Inspection on 10/08/05 for The Normanhurst Annexe

This inspection was carried out on 10th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Normanhurst Annexe 16/10/07

The Normanhurst Annexe 27/04/06

The Normanhurst Annexe 30/11/05

The Normanhurst Annexe 06/01/05

The Normanhurst Annexe 07/07/04

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

CARE HOMES FOR OLDER PEOPLE The Normanhurst Annexe Brassey Road Bexhill-on-sea East Sussex TN40 1LB Lead Inspector Niki Palmer Unannounced 10th August 2005 12:30 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. The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Normanhurst Annexe Address Brassey Road Bexhill-on-sea East Sussex TN40 1LB 01424 217577 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) Mr David Lewes Mr Robert Hebbes Mrs Janet Mellor Care Home 18 Category(ies) of Dementia (DE), 18 registration, with number of places The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of residents to be accommodated will be eighteen (18) 2. The people accommodated will be aged sixty five (65) or over on admission 3. Only service users who have a dementia type illness are to be accommodated Date of last inspection 6 January 2005 Brief Description of the Service: The Normanhurst Annexe is situated on Bexhill seafront and is a three storey building interconnected with the Normanhurst nursing home and the Normanhurst residential home. The three homes are independently registered with reference to the category of the residents catered for. Each has a registered manager responsible for the day-to day running of the home. The Annex cares for up to 18 residents with a dementia-type illness. All bedrooms are centrally heated, two of which have ensuite facilities. Residents are welcome to bring their own furniture and other personal possessions with them. The home is close to local shops with rail and bus services within easy walking distance. Carers are on duty 24 hours a day. The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulation Act 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at The Normanhurst Annexe will be referred to as ‘residents’. This unannounced inspection took place on a Wednesday between 12.30pm and 3.30pm and was carried out by two Inspectors. The inspection began with discussions with one of the senior carers on duty in respect of progress made since the last inspection, followed by the examination of six care records. In order to gather evidence on how the home is performing, individual discussions took place with three residents, although because of their mental health needs not all residents were able to fully express their views about the home and the service provided. In addition, three care staff were spoken with during the visit, and a visiting Community Nurse. A detailed inspection of the premises and its facilities took place. 15 residents were accommodated at the time of the inspection. Other records and documentation inspected included: the home’s medication procedures, health and safety records, activities, staffing rotas and recruitment files. What the service does well: What has improved since the last inspection? Since the last inspection the home has worked hard to ensure that all residents are offered a variety of stimulating leisure and social activities. All activities are now clearly recorded. A vast amount of maintenance work and redecoration has been carried out to improve the standard of the environment. This is immediately noticeable on entering the building. The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 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. The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 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 The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 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) 3 and 5. Prospective residents and their relatives are invited to visit the home prior to making any final decision of where to live, however the home’s pre-admission assessment procedure fails to fully adequately identify residents’ needs. EVIDENCE: It has been a requirement of the two previous inspection reports for the home to assess all residents thoroughly prior to admission. It was concerning to note that all four of the pre-admission assessments seen were very brief in nature and failed to provide details of individuals’ mental state and their level of cognition, which is imperative for a care home providing support to residents with a dementia type illness. For example it was recorded in two of the assessments that their memory state was ‘poor-good’. It was also of concern to note that one resident who had been admitted from the adjoining care home, had not been assessed by a qualified member of staff from The Annexe prior to admission. All residents are invited to visit the home prior to admission in order to help them in their decision of where to live. It is recommended that the home include details of the flexible trial period offered by the home in its Statement of Purpose and Service Users’ Guide. The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 Page 9 This would offer prospective residents and their relatives the assurance that they would be able to ‘test drive’ the home and it’s facilities prior to any final decision being made to move in to the home on a permanent basis. Intermediate care is not provided. The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 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 and 9. Minimal efforts have been made by the home to ensure that all residents assessed needs are identified in their plans of care. Therefore not all of their healthcare needs are fully met. EVIDENCE: Six individual plans of care were seen on the day of inspection, which identified a number of concerns. All were found to contain minimal information for