention to residents last wishes and planning for this final stage to be in place. We note however that the families of residents who have died have commended the care provided by the home. Whilst the staff files we checked were generally to an acceptable standard, all staff have had a police check [CRB] we were told, however, the staff training records need to be brought up to date so it is possible to check which staff have had what training. We took verbal evidence from the owners, and from the care staff themselves, that staff have been trained in key areas of their work. 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. Norbury Hall DS0000025819.V355180.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 Norbury Hall DS0000025819.V355180.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): NMS 3 (key standard 6 does not apply to this care home): Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. Pre-admission assessments are in place for each service user and form the basis of the initial care plan and risk assessment. This ensures the care, including health care, needs of service users are assessed prior to admission so it is clear to prospective service users how their needs can be met if they choose to enter this home. EVIDENCE: The only key standard that applies to this section is standard 3 and this standard has been assessed again as being as it been in previous inspections and so it was not fully re-evaluated in great detail on this occasion but it was confirmed that service users do have information including a contract. As a minimum, each service user will have the home’s in-house contract in addition to any local authority contract provided by a care manager when they eventually arrive. A copy of the Service User Guide is also available for each resident. Residents and relatives confirmed that they had an opportunity to visit the home prior to admission and have agreed to a ‘trial period’ before deciding to stay.
Norbury Hall DS0000025819.V355180.R01.S.doc Version 5.2 Page 10 The home is commended for liaising with the commission and local authority care mangers before admitting residents with unusual or complex needs. Areas of strength are information provided and the pre-admission assessments and as no matters requiring improvement arise this section, about choice, is assessed as good. Norbury Hall DS0000025819.V355180.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): NMS 7 to 11: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans are in place for residents but not very detailed so they do not entirely ensure their social and health care needs can be fully met. Residents confirm that they are treated with respect and dignity. Medicines are being handled safely. Families say ‘end of life care’ is good in this home but there is little documentation to reflect this. EVIDENCE: Residents have access to health care services both within the home and in the local community. Residents are visited regularly by a GP and either attend local dentists, opticians and other community services or, more usually these services call to the home to see residents. A visiting Community Nurse confirmed this was the case and advised the commission that she was happy with the service in so far as she could judge by her limited contact with the home and from her contact with the several residents whom she supported. Health needs are monitored and appropriate action and intervention taken and this is being recorded in the daily notes. The home is able to provide the aids and equipment recommended, for example resident who need an alternating Norbury Hall DS0000025819.V355180.R01.S.doc Version 5.2 Page 12 air-flow mattress can be provided with one from the community occupational therapy service. There is a record of general health care information and evidence in the Care Plans of health and social care intervention. However these care plans are very limited and repetitive, confined not infrequently to one on ‘Hygiene’ and another on ‘Motivation and stimulation’. So they are not very ‘person centred’ nor individualised, they could apply to anyone at any time. The daily notes are equally bereft of detail; a common entry to describe a resident’s entire day, even a week, is, “3/4/07, [resident] had a nice bath today”. In one folder the entry was repeated 21 times in what are called the ‘continuous evaluation’ notes for a resident. This is not to imply bathing was the only activity residents experienced but it was the only ‘activity’ recorded in some of the files we checked. The home has a medication policy which is accessible to staff, medication records were up to date for each resident and medicines received, administered and disposed of are being recorded we were advised. There was no evidence of any residents administering their own medication. Staff are aware of the need to treat individuals with respect and to consider dignity when delivering personal care and both residents and their visitors commended the staff for their approach. The home has a training plan and intends to train its staff in health care to and we were shown examples of a detailed in-house training programme dealing with dementia for example. Residents are happy with the way that most staff deliver their care and respect their dignity. Since this is a home for elderly, frail residents it is not unusual for the commission to have received notifications of the deaths of 12 residents in 2007. As with care plans, end-of-life care is not well documented in the residents’ case files. The introduction of the new Mental Capacity Act affords an opportunity to address this shortcoming so as to take account of any ‘advance directives’, last wishes and decisions about treatment and resuscitation as well practical details about who may have the new form (Lasting) Powers of Attorney and resident’s last wishes. The resident, family and doctors should be involved in the planning so that residents do not spend their last days in hospital unnecessarily, “Be spared from further medical procedures” as one family member put it. The wishes of individuals about terminal care and arrangements around the time of impending death is not always recorded, but staff were able to give an account of the arrangements. Letters from relatives indicate this sensitive area of work is being handled well. Areas of strength include the many commendations from residents, “It is fine here”, and from relatives about the home and care staff, “Their tremendous kindness and care”. Matters needing improvement include care planning, daily notes and planning for end of life care. This section, about health and social care, is assessed as good. Norbury Hall DS0000025819.V355180.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 to 15: Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. Service users appreciate the comfort and lifestyle provided in this care home. They maintain contact with their families. So residents are given every opportunity to exercise choice and control commensurate with their health and abilities. Service users say the meals are very nice in this home. EVIDENCE: As we have observed in previous reports, the most important aspect of this section is that the residents say they are happy in Norbury Hall, though many were unable to express a clear opinion because of their failing memory. This reflects the quiet, tranquil atmosphere evident during this visit. There is ample space for residents to sit where and with whom they please. It was suggested in 2006 that greater use is made of the layout of the ground floor to separate the Dementia Care Unit from the newer wing of Norbury Hall - where most residents without dementia reside. This suggestion has been taken up, so now residents have a choice - but often choose to sit in the larger lounge and dining room rather than the newer, quieter lounge/dining area. This area has been called the ‘Norbury Wing’ but may change after consultation with residents and visitors. It is expected that a care home will support residents to maintain links with their family, friends and the wider community and this appears to be the case.
