Inspection on 10/05/05 for Norfolk Lodge

This inspection was carried out on 10th 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

Norfolk Lodge 01/09/05

Norfolk Lodge 19/03/05

Norfolk Lodge 23/11/04

Norfolk Lodge 23/06/04

Similar services:

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Insight - Eastchurch

Southfields

Magenta

Seabourne House

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Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Norfolk Lodge 9 Norfolk Road Horsham West Sussex RH12 1BZ Lead Inspector Annette Turner Unannounced 10 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 Lodge H60-H11 S14640 Norfolk Lodge V224716 100505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Norfolk Lodge Address 9 Norfolk Road, Horsham, West Sussex, RH12 1BZ 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) 01403 218876 Sussex Health Care Ms Anne Bicknell CRH 8 Category(ies) of LD learning disability registration, with number of places Norfolk Lodge H60-H11 S14640 Norfolk Lodge V224716 100505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23 November 2004 Brief Description of the Service: Norfolk Lodge is registered to provide personal care for up to eight service users between the ages of eighteen and sixty-five in the registration category LD (learning disability). Norfolk Lodge is a semi-detached building in a residential road in the town of Horsham. Service users are accommodated in rooms on the ground and first floor. The laundry room and staff office are on the second floor. There are three rooms on the ground floor set aside for communal use including the dining room. There is a communal room on the first floor that is used for staff on sleeping in duties; this room can also be used for meetings or other events. There is a secluded garden at the back of the building. Sussex Health Care owns the service; Mr S Boghani and Dr S Sachedina are the registered providers. Ms Anne Bicknell is the registered manager responsible for the day-to-day running of the home. Norfolk Lodge H60-H11 S14640 Norfolk Lodge V224716 100505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection began in the late afternoon of Tuesday 10th May and took place over two and a half hours. Two of the service users were on holiday with the manager. There were six people at home with two people feeling unwell. There were two care staff on duty and a part time activities organiser who was just finishing her shift; she had taken one of the service users out for the afternoon. The six service users were seen. Two people sat with a member of staff and went through pictorial comment cards produced by the Commission to assist people who have communication difficulties. A tour of the building took place and the three members of staff were spoken with. Case records were seen and other documents related to the care of the service users. The Commission has been kept informed of recent incidents that have occurred in the home. A social worker involved in the ongoing care of two service users has returned a comment card that indicated that her contact with Norfolk Lodge has been very positive. What the service does well: The atmosphere in the home was relaxed and service users were well cared for. There are efficient systems for recording information and the progress of people so that the staff understand service users’ needs. The people who filled in comment cards were very happy with their home. They said that staff treat them well and that they feel safe. The service users are encouraged to follow their interests and take part in community activities. Some people help with tasks in the home and one person is a very keen gardener. The care staff said that they understand how to provide the care that people need. They receive training and support to help them do this well. The staff were very happy working in the home and want to provide the best care for the men who live there. The management team have provided a relaxed and supportive home for the people living and working at Norfolk Lodge. Norfolk Lodge H60-H11 S14640 Norfolk Lodge V224716 100505 Stage 4.doc Version 1.30 Page 6 What has improved since the last inspection? 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 Lodge H60-H11 S14640 Norfolk Lodge V224716 100505 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Norfolk Lodge H60-H11 S14640 Norfolk Lodge V224716 100505 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 4 and 5 The systems in place ensure that people who are able to will be sure that their needs will be met. They have an opportunity to visit the home with their relatives before making a decision to move in. EVIDENCE: There is a thorough pre-assessment process that is carried out by the manager so that service users’ aspirations and needs are assessed. All aspects of service users’ needs and wishes are included. Information from health and social care professionals has been provided to make sure people get the care that they need. There is a planned introduction so that people can be sure that they would like to live at Norfolk Lodge. The trial visits for one person were documented and showed that he had an opportunity to get used to the home and other people living there before he moved. Each person has a written contract so that they know what they can expect from the home. This is in symbol format for people who more easily understand this form of communication. Norfolk Lodge H60-H11 S14640 Norfolk Lodge V224716 100505 Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 and 9 Service users living at Norfolk Lodge are at the centre of the care planning and reviewing process. Service users’ personal goals are reflected in their care plans. People are supported to develop their independence skills within a risk assessment framework. EVIDENCE: Care plans are thorough and service users’ personal goals are clearly documented. It is evident that service users have been involved in the care planning process. People’s changing needs are monitored and documented. There are good systems in place to make sure that staff know how to communicate any changes in well-being. Reviews are held and from discussion with one person it was clear that he had been involved in decisions made about him. Aspects of risk had been assessed and reviewed to make sure that staff know what actions to take in order to keep people safe. It was clear from case records and discussion with staff and service users that people are supported to make decisions about their lives. One person indicated that he likes to go into town independently to visit a café. The case records showed that the risks had been assessed. Norfolk Lodge H60-H11 S14640 Norfolk Lodge V224716 100505 Stage 4.doc Version 1.30 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 15 and 17 Service users are provided with opportunities for personal development and are encouraged to maintain a presence in the community. Service users