Inspection on 25/04/05 for Norfolk House

This inspection was carried out on 25th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 02/06/06

Norfolk House 31/10/05

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 Megan McHugh Announced Inspection 25 April 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. Norfolk House Version 1.10 Page 3 SERVICE INFORMATION Name of service Norfolk House Address 39 Portmore Park Road Weybridge Surrey KT13 8HQ 01932 352766 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) Ashbourne Homes Ltd To be confirmed CRH (N) 76 Category(ies) of Old age, not falling within any other category registration, with number (OP) 76. of places Physical disability over 65 years of age (PD(E)) 3. Norfolk House Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 52 beds providing nursing care for elderley 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. Date of last inspection 23 November 2004 Brief Description of the Service: Norfolk House Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection carried out by two inspectors over seven (7) hours. Three additional complaint visits have been carried out since the last inspection on the 24th November 2004. Letters sent to the registered person following those visits can be obtained from the CSCI Surrey Local office on request. A tour of the premises was undertaken and staff and care records were sampled during the day. Staff were spoken with during the course of their duties and thirteen of the sixty-six residents were spoken to in depth. A number of other residents were spoken with in passing or during the lunchtime meal. Three visitors also talked with the inspectors and gave feedback about the service. What the service does well: What has improved since the last inspection? The biggest improvement noted was that mandatory training was now in place for all staff, except the newest staff member. There has been numerous group supervision sessions taking place with staff, which includes quality care and attention to detail. A number of staff meetings have taken place with the Norfolk House Version 1.10 Page 6 manager to encourage staff and keep them up to date with the progress the home is making. Many residents stated that the food had improved and that the menu alternative was good. The chef is in the process of changing the menus with residents’ input, which was another positive move forward. Many residents have had care reviews held with their care managers and any new or additional care needs have been identified. Following this, some residents who were on the residential floor have been transferred to the nursing floors for additional care. A number of the review notes have been signed by the resident acknowledging they are aware of the review. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Norfolk House Version 1.10 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 Norfolk House Version 1.10 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) 1, 3 and 5 Residents have access to information about the home to enable them to make an informed choice about the service. This includes information about the level of needs the home can cater for and any specialist equipment available. People are invited to visit the home prior to making a decision. EVIDENCE: The statement of purpose was found in residents bedrooms and one resident stated that he had not read it but knew it was there for him to read if he liked. He also stated that he was aware that it was information about the home, however, he was only here for respite and his family read all about the home. It was noted that the statement of purpose had been updated with the new manager’s details. All residents are assessed by the home or by the social care team prior to admission to the home. The resident then has a comprehensive admission assessment completed which looks at physical, emotional, social, health and nutritional needs. These are reviewed as part of the care planning process each month. Any needs that are identified as requiring specialist equipment, are provided through the home or the occupational therapist. Norfolk House Version 1.10 Page 9 The statement of purpose and the admission policy state that residents and/or their family should come to visit the home prior to admission to ensure they are happy that this is the correct placement. Staff stated that usually relatives come to visit the home but it is not often that the prospective resident visits. One resident who had recently been admitted, was being shown around by a staff member during the inspection. Norfolk House Version 1.10 Page 10 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, 8, 9 and 10 The resident’s health, personal and social needs were documented in the care plan and their health care needs were being met. The administration of medication whilst safe could be improved. Residents who were able were responsible for their own medication, were self-administering. Some issues around privacy in en-suite bathrooms were highlighted. EVIDENCE: Care plans and the admission plan were reviewed on a monthly basis and amended as required. However, not all the amendments were dated on the plans and this would be helpful to do so. Copies of letters to relatives and on the back of bedroom doors invited residents and relatives to participate in the care planning process. Staff said that those residents who were unable to communicate very well, the majority of the information they received was from the relatives. There was a clear record maintained of visits received from the multi disciplinary team including the GP, chiropodist, optician etc. Daily note/record keeping was well done and contained information about what care had been given to a resident, what activities they had participated in and if they had eaten well during the day. One area of improvement could be that staff read the care review notes when they are received and ensure that any changes or needs noted in the review are added top the care plan. Norfolk House Version 1.10 Page 11 Medication administration was observed on one floor and was satisfactory. Staff stated that they have been appropriately trained to dispense medication. Some residents are able to self-administer their medication and risk assessments and disclaimers were in place for this. One resident stated that she keeps her medication locked in a drawer in her bedroom and she can also lock her bedroom door if she wishes to. No gaps were noted in the MAR (Medication Administration Record) charts. The CSCI Pharmacy inspector visited the home on the 26/04/2005 and found that medication stocks and records showed that the majority of service users were receiving their medication as intended by their doctors. However, one service user had not received their night sedation on one occasion and another