Norbury Hall DS0000025819.V355180.R01.S.doc Version 5.2 Page 14 Visitors are welcomed and representatives from the community come in regularly including church members and entertainers. Several visitors were on site to confirm that they may visit freely and are welcomed by staff. One visitor is always welcomed for his hearty rendition of popular hymns. In respect of diversity, the manager advised the inspector that all residents use English as their language of choice although one or two are not English by birth. Other aspects of diversity were discussed such as the accommodation of residents who may sensory or mobility problems – the home seeks to meet such needs whenever possible. Matters of sexual diversity have been also discussed and the manager said residents will be treated with tolerance and forbearance whatever their lifestyle or sexual orientation. The manager and staff do have some training and experience in dementia care; this has been largely in-house. For example, we were shown a training manual, which a senior member of staff is using to train staff - if it is followed through it will at regular intervals it will provide very detailed and thorough knowledge of the special needs of people with dementia. We also recommended that the home establish contact with the Alzheimer Society, and other experts, for advice on caring for people with dementia - with particular regard to recreation, occupation and sustaining mental skills - and for their advice on supporting the relatives of people with dementia and the senior involved in training has taken up the suggestion, for which she is commended. The manager and staff were reminded of the provisions of the new Mental Capacity Act, which will help identify residents’ capacity to make day-to-day decisions such as those affecting their rights to have a bedroom door key. The inspector also checked the kitchen and in particular confirmed that fresh fruit and vegetables are available and were served for the midday meal to an acceptable standard. The manager confirmed that if and when a resident requests meals to be provided in a particular manner the cook works hard to meet those requests - and this appeared to be the case on the day of inspection. The service of meals had been very protracted in the past but on the day of inspection it appeared that most residents were waiting no more than about a quarter of an hour for their meal to come to the table. It was again noted that all the meals were plated in the kitchen – this gives residents limited choice of meal or quantity at the point of delivery but residents are however given a choice earlier in the day. We checked the kitchen and catering arrangements and whilst in general standards are acceptable we noted two problems requiring attention, firstly two tins of food were past their use-by date and the handle to the large fridge in the kitchen was broken and dirty; this would contaminate the hands of the cook when using the fridge. Areas of strength include residents’ opinion that this is a lovely setting for them to be cared for in and the efforts the staff make to ensure residents are happy and comfortable. Matters requiring improvement include the need to keep food stocks in-date and maintain kitchen equipment in good, clean order. This section, about daily life, is assessed as good. Norbury Hall DS0000025819.V355180.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): NMS 16 and 18: Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place for service users and their representatives to either complaint or compliment the service. Effective procedures are in place to deal with complaints. Arrangements are in place to protect vulnerable residents. EVIDENCE: No complaints arose during the course of the inspection and no further complaints have been made directly to the Commission since the earlier inspection in November 2006. Suitable arrangements for dealing with complaints were in place and the manager and staff were aware of how to refer untoward incidents to the local social service department. An example of good practice was underway when we inspected in so far as an unexplained injury, identified when residents came to the home from hospital, was referred to the local authority care management team so that it could be investigated thoroughly. The home has ample evidence of letters of thanks from many relatives, several on display in the corridor. This can be regarded as ‘customer satisfaction’ feedback. Areas of strength are the procedures for dealing with complaints and representations and as no matters requiring improvement arise this section, about complaints and protection, is assessed as good. Norbury Hall DS0000025819.V355180.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 and 30: Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Service users live in a mainly safe, well-maintained and comfortable environment. This is not a purpose built care home and as a rather old (and historic) building it is subject to ongoing refurbishment. It was clean and comfortably warm at the time of inspection. Unsafe areas are listed under health and safety in the management section of this report. EVIDENCE: Communal areas are pleasantly decorated and many bedrooms are spacious. Some of the newer bedrooms have ensuite facilities and all have a range of bedroom furniture and fittings, however some of the furniture is now rather old and worn. The manager confirmed that a programme of refurbishment and renewal of furnishings is in place. It was noted that some furniture and fittings in the bedrooms, chests of drawers and curtains, need repair or replacing as soon as practicable, we photographed these items to follow up and make sure they are replaced. Chairs that are damaged must also be replaced. We required similar improvements in 2006. We accept the owner’s explanation