staff to follow in order to meet individuals’ assessed needs. There was insufficient evidence that these were based on a comprehensive pre-admission assessment (see Standard 3). In one person’s care plan it had been identified that she is underweight. The only guidance for staff stated ‘encourage food’. It was concerning to note that there was no detail of her preferred diet, any evidence that specialist advice had been sought or that the home had undertaken a nutritional screening assessment. In addition, her weight is only recorded on a six monthly basis. Another persons care plan identified that her pressure areas were at risk of breaking down. Although specialist equipment is in place, there was no evidence of a risk assessment being carried out or guidance for staff to follow in order to maintain pressure area care. The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 Page 11 The home’s medication procedures were viewed. A pre packed medication system is used, which can be easily monitored. A sample of records and medication storage were examined and found to be in order. It was noted that one resident has been regularly refusing to take his medication. Staff when questioned said that his General Practitioner was aware of this and had said for the staff to continue to try and persuade him to take it, yet there was no reference made to this in his care plan or in any other records. There were no prescribed controlled drugs in use within the home on the day of inspection. The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 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. The Normanhurst Annexe provides residents with a variety of stimulating leisure and recreational activities. EVIDENCE: A monthly newsletter is produced by The Normanhurst, which is distributed to each of the homes. All details of activities and forthcoming events (including residents birthdays) are advertised within this, including a crossword and word search for residents to complete. Since the last inspection the home has implemented a structured activities programme for residents. From a selection of records examined and discussions with residents it was evident that a range of activities are provided; these include Bingo, sing songs, ball games and musical entertainment etc. One resident stated that they had been for a walk in the morning with staff to the seafront. A record is now kept of all outside activities. On the day of the inspection many of the residents were playing a ball game, some were watching television (however the reception was unclear), whilst others accessed a small patio area to the rear of the property. The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 Page 13 The home must ensure that the TV reception is clear at all times and perhaps consider purchasing a wide-screen TV to ensure that all residents are able to see it clearly, as the lounge area is quite large. In addition, the home could consider making an area of the garden accessible to residents. The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 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 and 17. This home has adequate systems in place to ensure that all complaints will be handled appropriately. Advocacy services are accessible to residents in order to ensure their rights are protected. EVIDENCE: The Normanhurst Annexe has recently updated and amended its Complaints procedure. It now clearly states how someone should make a complaint to the home, how they can expect it to be dealt with, and provides details of how the Commission for Social Care Inspection can be contacted at anytime during the investigation. A record of all complaints are kept within the home. No complaints have been made to either the home or the CSCI since the last inspection. Due to the nature of the residents accommodated, it was pleasing to see that specialist advocacy services for older people are advertised in the home’s reception area. Referrals can be made on an individual basis to ensure that residents’ rights are protected. The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 Page 15 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 and 26. The Normanhurst provides residents with a comfortable and homely place to live. EVIDENCE: All areas of the home were inspected. It was pleasing to note that since the last inspection a great deal of redecoration and maintenance work has been carried out. The building was found to be well-maintained, clean and hygienic throughout. All carpets had recently been cleaned and in some areas replaced. A shower room has recently been refurbished on the first floor. The environment was generally safe for residents, although it was noted that a window in the shower room was not fitted with restrictors and therefore posed a risk to residents. Action has been required to address this matter. The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 Page 16 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, 28, 29 and 30. Staffing levels are adequate to meet the needs of residents, however the home’s recruitment procedures and practices have the potential to jeopardise the safety of residents. EVIDENCE: A total of 16 care staff are employed by the home, four of which are currently working towards NVQ level 2 in care. In addition the home employs domestic and maintenance staff. Staffing rotas showed that four carers are rostered to work each morning and three in the afternoons. On the day of inspection, a new member of staff was on duty who was considered to be supernumerary as they had recently been employed and were being inducted to the home. Staff and others spoken with confirmed that the home is always adequately staffed to meet the needs of residents. The recruitment records of the two most recent staff to be employed were examined. It was concerning to note that in one instance a