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Inspection on 11/01/06 for Norton Hall Nursing Home

Also see our care home review for Norton Hall Nursing Home for more information

This inspection was carried out on 11th January 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home is well managed by a competent and effective registered manager. Residents are well cared for and their privacy and dignity is respected at all times. The standard of accommodation offers residents a comfortable ad safe place to live. A wide variety of activities are offered to residents six days a week. Staff development is a priority and ensures staff have the necessary skills to care for residents in the home.

What has improved since the last inspection?

Since the last inspection medication procedures have improved and requirements from the last inspection report have been met. The home has ensured all staff employed in the home are subject to a robust recruitment procedure, which ensures they are safe to work with vulnerable adults.

What the care home could do better:

The storage and security of personal residents files should be reviewed. Fire bells were not tested during a one week period in January 2006 it is important the home understands the necessity to test equipment regularly. There were a number of wedges in fire doors and fire doors, which should have been kept shut to bedrooms that were unoccupied during the day, were open. A legionella risk assessment had not been carried out by a competent company for three years.

CARE HOMES FOR OLDER PEOPLE Norton Hall Nursing Home Woodbury Lane Norton Worcester Worcestershire WR5 2PT Lead Inspector C Presley Unannounced Inspection 11th January 2006 10:30 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 Norton Hall Nursing Home DS0000004129.V272517.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. Norton Hall Nursing Home DS0000004129.V272517.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Norton Hall Nursing Home Address Woodbury Lane Norton Worcester Worcestershire WR5 2PT 01905 357766 01905 357766 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) Norton Manor Care Limited Mrs Sally Elizabeth Carter Care Home 30 Category(ies) of Dementia - over 65 years of age (3), Old age, registration, with number not falling within any other category (30), of places Physical disability over 65 years of age (30) Norton Hall Nursing Home DS0000004129.V272517.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st August 2005 Brief Description of the Service: Norton Hall Nursing Home is located approximately three miles away from the centre of Worcester and a mile from junction 7 of the M5 motorway, with easy access to Pershore and the surrounding rural areas. The home is registered to provide care and accommodation for a maximum of 30 older people. As part of this registration the home can provide care for up to three older people who may have a dementia related illness and thirty older people with a physical disability. Accommodation is provided over two floors with a passenger lift providing additional access to first floor rooms. The home has fourteen single bedrooms of which four have ensuite facilities and eight shared rooms. A trained nurse is on duty in the home at all times. Norton Hall Nursing Home DS0000004129.V272517.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and started at 10.30am and lasted three hours. The main focus of the inspection was to review standards not inspected at the last inspection and assess if requirements from the last inspection report had been actioned and met. Time was spent with the registered manager, the responsible individual and the trained nurse responsible for medication ordering. A brief tour of the premises followed and a number of residents were spoken to and were observed enjoying lunch. What the service does well: What has improved since the last inspection? Since the last inspection medication procedures have improved and requirements from the last inspection report have been met. The home has ensured all staff employed in the home are subject to a robust recruitment procedure, which ensures they are safe to work with vulnerable adults. Norton Hall Nursing Home DS0000004129.V272517.R01.S.doc Version 5.0 Page 6 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. Norton Hall Nursing Home DS0000004129.V272517.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Norton Hall Nursing Home DS0000004129.V272517.R01.S.doc Version 5.0 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 the following standard(s): None of the standards in this section of the report were inspected during this visit, for further information refer to previous report. EVIDENCE: Norton Hall Nursing Home DS0000004129.V272517.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 & 10 Medication procedures are robust which ensures medication is handled and administered safely. Resident’s privacy and dignity is respected at all times by staff. EVIDENCE: The home has a number of single bedrooms where residents are able to see visitors in private. Shared rooms have adequate screening, the home ensures those residents in shared rooms are offered the same facilities as those residents in single rooms regarding privacy when seeing visitors. Residents look well cared for and staff were heard speaking kindly to them and offering assistance in an appropriate manner. Medication procedures have improved since the last inspection and requirements regarding medication from the last inspection have been met. During a tour of the premises a prescription cream was found in a residents unlocked cabinet. Norton Hall Nursing Home DS0000004129.V272517.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 & 15 A stimulating programme of activities is offered to residents six days a week. Residents are offered a wholesome and appealing balanced diet, which is seasonally changed. EVIDENCE: The home employs activities co-ordinators who are able to offer residents a stimulating range of activities six days a week. The home has a mini bus, which is able to take residents out if they are able. The home has constructed a wish list chart for all residents to fill in; the home hopes to meet many of their wishes, which include visits to the arboretum. A monthly newsletter is produced for residents and families. Communion and other denominational services are offered to residents. The home offers a varied and appealing diet to residents; some residents require a pureed/liquefied diet this is served in an appealing manner. Staff supported those residents requiring assistance in an appropriate and unhurried manner. Kitchen records are in order and the requirements from the Environmental Health Officers visit had been met. Norton Hall Nursing Home DS0000004129.V272517.R01.S.doc Version 5.0 Page 11 Norton Hall Nursing Home DS0000004129.V272517.