Norbury Hall DS0000025819.V355180.R01.S.doc Version 5.2 Page 17 that he has replaced some furniture and fittings but more now need to be renewed and for that reason the requirement will be restated. We also note that Mr Dhir has advised us that much of the older furniture belongs to residents and not the care home itself. The lino-type floor is now quite unsightly and the owners tell us that this will be replaced ‘very soon’ with wood flooring. Although the home was clean and tidy and free of unpleasant odour two matters of hygiene arise. The mechanical sluice was broken, it has been replaced with an old style open sluice sink. Whilst there is no absolute prerequisite to have an enclosed mechanical sluice this seems a retrograde decision for the owners to have taken, since an enclosed sluice would reflect best practice for good hygiene and infection control. We have been assured that staff no longer wash commodes in the laundry area and that they have supplies of gloves and aprons. One bedroom door was not closing fully to its stop and had a small hole in surface mounted fire retardant panel. These problems may reduce its effectiveness in resisting smoke and fire. A radiator was too hot in one of the bathrooms and as it is near to both the bath and hand wash basin was a serious hazard to residents undressed and bathing. Other radiators though not as hot did have broken thermostatic valves and could potentially become hot and scold a resident. The laundry room remain unchanged and is very small and as the dependency of residents increases so will the pressure on laundry services so the home may need to reconsider laundry arrangements. Areas of strength are nice setting and spacious communal facilities and matters requiring improvement are fire safety, radiator safety, general decor, old furniture, and matters of hygiene and chemical storage and maintenance of equipment. In view of the safety issues a home that is otherwise very comfortable is assessed as poor. Norbury Hall DS0000025819.V355180.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 to 30: Quality in this outcome area good. This judgement has been made using available evidence including a visit to this service. The number of staff employed and their skill mix are appropriate to the assessed needs of the current service users in this home – so this will ensure that their needs are being met. The required procedures are in place to ensure recruitment of staff protects service users. The home has a staff induction, training, support and supervision regime in place so service users can be assured that staff are competent in their jobs. The recruitment, training and support of staff is in place so service users may feel they are ‘safe in their hands’. EVIDENCE: Staffing levels must be no less than required by the previous regulators; that is, 13 day-care hours per service user, per week for the older person category and 15 day care hours per service user to care for those with dementia. The manager has now made sure all staff have the correct police and other checks before employing staff including those from overseas. Whilst noting that foreign staff bring with them skills and qualifications the quality of spoken English is not as good as might be expected in a care setting, and this is particularly true when residents are forgetful and confused. It is acknowledged that the manager says he encourages these foreign staff to attend courses designed for people whose first language is not English. Norbury Hall DS0000025819.V355180.R01.S.doc Version 5.2 Page 19 The manager and staff were reminded of the provisions of the New Mental Capacity Act, which will help identify residents’ capacity to make day-to-day decisions. In respect of staff training the member of the Dhir family has joined the staff team as a senior member of staff with specific administrative and training roles. Her enthusiasm and skills are noted, particularly the introduction of inhouse training manuals that will provide a guided and thorough preparation in dementia care for the staff team It is therefore unfortunate that we could not track the training so far provided nor the training plan for the coming months as the recording of this was out of date and not well coordinated with no matrix of training, either computer based or in paper form. The staff files did not help us in trying to monitor who has had what training although the staff themselves advised us they have received training for a variety of areas such as fire safety, moving and handling, dementia care and so forth. Without this information it was not possible to verify that 50 of care staff have been trained to at least NVQ level. Policies and procedures have been checked in the past but were not re-examined on this occasion. Areas of strength are improvement in recruitment practices and the dementia care training and the owners are monitoring staff language; we recommend improving the records of staff training. This section, about staffing, is assessed as good. Norbury Hall DS0000025819.V355180.