enjoy a varied and healthy diet and mealtimes are as relaxed as possible. EVIDENCE: Records showed that service users receive advice from healthcare professionals as required to support them in their personal development. The individual activities programmes showed that people are encouraged to take part in various activities of their choice. Two service users indicated that they are able to do the things they enjoy. One person showed me the work he had been doing in the garden and took great pride in what he had achieved. Service users have a presence in the community. Staff said that neighbours and local shopkeepers are supportive. People who have relatives told me about their visits. The menus were varied and showed that people have a choice of food. Several service users are able to go shopping for food with staff. Daily records of food and drink are kept for each service user in order to monitor their health. The kitchen door is kept locked for safety reasons. Service users are supervised by staff in the kitchen. Norfolk Lodge H60-H11 S14640 Norfolk Lodge V224716 100505 Stage 4.doc Version 1.30 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 19 There is a commitment to make sure that service users receive the personal and healthcare that they need. Service users are supported to make decisions about their own health and well-being. EVIDENCE: Service users’ personal and healthcare needs were documented on their case records. Individual needs and choices were clearly identified. Staff are provided with the policies and guidance they need to make sure that they understand how to provide care for service users. Several people were being supported with their personal hygiene during my visit. This was being provided in a sensitive manner to protect the privacy and dignity of service users. Medical and hospital appointments were logged. Service users who were unwell were being closely monitored and supported by staff. It was evident from case notes that medical advice is sought as required and that the staff team are aware of the health needs of the people in their care. Norfolk Lodge H60-H11 S14640 Norfolk Lodge V224716 100505 Stage 4.doc Version 1.30 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 23 The policies and guidance provided ensures that service users are protected from abuse, neglect and self harm as far as possible. EVIDENCE: Staff are provided with policies, training and guidance about the way that service users should be kept safe. People who have difficulties with their behaviour which means that they may cause harm to themselves or others receive specialist support. There are risk assessments and guidance about providing protection for everyone in these circumstances. The staff were clear about what to do in the event of an accident or allegation of abuse. The service users spoken with indicated that they feel safe at Norfolk Lodge. Norfolk Lodge H60-H11 S14640 Norfolk Lodge V224716 100505 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28 and 29 Service users are provided with a safe, homely and comfortable environment. The ongoing refurbishment programme ensures that standards and safety are maintained. EVIDENCE: The service users spoken with indicated that they like their rooms. Bedrooms are decorated to meet individual needs and all rooms are lockable. There is an ongoing programme of maintenance. The kitchen is due to be refurbished. A shower room has been upgraded and one service user has new en-suite toilet facilities to meet his changing needs. Two of the communal lounges, the dining room and the garden are available for everyone to use. One communal lounge is used for staff who are on sleeping in duties and as a meeting room. There is some special equipment for those who need it. The mobility of service users is kept under review. There are window restrictors on the first and second floor windows. Radiators are covered and hot water temperatures are maintained at a safe level. Norfolk Lodge H60-H11 S14640 Norfolk Lodge V224716 100505 Stage 4.doc Version 1.30 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 36 Service users benefit from competent staff who are well supported and supervised. Care staff have the training and guidance they need to provide the best possible care for service users. EVIDENCE: The people who were at home during the unannounced inspection were receiving the care that they needed. There were sufficient staff on duty and they were clear about the needs of the service users. There are good communication systems in place to make sure that key information is passed between all staff. There is an on-call system if additional help is needed. The care staff said they have training opportunities and are encouraged to attend courses that will help them to provide better care. They said that they have regular supervision with the manager to help them do their jobs more effectively. They said the service users benefit from this and that the manager is always approachable. Norfolk Lodge H60-H11 S14640 Norfolk Lodge V224716 100505 Stage 4.doc Version 1.30 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 41 and 42 The leadership and management approach at Norfolk Lodge ensure that service users receive a good quality of care. The systems for recording and the policies and procedures promote the health, safety and welfare of service users. EVIDENCE: Staff are provided with clear systems and guidance for recording all aspects of care provided to service users. Lockable facilities are available to ensure service user confidentiality. Comments from staff and service users indicated that the management team provide strong leadership and guidance. There are clear lines of accountability and support for staff. There is an on-call system that staff feel they can depend on. Records showed that the staff training and information on health safety issues protects service users. Risk assessments are carried out to make sure that a safe environment is provided. Norfolk Lodge H60-H11 S14640 Norfolk Lodge V224716 100505 Stage 4.doc Version 1.30 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 3 3 3 Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 x Standard No 11 12 13 14 15 16 17 3 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score x x 3 x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Norfolk Lodge Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x 3 x x 3 3 x H60-H11 S14640 Norfolk Lodge V224716 100505 Stage 4.doc Version 1.30 Page 17 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 Regulation Requirement Timescale for action 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 Norfolk Lodge H60-H11 S14640 Norfolk Lodge V224716 100505 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection 2nd Floor, Ridgeworth House Liverpool Gardens Worthing, West Sussex BN11 1RY 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. 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