CARE HOMES FOR OLDER PEOPLE
Norbury Hall 55 Craignish Avenue Norbury London SW16 4RW Lead Inspector
Michael Williams Unannounced Inspection 12th January 2006 10:00 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.V277885.R01.S.doc Version 5.1 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.V277885.R01.S.doc Version 5.1 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 45 Category(ies) of Dementia - over 65 years of age (13), Old age, registration, with number not falling within any other category (32) of places Norbury Hall DS0000025819.V277885.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. A variation has been granted to allow 13 older persons with dementia (DE(E)); in addition there are variations in place for 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. 19th May 2005 Date of last inspection Brief Description of the Service: Norbury Hall is sited within the grounds of Norbury Hall estate and is a short distance from the town centre. The home is a residential care home registered to provide personal care for up to 45 elderly persons. It has recently changed its registration to cater for up to 13 older service users with Dementia; 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 6 double bedrooms and some bedrooms are ensuite. Norbury Hall DS0000025819.V277885.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was conducted on 12th January 2006 commencing at 10 am and was to monitor progress in meeting earlier CSCI requirements and to check the well being and safety of service users. Many of the service users and a visiting District Nurse contributed to the inspection and their helpful assistance is acknowledged. What the service does well: What has improved since the last inspection? What they could do better:
The most critical issue affecting the welfare of service users was a delay in acquiring a police check for a new member of staff. The manager gave an undertaking to postpone this person working until the required checks are in place. The home will need to recruit a senior member of staff to act as team leader in the new dementia care unit on the first floor when it is fully operational. Staffing levels must be maintained to meet these changes; for example staffing levels must be no less that required by the previous regulators; i.e. 13 day-care hours per service user per week for the older person category 32 service users in all. For the dementia care unit, 13 service users, there must be two carers on duty for all day-time shifts, one of whom must be a senior carer with relevant experience of dementia care. At night a total of three carers (on waking duty), including one on each of the two floors. Other matters include fire safety matters such as fire doors that do not fully close to their stops and a bedroom door was wedged open - which puts at potential risk both the individual service user and the remainder of the resident group. A hot radiator needs to be reduced in temperature or covered to protect residents.
Norbury Hall DS0000025819.V277885.R01.S.doc Version 5.1 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. Norbury Hall DS0000025819.V277885.R01.S.doc Version 5.1 Page 7 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.V277885.R01.S.doc Version 5.1 Page 8 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 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 is clear to prospective service users how their needs can be met if they chose to enter this home. EVIDENCE: The only key standard that applies to this section, standard 3, was assessed as met in the previous inspection and was not re-evaluated in great detail on this occasion but it was confirmed again that service users do have contracts – as minimum each service user will have the home’s in-house contract in addition to any local authority contract provided by the services of a care manager when they eventually arrive. Norbury Hall DS0000025819.V277885.R01.S.doc Version 5.1 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8 Individual plans of care are in place for all service users so as to ensure their social and health care needs can be met. Medication is administered by the care staff; rarely do service users wish to hold and administer medication themselves in this care home. Service users confirm that they are treated with respect and dignity. EVIDENCE: With the exception of standard 8 the other key standards were assessed as met in May 2005. In respect of standard 8 a number of case files were examined, staff were interviewed and a visiting District Nurse offered her observations about the support given to residents requiring wound care. A number of service users also commented upon how their health care needs are being met. Care plans are in place, risk assessments are in place for specific issues such as moving and handling risks and support required to be given to residents in matters of continence are recorded. The records also show that medical assistance is requested as required including g General Practitioners, District Nurses, Dentistry, Chiropody and so forth. This home is not registered to provide Nursing care so when a resident’s needs can no longer be met in this particular home the local care manager team is requested to assist in review residents’ needs.
Norbury Hall DS0000025819.V277885.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Service users appreciate the comfort and lifestyle provided in this care home. They maintain contact with their families and 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 and this was confirmed in the inspection. EVIDENCE: The standards in this section were all assessed as met in May 2005 and only standards 15 was re-evaluated following comments from a service user about the quality and presentation of meals. Other residents commended the cook for his homely meals. The inspector 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. Norbury Hall DS0000025819.V277885.R01.S.doc Version 5.1 Page 11 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 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 also in place to protect the vulnerable service users. EVIDENCE: No complaints arose during the course of the inspection and no complaints have been made directly to the CSCI since the earlier inspection in May 2005. At that time the CSCI checked that suitable arrangements for dealing with complaints were in place and that the home and staff were aware of how to refer untoward incidents to the local social service department. Norbury Hall DS0000025819.V277885.R01.S.doc Version 5.1 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 26 Service users live in a safe, well-maintained and comfortable environment. This is not a purpose built care home and as a rather old (and historic) building is subject to ongoing refurbishment. It was clean and comfortably warm at the time of inspection. EVIDENCE: Communal areas are pleasantly decorated and most room bedrooms are spacious. Some of the newer bedrooms have ensuite facilities and all have a range of bedroom furniture and fittings. Some furniture is now rather old and worn but the manager confirmed that a programme of refurbishment and renewal of furnishings is in place. The home was clean and tidy and free of unpleasant odour. Norbury Hall DS0000025819.V277885.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29 Whilst it was evident that service are in general safe in the hands of the staff team a delay in the completions of police checks could potentially put service users at risk. 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 (32 service users in all). For the dementia care unit (13 service users) there must be two carers on duty for all day-time shifts, one of whom must be a senior carer with relevant experience of dementia care. At night there must be a total of three carers in the home (on waking duty, not sleep-in), including one on each of the two floors. Standard 28 is now a key standard and so the inspection was used to confirm that residents are safe in the hands of the current staff team; this point is compromised by the incomplete checks of a member of staff. The documentation is in place to support care practices and the inspector observed care practices whilst on the premises and care and kindly approach was taken by staff of all levels. In one instance the necessary police checks had not been completed and in particular the POVA list check (Protection of Vulnerable Adults list) had not been checked as a minimum prior to employment. The manager gave an undertaking not to allow that person to work on the premises until such checks have been completed and are in place. Norbury Hall DS0000025819.V277885.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 33 35 38 This is a competently run care home. 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. The home is being managed so as to ensure the health and well being of the service users. In general this home is managed safely with some exceptions listed below. Arrangements are in place so as to ensure residents’ funds are accounted for correctly when held by the home. EVIDENCE: A series of satisfactory inspection reports suggests this home is competently. The service users attest to the quality of the services including personal care, catering and comfort of the setting. A sample of the home’s money records was checked and it was noted that suitable money records were in place and a audit of a sample of those records indicated they are well organised so as to protect the service users from financial abuse. The lapse in recruitment checks is critical to welfare of residents. Fire safety matters such as fire doors not closed or not fully closing are listed in the findings table must also be addressed. A hot radiator adjacent to a toilet is also a potential safety risk.
Norbury Hall DS0000025819.V277885.R01.S.doc Version 5.1 Page 15 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 X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 1 Norbury Hall DS0000025819.V277885.R01.S.doc Version 5.1 Page 16 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 OP29 Regulation 19(1)(b) Requirement Timescale for action 30/01/06 2 OP38 13(4) 3. OP38 23(4) Staff: not all new staff have had up to date Police checks so they must be supervised in accordance with the revised Regulations and Schedule 2. 28/02/06 Safety: All hot surfaces must be either set to a fail-safe temperature (43oC) or to have protective covers. Fire Safety: All fire doors must 28/02/06 be periodically checked to ensure they close fully and automatically. 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.V277885.R01.S.doc Version 5.1 Page 17 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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