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, 35, 37 and 38: Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager, who is also one of the owners, has been assessed by the regulatory authorities as competent and fit to manage this home. Although largely a competently run care home there are some serious safety issues that mean residents cannot always be assured that the home is being managed so as to ensure the health and well being of the service users. The exceptions are listed below. EVIDENCE: A series of satisfactory inspection reports suggests this home can be competently run but not without some lapses in standard from time to time. The service users attest to the quality of the services including personal care, catering and comfort of the setting. The lapse in recruitment checks identified in the previous inspections was critical to the welfare of residents but has now Norbury Hall DS0000025819.V355180.R01.S.doc Version 5.2 Page 21 been corrected, although training records need to be updated to demonstrate that staff have the skills and competency to care for residents. A range of records were checked including food records; medication; residents’ files; staff files; complaints; accidents; incidents; fire safety and visitors record book. Record keeping is to an acceptable standard in this care home. The records used to account for residents’ money held by the home has been checked on several occasions and the system appears sound. A number of safety matters were identified and which pose immediate risks with the potential to harm residents and so ‘immediate requirements’ were made to correct these matters within 48 hours. They include fire safety matters such as a fire door not fully closing and it had a hole that reduced its capacity to prevent the spread of fire into a resident’s bedroom. A bath and a radiator both were checked and found to have a temperature above the recommended 43oC. Both were measured at 48oC. Prior to this inspection, in 2008 we had previously noted, for example in our report of November 2006, that the owners had chosen not to cover or box-in the old cast-iron radiators (as most care homes have now done); instead they relied upon keeping the temperature of the radiators at a safe level. On this occasion it was clear this is not always an effective way to safeguard residents. In the kitchen we found two tins in the dry-food store that were past their safe use-bay dates, they were dated ‘Sep 2007’ and ’10 2007’, a potential food hazard risk. The large fridge in the kitchen had a broken, and dirty, handle posing a contamination risk. These safety matters are of course in the control of the management team and do not reflect a well managed service. The owners have advised the Commission that they will respond to the immediate safety requirements without delay and have sent us documentary evidence to support this. Areas of strength; the home appears to be run in a reasonably satisfactory manner and matters requiring improvement are fire safety, kitchen hygiene matters and the general maintenance of the environment (such as furniture and curtains). This section, about management and administration, is assessed as adequate. Norbury Hall DS0000025819.V355180.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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 2 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 1 X X X X X X 2 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 2 X X X 3 X 3 1 Norbury Hall DS0000025819.V355180.R01.S.doc Version 5.2 Page 23 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 OP7 Regulation 15 Requirement Timescale for action 30/03/08 2 OP11 15 3 OP26 OP38 16(2)j Care plans: it is required that care plan be more ‘person centred’ and provide clearer details about each individuals residents’ particular needs and that the daily recordings demonstrate how those needs being met. This is so residents will know that their personal needs are known and addressed. 30/03/08 End of life care: It is required that the care plans provide more detail of the residents’ last wishes, their decisions about end of life, what family involvement is expected and what medical treatment is required or not required at the later stage of life, including any ‘living wills’ and provisions under the Mental Capacity Act. This is so residents know in advance that their wishes will be taken into account when they can no longer make their needs known. Safe cooking: All out date food 28/02/08 must be removed. This is so residents to not risks food poisoning.
DS0000025819.V355180.R01.S.doc Version 5.2 Norbury Hall Page 24 4 OP28 18(1)a Staff qualifications: The must 30/03/08 ensure that a suitable proportion of care staff have a relevant qualification in the care of people with dementia to at least NVQ Level 2. Records must be maintained so the commission can confirm this is the case. This is so residents will know that they are being cared by staff team that has the necessary skills and competence. This remains an outstanding requirement from 30/06/07. Fire safety: A fire door had a hole in it and was not closing fully. An immediate requirement was issued on the day of inspection requiring this to be corrected without delay so that residents are safe. Hot water and surfaces: bathwater measured at 48oC a radiator near a bath was also 48oC; so as to protect residents, an immediate requirement was issued to reduce risk of scolding residents by maintaining water and radiators at a safe temperature at all times. Premises: The furniture and fittings and the décor of the home must be maintained to a reasonable standard in all areas. This requirement is restated because more fittings need to be replaced. Premises: Radiator valves must be refitted where they are broken without delay this is so residents can control room temperature and reduce risk of scalding. 12/01/08 5 OP38 23(4) 6 OP38 23(4) 12/01/08 7 OP19 23(2)b 30/03/08 8 OP19 23(2)b 30/03/08 Norbury Hall DS0000025819.V355180.R01.S.doc Version 5.2 Page 25 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 Norbury Hall DS0000025819.V355180.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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
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