CARE HOMES FOR OLDER PEOPLE
Norfolk House 39 Portmore Park Road Weybridge Surrey KT13 8HQ Lead Inspector
Mavis Clahar Unannounced Inspection 31st October 2005 08:50 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.V262253.R01.S.doc Version 5.0 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.V262253.R01.S.doc Version 5.0 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 To be confirmed 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.V262253.R01.S.doc Version 5.0 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. 25th April 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, 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 is 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 back of the property is a large garden with patio area, whilst the front of the property is laid out for car parking. Norfolk House DS0000017628.V262253.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This is the second inspection to be undertaken in the Commission for Social Care inspection year April 2005 to March 2006. For a fuller understanding of how the home performed for the year, it is necessary to read the report of 25/04/05. The home received an announced inspection on 25th April 2005. This unannounced inspection took place on 31st October 2005. This means that no one at the home or the company knew of the inspection. The first part of the inspection was spent touring the home and speaking with service users and carers, to ascertain their views on the running of the home, the care they receive and training carers received. Service users spoken to on the day who were able to converse all spoke very highly of the care they received, of the kindness of the care staff and how good the food was. The inspector noted that various fruit juices and water were available in the lounges where service users sat and one or two carers were with the service users. Generally the home was clean with some bedrooms needing redecoration and the manager informed the inspector that this was included in the budget. Some of the bedrooms were odorous and the manager explained this was due to lack of ventilation. The manager explained that service users are encouraged and enabled to make choices and situations like these do arise from the choices service users makes. Health and safety issues for care workers were discussed and the manager agreed to discuss bedrooms ventilation with the maintenance manager. The second part of the inspection was spent sampling medication records, care records and recently employed staff files. This was followed by feedback to the manager on the findings of the inspection. What the service does well:
Residents stated that staffs were kind and caring and that the activities lady was good at her job. It was noted that many of the female residents had their nails painted and they said staff always did this for them, which was very pleasing to hear. Many residents mentioned that individual choice was promoted and respected by staff.
Norfolk House DS0000017628.V262253.R01.S.doc Version 5.0 Page 6 The daily record keeping was well done and contained information about care provided and what needs were met. The monthly reviews of resident’s care plans and risk assessments was well maintained. Staff played an active role in serving meals and advising the kitchen staff member on portion sizes for residents. A caters comment book was available and this was used by residents to comment on food. What has improved since the last inspection? What they could do better:
Have some old time music in the first floor lounge for the benefit of the service users. Ensure service users have access to call system whilst they are seated in the lounge. Norfolk House DS0000017628.V262253.R01.S.doc Version 5.0 Page 7 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.V262253.R01.S.doc Version 5.0 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.V262253.R01.S.doc Version 5.0 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): 6 Standard six does not apply to this home. EVIDENCE: Standards 1 3 and 5 were assessed on the last inspection. For information on these standards please refer to the report of 25/04/05. Norfolk House DS0000017628.V262253.R01.S.doc Version 5.0 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 the following standard(s): 7 8 9 10 The above standards were assessed on the last inspection. EVIDENCE: For information on these standard please refer to the report of 25/04/05. Norfolk House DS0000017628.V262253.R01.S.doc Version 5.0 Page 11 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 Dietary needs of service users are well catered for with a balance and varied selection of food available that meets service users tastes and choices. EVIDENCE: Service users spoken to on the day of inspection all praised the food. They said, the quantity was enough, the presentation was appealing and fluids were served at regular intervals throughout the day. The inspector did not sample the food, but agreed with the service users that the lunch looked appetising. The dietician has reviewed the homes menu, which includes choices for main courses and has passed it as satisfactory for older service users. Norfolk House DS0000017628.V262253.R01.S.doc Version 5.0 Page 12 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 17 18 The above standards were assessed on the last inspection EVIDENCE: For information on these standards please refer to the report of 25/04/05. Norfolk House DS0000017628.V262253.R01.S.doc Version 5.0 Page 13 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): 22 26 On the day of inspection the home was clean, communal areas pleasant and hygienic; but some bedrooms needed to be ventilated. EVIDENCE: The inspector noted that many of the nurse call bells were not working. In discussion with the manager it transpired that the maintenance person was working on this and an expert was called in who said the system could not be repaired. Service users were observed sitting in the lounges with no means of attracting attention of the care staff if and when the need arose. A requirement was issued on this standard. It was also observed that the door handle to G16 was defective. An immediate requirement was issued on this standard. Whilst touring the home it was noted that a number of bedrooms had offensive odours. Full discussion with the manager revealed that service users are encouraged and enabled to exercise their right to choose, and some service users choose not to have any ventilation in their bedrooms. Whilst this is
Norfolk House DS0000017628.V262253.R01.S.doc Version 5.0 Page 14 commendable, the manager has a duty of care to protect the care workers health and safety. A requirement was issued on this standard. Norfolk House DS0000017628.V262253.R01.S.doc Version 5.0 Page 15 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): 28 29 Staff morale is high, resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. EVIDENCE: Talking with carers about their abilities to care for service users and their training needs, also reviewing a random selection of care workers training records and review of the homes training record, it was evident service users are being cared for by carers trained to deliver their assessed care needs. Review of the personal file of the latest member of staff to be employed by the home, revealed that the home has complied with their employment policy and procedure. All required documentations were available, with POVA coming through on 17/10/05 and the carer commenced work on the 20/10/05. On the day of inspection the carer was not on duty. Norfolk House DS0000017628.V262253.R01.S.doc Version 5.0 Page 16 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): 35 The home was found to be operating effectively against the standard assessed. EVIDENCE: 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. Norfolk House DS0000017628.V262253.R01.S.doc Version 5.0 Page 17 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 X X X X HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 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 X 17 X 18 x X X X 2 X X X 2 STAFFING Standard No Score 27 X 28 3 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X 3 X X X Norfolk House DS0000017628.V262253.R01.S.doc Version 5.0 Page 18 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 2 Standard OP22 OP22 Regulation 12 12 Requirement Repair the door handle to bedroom G16 The home should provide a suitable call system whereby all service users have access, and shows where the call has originated. 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. Timescale of 10/05/05 was not met. Timescale for action 31/10/05 31/01/06 3 OP26 16 01/12/05 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.V262253.R01.S.doc Version 5.0 Page 19 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
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