service users had an extra dose of medication taken from stock than recorded as given. All medication was stored securely for the protection of service users, including that held by service users for their own use. Risk assessments were in place for all those service users whose records were sampled, including a person who only held topical products. However there was no record kept of when medications were given to the service users. During the day the staff were seen to knock on bedroom doors when entering rooms and many residents said that the staff were courteous and respected them. However, one resident stated that staff often do not knock when entering the en-suite bathrooms and that this was an invasion of her privacy. Further discussion revealed that this was not only when staff had been called to assist in a bathroom but also sometimes when they were looking for the resident. It was noted during the visit that one resident’s bedroom door did not close properly. This was reported to the nurse in charge of the floor and was dealt with by the maintenance man on duty. Norfolk House Version 1.10 Page 12 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 and 15 Social activities were well managed and provided a choice, daily variation and social contact for residents. Residents had a right to make choices and exercised some control over all aspects of daily living. EVIDENCE: There is an activities co-ordinator in post who provides activities in the afternoons. Many residents still don’t attend the activities although those spoken to on the day were aware of the activities and had chosen not to participate. The activities list is displayed on the notice board on each floor and cards are placed on the dining room tables at lunch with what activity is taking place and where in the home. The activity on the afternoon of the visit was ‘Play your cards right’ and the inspectors heard laughter coming from the activities room. The activities lady and staff went around the home asking who wished to go to the activity and these residents were assisted to get to the activity. Many residents were very complimentary about the activities coordinator. Visitors were seen in the home throughout the day and many residents spoke about their families coming in to see them. One resident said that she and some other residents had gone out to a local amateur dramatics society play Norfolk House Version 1.10 Page 13 on Saturday and stated that the outings will start to increase now that it is heading into summer. Residents stated that choice is promoted by staff and that they have control over their lives, although they are aware that there are some restrictions placed on them to ensure their safety. The kitchen was inspected and this was clean and tidy. The menu was viewed and the chef stated that she was in the process of asking residents what they wanted on the menus and would then change them. Residents stated that the meals had improved over the last few months and this was generally reflected in the catering comments book. There were still some issues with meat not being tender enough, but on the whole residents were positive about this area. One resident was pleased with the choice of alternative and stated that if they did not like any of the choices, they could ask for something else. For example: an omelette. The chef has been in post for a few months now and was previously a chef in schools. It was recommended that the chef attend additional training in catering for older people. Norfolk House Version 1.10 Page 14 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, 17 and 18 Complaints were logged in the complaints file and information about action taken was made available. Residents also have access to a comment book in the dining room for complaints in relation to food. Procedures were in place in respect of the protection of vulnerable adults and training and induction was available for staff. EVIDENCE: The home has a clearly written complaints procedure and a log is held of all complaints received by the staff and manager and what action has taken following the complaint. Some residents stated they knew what action they should take should they wish to complain however not all were sure of what the procedure said they should do. However they did state that they would talk to the nurse in charge if they had a problem. A number of complaints have been received by CSCI in relation to the service and these are being investigated. Residents spoke about the coming election and that they were able to complete postal votes or if able, would be taken down to the polling station to vote on the day. Many felt this was an important area and were glad to be able to participate. Staff receive training in their induction and full abuse training that teaches them how to recognise signs of abuse and what to do if the witness or suspect that a resident is being abused. Residents spoken to stated that staff were caring, kind and polite at all times. Good record keeping of falls and injuries Norfolk House Version 1.10 Page 15 was an effective way for staff to be able to notice any additional bruising or issues to be reported. Norfolk House Version 1.10 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 standard(s) 19, 20, 21, 23, 24, 25 and 26 On the day of the inspection the home was clean, pleasant and safe to live in. It was well maintained, bedrooms were personalised and there was sufficient facilities and equipment to meet residents’ needs. EVIDENCE: All areas of the home were well maintained and there is a rolling redecoration plan in place. Last year chairs and stools were bought for the ground and second floor and this year the first floor’s chairs and stools were due to be replaced. The manager stated that there were plans in place to redecorate the second floor corridor and dining room later this year. Each floor has a communal lounge and large dining room that is open plan to a second smaller seating/lounge area. There are gardens accessible from the ground floor dining room, which are partly paved to allow for wheelchair access. Norfolk House Version 1.10 Page 17 Each bedroom has an en-suite facility consisting of a toilet, hand basin and walk-in shower or assisted bath. There are additional communal toilets along the corridors near to the communal areas. Those bedrooms that were viewed on the day of the visit, were large in size, many exceeding the National Minimum Standard’s size requirements, and were decorated with residents’ furniture, photos, pictures and ornaments. Residents stated that the staff were helpful in decorating their bedrooms and hanging photos. Many residents stated they liked their bedrooms and that they were spacious. Specialist equipment in the form of handrails, safety rails in bathrooms, specialist baths, hoists, wheelchairs, Zimmer