Inspection on 02/06/06 for Norfolk House

This inspection was carried out on 2nd June 2006.

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

Norfolk House 29/11/06

Norfolk House 26/07/06

Norfolk House 31/10/05

Norfolk House 25/04/05

Norfolk House 23/11/04

Norfolk House 07/06/04

Norfolk House 15/01/04

Similar services:

Springfield House

Sutton Lodge Nursing Home

The Shelley

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Norfolk House 39 Portmore Park Road Weybridge Surrey KT13 8HQ Lead Inspector Mavis Clahar Unannounced Inspection 2nd June 2006 09:00 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 Norfolk House DS0000017628.V301081.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. Norfolk House DS0000017628.V301081.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norfolk House Address 39 Portmore Park Road Weybridge Surrey KT13 8HQ 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) 01932 820300 Ashbourne Homes Limited Mrs Elizabeth Werrett Care Home 76 Category(ies) of Old age, not falling within any other category registration, with number (76), Physical disability over 65 years of age (3) of places Norfolk House DS0000017628.V301081.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 52 beds providing nursing care for elderly people from the age of 60 years. 24 residential beds including up to three service users in the category PD(E). 1 person aged 56 years or above may be admitted for short term convalescent residency at any time. 31st October 2005 Date of last inspection Brief Description of the Service: Norfolk House is a purpose built home situated in central Weybridge, providing nursing and personal care to seventy-six older people. Accommodation is provided over three floors, with six spacious lounges and, three dining rooms. The majority of the bedrooms are single with a few double rooms. All bedrooms have en-suite facilities. Passenger lifts and stairs serve the first and second floors. The home is served by good transport system, the railway station is close by, and the home is easily reached from junction 11 of the M25. The home has its own transport in the form of a mini bus in which service users can enjoy visits to many of the local attractions such as Hever Castle, Polsden Lacey and Gamshaw mill. To the rear of the property is a large garden with patio area, whilst the front of the property is laid out for car parking. Fees at this home are in the range of £635.00 to £950.00 per week. Norfolk House DS0000017628.V301081.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is the first inspection to be undertaken in the Commission for Social Care Inspection Year April 2006 to March 2007. This unannounced inspection was carried out on the 2nd June 2006 by Mrs Mavis Clahar and lasted seven hours. The first part of the inspection was spent touring the home and speaking with service users, observing carers’ interacting respectfully with service users, and speaking with carers between their busy schedules. Not all the service users at this home are able to converse with the inspector, therefore the information contained in this report was obtained by observation of service users ’body language when spoken to, observing service users interaction with carers, speaking with service users, carers reviewing specifically selected and randomly selected service users files and finally discussion with the deputy manager. Generally the home was clean and tidy and free of odour. The home has invested in a number of ionisers, which have proved to be very successful. The visitor’s book showed that there were visitors to the home during the inspection, but no one wanted to speak with the inspector. It was noted that visitors were frequent and stayed for short periods, this could be because the home is within walking distance from the town centre and visitors can pop in during their shopping trips to town. Service users spoken to on the day of inspection who were able to converse said they were contented in their home, even though this is not like being in their own home. Another service users said “I like it here, it is like being in a hotel, with breakfast served in bed. I love it.” Time was spent with the Chef, reviewing the menu, discussing the nutritional needs of the service users, and observing the preparation of the day’s mid-day meal. Time was spent with service users who attended the fashion show put on by a company, which comes to the home to show and sell their garments. A tour of the grounds was undertaken. Service users have good wheelchair access to the garden and patio area, which is flat and can be accessed easily by all service users. The second part of the inspection was spent reviewing service users care notes and sampling care workers records. Some policies and procedures were reviewed in order to substantiate practice. One immediate requirement was issued on standard 9 on this inspection. The final part of the inspection was spent giving feedback about the inspection findings Norfolk House DS0000017628.V301081.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? The Nurse call bell has been repaired and upgraded. The home manager has obtained quotation for a new call bell system, which is being forwarded to the company’s head office. The home has purchased new towels, sheets and bed spreads for all three floors; also cutlery and crockery has been replaced. Four sensor mats, (to place beside service users’ beds to prevent injury should service user fall.) have been purchased. New service users refrigerator has been purchased for the exclusive use of the ground floor service users. New fully stocked fish tank has been purchased for the ground floor service users lounge. The residents Council has purchased new seating for the front entrance for the use of service users whilst awaiting transport. On the first floor, there is a new music centre in the lounge for the service users. The lounge and dining area has been recarpeted and seven bedrooms on first and second floors have now been fully redecorated. The home has purchased a new camera, which enables a better quality of photographs. The Chef has ordered a new Combi-oven, as the currant oven is broken. A new food processor has been purchased. Norfolk House DS0000017628.V301081.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. Norfolk House DS0000017628.V301081.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 Norfolk House DS0000017628.V301081.