Inspection on 19/05/05 for Norbury Hall

This inspection was carried out on 19th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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

Norbury Hall 10/01/08

Norbury Hall 02/11/06

Norbury Hall 12/01/06

Norbury Hall 07/02/05

Norbury Hall 05/05/04

Similar services:

Spinney (The)

Queen Elizabeth House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Norbury Hall 55 Craignish Avenue Norbury London SW16 4RW Lead Inspector Michael Williams Unannounced 19th May 2005 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 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 G53-G53 S25819 Norbury hall V229031 190505 stage 0.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Norbury Hall Address 55 Craignish Avenue, norbury, London, SW16 4RW Telephone number Fax number Email 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 46 Category(ies) of Old Age, not falling within any other category registration, with number (46) of places Norbury Hall G53-G53 S25819 Norbury hall V229031 190505 stage 0.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7/2/05 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. There are now 45 places; 33 places single and 6 double bedrooms. Some bedrooms are enuite. Norbury Hall G53-G53 S25819 Norbury hall V229031 190505 stage 0.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection, in May 2005, was to confirm the changes in Norbury Hall’s registration categories and to add conditions of registration in respect of service users whose conditions fall outside the main registration categories but whose needs can still be met in the home. The inspection was conducted at the time of the midday meal and service users said how nice the food was, they also commended the staff for their kindness. The home was clean and tidy and free of observable hazards at the time of inspection. What the service does well: What has improved since the last inspection? What they could do better: The next phase of work for the home is to ensure staff receive appropriate training and support so as to ensure they can meet the needs of the new service users. The home is recruiting a senior member of staff to act as team leader in the new dementia care unit on the first floor. Staffing levels need to be modified to meet these changes. Staffing levels must be no less that 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 a total of three carers (on waking duty), including one on each of the two floors. Norbury Hall G53-G53 S25819 Norbury hall V229031 190505 stage 0.doc Version 1.30 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 G53-G53 S25819 Norbury hall V229031 190505 stage 0.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Norbury Hall G53-G53 S25819 Norbury hall V229031 190505 stage 0.doc Version 1.30 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 standard(s) 3 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 and it is made clear to them how their needs can be met. EVIDENCE: The assessments include general information about each service user, details of their background medical and social history and comprehensive details of specific areas such as dietary needs, mobility, medication and so forth. Service users, with help of their representatives, assist in the compilation of these case notes. Norbury Hall G53-G53 S25819 Norbury hall V229031 190505 stage 0.doc Version 1.30 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 standard(s) 7, 9 10. Individual plans of care are in place for all service users. 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: The care plans include details of social and health-care needs. A sample of case notes were checked and it is clear that care needs are being monitored and appropriate intervention provided either by the care or by involving professional agencies such as the General Practitioner or hospital specialists such as the District Nurse or Diabetic advisor. During the course if the inspection no service users were identified as self-medicating but nursing staff will support them if they wish to do so. Provision is made to ensure service users’ right to privacy, (including for example staff training and the provision of curtains and door locks and private areas to meet visitors). Several service users said they are treated with respect and kindness by staff. Norbury Hall G53-G53 S25819 Norbury hall V229031 190505 stage 0.doc Version 1.30 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 standard(s) 12, 13 14, 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 is confirmed in the inspection. EVIDENCE: A programme of activities is provided, frequently lead by the co-proprietor Mrs. Dhir. This is a care home so many of the service users are now quite aged somewhat dependent and vulnerable so the exercise of choice and control of their daily lives is inevitably restricted but within those constraints the home offers a typical range of choices such as choice of meals, of activities, the time they rise and retire to bed, where and with whom they sit each day. Norbury Hall G53-G53 S25819 Norbury hall V229031 190505 stage 0.doc Version 1.30 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 standard(s) 16, 18. 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 this inspection. Staff are aware of their responsibility to protect service from abuse and to report untoward incidents to the correct authorities. Norbury Hall G53-G53 S25819 Norbury hall V229031 190505 stage 0.doc Version 1.30 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 standard(s) 19, 26 Service users live in a safe, well-maintained and comfortable environment. This is a purpose built care home and 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 G53-G53 S25819 Norbury hall V229031 190505 stage 0.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29, 30. The purpose of this inspection was to confirm the new staffing arrangements requirement to meet the needs of a new service user category. Agreement has been reached between the proprietor and CSCI and minimum staffing levels have been agreed. EVIDENCE: As outlined in the summary the staffing levels need to be increased a little to take account of the different needs of two distinct client groups and to allow for the different settings in which they will be cared for, older persons on the ground floor and those with dementia on the first floor. Staffing levels must be no less that 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. Norbury Hall G53-G53 S25819 Norbury hall V229031 190505 stage 0.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 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. No health and safety hazards were identified. EVIDENCE: A series of good inspection reports suggests this home is well run. The service users attest to the quality of the services including personal care, catering and comfort of the setting. Money records were not checked on this occasion but in previous inspection 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. No hazards were identified on this occasion and those identified in previous inspection have been eliminated such as the use of wheelchairs without footrests (unless the service is able to self-propel and is doing so). Norbury Hall G53-G53 S25819 Norbury hall V229031 190505 stage 0.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 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 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 3 x x x 2 3 Norbury Hall G53-G53 S25819 Norbury hall V229031 190505 stage 0.doc Version 1.30 Page 16 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 6(a)(b) Requirement Timescale for action 30/8/05 2. OP37 17 3. 19 23(2)(b) 4. 29 19(1)(b) Statement of Purpose: requires further revision to provide all the details listed in Schedule 1 of the regulations, including staffing details; room sizes and to make clearer to whom complaints can be made and agreed changes to registration. The timescale is extended from 30/5/05 to take account of chages to registration categories. Care: the service users’ case 30/8/05 files must be checked to ensure they all contain the details listed in schedule 2 of the regulations. This previous requirement was underway at the time of inspection, the timescale is extended. Environment:worn out furniture 30/8/05 was seen in the home so a requirement is made that all furniture and fittings be maintained in good repair; an ongoing requirement that is underway. Staff: not all staff have had up to 30/8/05 date Police checks so they must be supervsion in accordance with the revised Regulations and Schedule 2 Version 1.30 Norbury Hall G53-G53 S25819 Norbury hall V229031 190505 stage 0.doc Page 17 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Norbury Hall G53-G53 S25819 Norbury hall V229031 190505 stage 0.doc Version 1.30 Page 18 Commission for Social Care Inspection CSCI 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 © 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 Norbury Hall G53-G53 S25819 Norbury hall V229031 190505 stage 0.doc Version 1.30 Page 19 - 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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