frames and specialist pressure relieving equipment was found throughout the home. The manager stated that she has requested for another sling hoist to be purchased to be used on the two nursing floors, as she had worked a day out on the floor and felt there was a need for this. The regional manager stated that the home was also in the process of purchasing a few nursing beds that lower to the floor. The only concern that was raised at a previous visit and was addressed by the manager at this inspection, was the guttering on the roof. This needs cleaning and some areas may need to be replaced. The manager stated that this was due to be done and was on the refurbishment plan as urgent. There was a concern from staff on how they should deal with cleaning issues once the housekeeping staff had gone off duty. This was discussed with the head housekeeper who was unsure of the procedure staff should follow. The manager stated that the nurse in charge had keys for the cleaning cupboards if cleaning equipment should be required. A recommendation was made that the head housekeeper should have a plan in place to deal with any out of hours cleaning. Norfolk House Version 1.10 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 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 and 30 The staffing levels in the home are satisfactory to meet the needs of the current residents. Mandatory training for staff was done and additional training was in progress. EVIDENCE: The staffing rota indicated that each floor is staffed to meet the number of residents and their assessed needs. The home is using high numbers of agency care staff to cover shifts at present and is trying to have regular staff filling in the shifts. The manager stated that she is actively recruiting care staff and has had a good response to the adverts. Residents stated that staff were kind and caring and no one said they felt rushed by staff. One resident mentioned that staff do not always knock on the en-suite bathroom doors and they thought this was perhaps a cultural issue rather than staff being rude. The residents explained that there are a number of foreign staff working in the home and that this is sometimes an issue although the ‘new’ manager is dealing with staff training and has sorted out many of the problems in the home. All staff, except the newest member, have now received and updated the mandatory training, including fire safety, manual handling, abuse/welfare, health & safety and food hygiene. The manager is working with the community training team to provide staff with additional training relating to the residents care needs. The deputy manager has completed the 4-day Ashbourne Homes Ltd trainers training and can now assist the other trainer with training sessions Norfolk House Version 1.10 Page 19 for the staff. In addition to this staff have completed a training needs form stating what training they feel they need or would like to have available to them. It was positive to see the progress the home has made in the areas of staff training in the last three months. Norfolk House Version 1.10 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 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) 31, 32, 33, 36 and 38 The home has good leadership, guidance & direction and the staff are aware of their responsibilities to ensure residents receive consistent quality of care. Residents benefit from the ethos and management approach in the home and their safety and welfare is promoted. EVIDENCE: The manager has been in post since January 2005 and has brought about positive changes in the home. She is continuing to work with CSCI and the social care teams, under the local authority multi-agency procedures, to improve the standards in the home. Residents stated that the changes that have happened since the manager took over have all been positive and that they have noticed improvements in all aspects of the home. The manager has held a relatives and residents meeting to keep everyone up to date with the changes in the home. Records of staff meetings and Head of Norfolk House Version 1.10 Page 21 department meetings were seen. There were other issues that were identified at separate meetings held under the local authority multi-agency procedures and these have been dealt with accordingly and with good results. Staff are receiving group supervision, which was seen to be satisfactory at the time. However, individual supervision must be commenced and should incorporate monitoring of the training staff have received. Records indicated that the monitoring of the safety, health and welfare of residents and staff was being monitored and action plans implemented to minimise any risks. Norfolk House Version 1.10 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 x 3 3 3 2 STAFFING Standard No Score 27 3 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 x x 3 x 3 Norfolk House Version 1.10 Page 23 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. 2. Standard OP 7 OP 9 Regulation 14 & 15(2)(b) 17(1)(a) Requirement The care management reviews must be used to update care plans where appropriate. Complete and accurate records must be kept of all medication administered or not administered, together with the reasons for the nonadministration to service users. Residents privacy and dignity must be respected at all times. The bedroom door on the ground floor must be fixed to allow the resident to close it properly All bedrooms, especially those that are unoccupied, must be cleaned appropriately, including drawers and cupboards. All areas of the home must be kept free from offensive odours. An action plan must be provided on how the home plans to meet this standard. Staff must be made aware of the homes policy regarding holding personal mobile phones on their person during duty hours. Timescale for action 16/05/05 26/04/05 3. 4. 5. OP 10 OP 10 OP 26 12(4)(a) 12(4)(a) 23(2)(d) 25/04/05 28/04/05 30/04/05 6. OP 26 16(2)(k) 10/05/05 7. OP 37 and 38 17 29/04/05 Norfolk House Version 1.10 Page 24 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. 2. 3. 4. Refer to Standard OP 15 OP 22 OP 26 OP 36 Good Practice Recommendations The head chef should attend a training course in relation to providing food for older people. The home should explore additional types of call bells/pads for residents who do not have the dexterity to use the call bells available. The head housekeeper should ensure there is a plan in place for out of hours access to cleaning products for staff. One to one supervision should be started as soon as possible. Norfolk House Version 1.10 Page 25 Commission for Social Care Inspection 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 Version 1.10 Page 26 - 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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