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 136 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has up to date statement of purpose which is in line with Care Homes Regulations 2002 Schedule 1. Each service user has a copy of the service users guide in their bedrooms alongside their daily care notes. Admission is not made to the home until a full needs assessment is undertaken by a registered nurse. The home is then able to confirm that tey can meet the needs of the individual through the service they deliver as detailed in their statement of purpose. EVIDENCE: Review of randomly selected service users files and in discussion with service users it was evident that service users had the information they needed to make an informed choice about becoming a resident of the home. They all had a trial period before deciding to make this home their home. Norfolk House DS0000017628.V301081.R01.S.doc Version 5.2 Page 10 A random sample of service users files demonstrated that pre admission assessment was undertaken prior to the service user being admitted to the home. Discussion with service users and staff revealed that care workers had the knowledge necessary to meet the care needs of the service users in their care. The home has demonstrated that they have the capacity to deliver intermediate care to service users. However, on the day of inspection there was no service user in the home under this category. Norfolk House DS0000017628.V301081.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This service has a strong belief that it is necessary to involve service users, (family/social services) if necessary in the planning of care that affects their lifestyle and quality of life. EVIDENCE: The randomly selected care plans were clear and easy to read, identifying actual and potential risks to service users. The daily work sheets along with discussion with service users demonstrated that service users assessed needs are being met. No service user at the home on the day of inspection was responsible for their medication. In discussion with the deputy manager, it was evident she was knowledgeable on what the home’s policy and procedure s were should this situation arise. Good clear records are kept of medication received, stored and returned. Documentation on the Medication Administration Record (MAR) chart was not in line with the home’s policy in that carers were not entering on the back of the MAR chart reasons why medication was not administered. A requirement was issued on this standard. Norfolk House DS0000017628.V301081.R01.S.doc Version 5.2 Page 12 There were no visitors to the home to speak with the inspector, but service users spoken to rate the personal care they receive at this home as very good. Most of them said they were contented, they had enough to eat and can do as they like. Many of the able service users said they often walk into town for personal shopping or to meet friends for coffee. Norfolk House DS0000017628.V301081.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 125 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient staff resources are provided to allow time for activities and stimulation. The home operates a named nurse and key worker system, which enables closer service user/carer relationships, where likes and dislikes and needs are shared. EVIDENCE: The home employs an activities co-ordinator who provides activities for service users in the afternoon. (The activity co-ordinator was away sick on the day of inspection). Many of the service users spoken to on the day of inspection informed the inspector that they are aware of the activities provided by the home but they don’t wish to attend. Some said the list is advertised and they choose which activity to attend. The activity in the afternoon of the inspection was “fashion show” where an outside company brought clothing in for the service users to purchase. The clothing were very up to date and of materials that can be easily laundered. It was good to see that although the activity coordinator was not on duty all members of staff including the maintenance person was involved in making the experience a worthwhile one for the service users. Norfolk House DS0000017628.V301081.R01.S.doc Version 5.2 Page 14 Some of the service users were out in the town centre with either their key worker or their relative. Service users said they are able to make choices and control over their lives. This was reflected in the care plans, which were signed by the service users to show they were consulted about their care needs. For those service users who were unable to give coherent answers, the inspector spoke with the Head of care, and cross-reference her response with documentation in the service users’ care notes. The service users said the food at the home is good and it was presented nicely. When questioned on the consistency of the meal they said the meat is tender, but they could do with more vegetables. This information was fed back to the Chef who said she had on order individual serving dishes in which vegetables will be placed so that service users can help themselves. The inspector returned to the two service users who had expressed this wish and gave feedback on the Chef’s answer. The service users expressed their thanks for the prompt feedback. The inspector did not sample the food but on observation the preparation of the mid-day meal was done in a safe and hygienic way. There were plenty fresh fruits, vegetables, and ample dry food in suitable storage, and ample amount of frozen food in the home. Generally the service users were very complimentary about the home serving breakfast in their bedrooms. One service user said “Its like being in a hotel and one can enjoy one’s breakfast at one’s leisure”. Norfolk House DS0000017628.V301081.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedure is widely distributed (in each service user’s bedroom with their care plans) and has a high profile within the home. Service users and staff demonstrated a good understanding of how to make a complaint and they are very clear of what can be expected to happen if a complaint is made. Usually the home responds within the agreed time frame. EVIDENCE: Service users who were able to give coherent answers said they knew how to complain and to whom they would complain if they needed to. No relatives or visitors were available to discuss this topic. Review of carers’ files and the training files demonstrated that carers are trained to recognise and report suspected or actual incidents of abuse of any service user resident in this home. In discussion with carers they said they are knowledgeable about the different forms of abuse, and how to report this. They were also knowledgeable about whistle blowing and aware of the support they would receive if they used the whistle blowing procedure. Complaints received at the home are logged with their outcomes. This demonstrated that service users and visitors to the home complaints are taken seriously and are dealt with within the company’s time frame. Norfolk House DS0000017628.V301081.