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 & 18 The homes complaints policies and procedures are robust and policies and procedures regarding the protection of the vulnerable adult ensure staff understand their responsibilities in protecting vulnerable adults in their care. EVIDENCE: The complaints policy and procedure is robust and ensures complaints are dealt with in an appropriate manner within a timescale. The policy should ensure that residents and their families are aware if they wish to complain to the Commission in the first instance they are able to do so. A recent complaint in the home had been thoroughly investigated and resolved using the homes procedures. There have been no further complaints to the Commission or the home since the last inspection. The home has policies and procedures in place regarding the protection of the vulnerable adult and staff receive regular training in this field. All staff are employed through a thorough recruitment procedure which includes references, and a POVA first and Criminal Record check at enhanced level. Staff are given a code of conduct which they sign following their induction period with the home; this highlights that under no circumstances must staff become involved in assisting or benefiting from residents wills. Norton Hall Nursing Home DS0000004129.V272517.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): 19, 21, 22, 23, 24, 25 & 26 The standard of the environment is good and provides residents with a safe place to live. EVIDENCE: The home is reasonably maintained; areas that needed attention were pointed out to the registered manager who said these would be addressed. Fire equipment had been tested; it was noted a week had been missed in January and although this had been logged as missed the responsible individual and registered manager must ensure the fire bells are tested weekly. Communal areas are furnished to a good standard and there are plans to recarpet the lounge area this year. Bedrooms were personalised it was noted that some bedrooms had their doors wedged; this is an unacceptable fire risk. Norton Hall Nursing Home DS0000004129.V272517.R01.S.doc Version 5.0 Page 14 Carpets in some bedrooms had been replaced. The home did not have a room furniture audit of each bedroom to ensure minimum furnishing were offered to residents and reasons if this was not appropriate logged in the care plan. Grounds in the home are well maintained and residents have access to these weather permitting. There are enough toilet and bathing facilities to meet the needs of residents, bath temperature records are kept when residents are bathed. There are plans to replace one of the parker baths this year that is showing wear and tear. The home had a number of hoists to assist staff when moving residents and all bedrooms had a copy of the moving and handling assessment available to staff. The home was warm and well lit on the day of this inspection and there were no odours. A legionella risk assessment had not been undertaken by an outside contractor for three years. The responsible individual will address this shortfall. Norton Hall Nursing Home DS0000004129.V272517.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): Staff have an induction programme which ensures they are adequately trained and can meet the needs of residents. EVIDENCE: Staff have an induction programme which is comprehensive. The home as a mentoring scheme in place, new staff work alongside their mentor for the induction period who trains and them observes practice. During this period core training such as fire, protection of the vulnerable adult, moving and handling and infection control. Staff do not handle any food in the home and therefore do not have food handling training. Staff are encouraged to undertake NVQ training and this is reflected in the number of staff who have an NVQ qualification or are working towards the qualification. Norton Hall Nursing Home DS0000004129.V272517.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): 33 & 35 The quality assurance system in place ensures residents have their say in how the home is run. EVIDENCE: There is a quality assurance programme in place and residents and staff views are taken into consideration. The programme requires further development to ensure other professionals who visit the home have their views taken into consideration also Residents monies are kept safe and systems are in place to regularly check accounts. Norton Hall Nursing Home DS0000004129.V272517.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 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 x 14 x 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 2 3 3 3 3 2 2 3 STAFFING Standard No Score 27 x 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 3 x 3 x x x Norton Hall Nursing Home DS0000004129.V272517.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? N0 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 3 4 Standard OP7 OP9 OP9 OP16 Regulation 17 13 (2) 13 (2) 22 Requirement Records containing personal information must be kept secure The medication policy must reflect the disposal arrangements for medication Prescription creams must be stored safely and kept locked at all times The complaints policy must reflect that residents and/or their families may bring a complaint to the Commission in the first instance. Fire bells must be tested weekly Fire doors must not be wedged All the items of furniture specified in standard 24.2 must be provided in rooms occupied by residents. If the provision of any item poses an unacceptable risk to the resident or they decline the provision, details of the discussions and decision about this should be recorded in the assessment of the residents needs. A legionella risk assessment that meets the current legislation must be undertaken DS0000004129.V272517.R01.S.doc Timescale for action 31/01/06 31/01/06 11/01/06 31/01/06 5 6 7 OP19 OP19 OP24 23 23 16 11/01/06 11/01/06 31/01/06 8 OP26 13 31/01/06 Norton Hall Nursing Home Version 5.0 Page 19 9 OP33 24 The quality assurance programme must include visiting professionals to the home 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP19 OP30 Good Practice Recommendations It is recommended that the replacement of any worn carpets be taken into consideration and included in the homes planned maintenance programme as appropriate. It is recommended that the responsible individual liaise with environmental health regarding staff having food handling training. Norton Hall Nursing Home DS0000004129.V272517.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW 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 Norton Hall Nursing Home DS0000004129.V272517.R01.S.doc Version 5.0 Page 21 - 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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