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a well-maintained environment, which provides aids and equipments to meet the care needs of the service users. It is a very pleasant and safe place to live with rooms that meet the National Minimum Standards or larger, and have en-suite facilities. EVIDENCE: All areas of the home are well maintained and there is a rolling redecoration plan in place. The building complies with the requirements of the local fire services and environmental health department. Records of servicing of lifts, boilers and passenger lift were kept. Bedrooms viewed on the day were large in size, many exceeding the National Minimum Standards size requirements and all had en-suite facilities. Service users personal belongings were used to personalise the bedrooms. Many service users said they liked their bedrooms and that they were spacious. The grounds of the home are kept in good order. The garden is laid mostly to lawn with seating and chairs placed with sufficient Norfolk House DS0000017628.V301081.R01.S.doc Version 5.2 Page 17 space to allow privacy for service users and their visitors should they choose to use the garden in the good weather. The home is noticeable free of offensive smells on the day of inspection. A number of ionisers were in use on a trial basis prior to final purchase. The nurse call bell has been repaired, but it is still not functioning adequately. The home has sent out invitations to tender quotes and these have been passed on to the company. The manager is awaiting their response. Generally the home is clean and tidy. Norfolk House DS0000017628.V301081.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 28 29. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good recruitment policy and procedure that clearly defines the processes to be flowed. This procedure is followed in practice with the home recognising the importance of effective recruitment procedures in the delivery of quality services and for the protection of the service users. EVIDENCE: Review of the staffing rota indicated that each floor is staffed to meet the assessed care needs of the service users. There were no staff member offering personal care to service users under the age of 21 years. Service users said that the carers were kind and caring. No one said they felt rushed by their carer. From observation of carer and service user interaction the inspector formed the opinion that carers were friendly but respectful of the service users. The training record demonstrated that carers are trained to do the job they are given and that regular updating of training is given. Carers are formally supervised and records were available to support this. Norfolk House DS0000017628.V301081.R01.S.doc Version 5.2 Page 19 Recruitment of staff to the home is through a process of equal opportunity, and in accordance with the code of conduct and practice as set by the GSCC. All staff are CRB and POVA checked prior to commencing employment and they are in receipt of terms and conditions of employment, as evidenced in their randomly reviewed personal files. All new members of staff have completed an induction programme. Norfolk House DS0000017628.V301081.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 35 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The registered manager has the required qualification and experience, is highly competent to run the home and meet its stated aims and objectives. The manager demonstrates sound knowledge of both strategic and financial planning and review, and manages the service effectively, providing value for money through effective management. The manager is visionary in her experience and ability and is highly competent in the following areas: care of older people, conditions and diseases associated with old age, quality assurance systems, equal opportunity issues, development and implementation of the services policies and procedures, good people skills, strong leadership of staff which lead to a confident work force. Norfolk House DS0000017628.V301081.R01.S.doc Version 5.2 Page 21 EVIDENCE: The registered manager is a registered general nurse with over 25 years experience of caring and management in the nursing and social care and teaching arena. She is also suitable qualified in management, being educated to degree level and has attained the (RMA) Registered Managers Award. She has kept herself up to date by regularly undertaking periodic training to ensure her knowledge; skills and competence are appropriate for running the home. She has worked constructively with CSCI and the social care teams, under the local authority multi-agency procedures, to improve the standards of the home. All issues identified and dealt with under the local multi-agency procedures are now satisfactorily closed. Service users said that they have noticed changes and improvements in all aspects of care. Care workers said regular staff meetings are held to keep them up to date with information pertinent to the smooth running of the home. They further stated that the manager is approachable and is very supportive. The home has a yearly development plan, and currently the bedrooms are being redecorated as part of this plan. The home’s policies and procedures and practices are regularly reviewed in light of changing legislation and of good practice. Currently carers are having training sessions on “diversity in care”. The home does not act as appointee for any service user. Pocket money is kept for service users who request this service. All transaction on behalf of the service user is documented and receipts obtained and are available for inspection. Review of the records for the central heating boiler, indicated that servicing is carried out on a yearly basis by a recognised company under CORGI, passenger lifts, hoists and wheelchairs were serviced, fire extinguishers were serviced and dated. Issues surrounding moving and handling has been a problem in the past and care workers files and the homes training records have demonstrated that intensive training has taken place with all grades of staff on night and day duty. The home has purchased a number of crash mats to be placed by the side of service users bed to prevent injury should they fall. The home has maintained the safe storage of hazardous substances, and disposal of soil and foul dressings. All incidents of illness or communicable disease, all accidents and injuries are reported to CSCI and copied to care manager are reported in a timely fashion. Norfolk House DS0000017628.V301081.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 X 3 X X 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 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 X 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 4 3 3 X 3 X X 3 Norfolk House DS0000017628.V301081.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. 1. Standard OP9 Regulation 13 (2) Requirement The registered person ensures that staff adheres to the home’s policy on recording of medication. Reasons for nonadministration of medication are to be entered on the back of the MAR sheet. Timescale for action 02/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Norfolk House DS0000017628.V301081.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Norfolk House DS0000017628.V301081.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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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