member of staff who had started work the previous day had not had a Criminal Records Bureau or POVA First check carried out. In addition written references had not yet been obtained. The Inspector was told that the individual’s immigration/work status had been checked, however no record of this was available for inspection. The importance of safeguarding residents from potential harm was addressed at the time of the inspection, and the home has been asked to supply the CSCI with a detailed action plan of how they intend to address the recruitment concerns raised. The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 Page 17 It is an outstanding requirement from the previous inspection report for the home to expand its current induction programme in order that it meets TOPPS specifications. It was pleasing to note that all staff are expected to attend regular update inhouse training sessions for the protection of vulnerable adults and the prevention of abuse. Notices advertising the dates for these were clearly on display in the staff room. Staff spoken with said that they found the refresher courses useful. The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 Page 18 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) 32, 33 and 38. The home needs to ensure that feedback from visitors to the home is sought on a regular basis in order to maintain and improve standards. Accurate records must be maintained in order to ensure residents are protected by the homes maintenance procedures. EVIDENCE: A copy of the homes most recent inspection report is kept on display in the main reception area for relatives and visitors to the home to read. One of the carers spoken with on the day of the inspection stated that although the staff have regular meetings, it has been difficult for the home to initiate residents’ meetings due to their level of dementia. Although this is appreciated by the CSCI, the home must consider ways in which feedback can be sought from visitors to the home. The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 Page 19 A sample of the home’s health and safety records were examined; it was noted that a record was not maintained of the testing of emergency lights and a record could not be found of a recent fire drill. A requirement has been made in respect of this. The home does not currently have an up to date policy for the prevention of falls. Due to the nature of the residents accommodated, the home is required to update its policy in accordance with the guidelines produced by the National Institute of Clinical Excellence for older people. In addition, risk assessments must be carried out and provide detail regarding the action that is to be taken to minimise any identified risks. The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 1 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 x COMPLAINTS AND PROTECTION 2 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 x x 3 2 x x x x 2 The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 Page 21 Yes 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 OP3 Regulation 14(1) Schedule3 (1)(a) Requirement It is required that the home does not admit any person to the home whose needs have not been thoroughly assessed [THIS IS OUTSTANDING FROM THE TWO PREVIOUS INSPECTION REPORTS]. It is required that the home review and amend its preadmission assessment procedures to ensure that individuals mental state and cognition is detailed and recorded [THIS IS OUTSTANDING FROM THE TWO PREVIOUS INSPECTION REPORTS]. It is required that the home review and amend its care planning documentation to ensure that all aspects of individuals needs are detailed and provide written guidance for staff to follow [THIS IS OUTSTANDING FROM THE TWO PREVIOUS INSPECTION REPORTS]. Timescale for action 10/08/05 2. OP3 14(1) Schedule3 (1)(a) 10/10/05 3. OP7 15(1) 12(1) 10/10/05 The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 Page 22 4. OP8 17(1)(a) Schedule 3 (p) 15(2) 5. OP8 14(1)(a) 2(a)(b) 17(1)(a) Schedule 3 (o) 13(2) Schedule2 13(4)(a) (c) 19 & Schedule2 6. OP9 7. 8. OP19 OP29 9. OP30 18(1) 10. OP33 24(1)(2) (3) 11. OP38 Schedule4 (14) 23(4) It is required that the home carry out detailed risk assessments for all residents who are at risk of pressure area care breakdown. All risk assessments must provide staff with specific instructions on how to manage the risk [THIS IS OUTSTANDING FROM THE PREVIOUS INSPECTION REPORT]. It is required that the home undertake nutritional screening on admission and on a periodic basis. A record must be maintained including weight gain or loss and appropriate action taken. It is required that any advice received from a GP in respect of medication is clearly documented. It is required that a restrictor is fitted to the window in the first floor shower room. It is required that staff are not employed to work in the home until all of the required pre employment checks have been carried out. It is required that the home reviews its induction and foundation processes in order that they are based on TOPPS guidelines [THIS IS OUTSTANDING FROM THE PREVIOUS INSPECTION REPORT] It is required that the home explore different ways in which feedback regarding the service provided is sought from visitors to the home. It is required that records are maintained of the testing of emergency lights and of fire drills undertaken. 10/10/05 10/08/05 10/08/05 24/08/05 10/08/05 10/10/05 10/10/05 10/08/05 The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 Page 23 12. OP38 13(4)(b) (c) It is required that the home update its policy for the prevention of falls in accordance with recent NICE guidelines and carry out detailed risk assessments for the residents accommodated. 10/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP5 OP12 OP12 OP28 Good Practice Recommendations It is recommended that details of the homes trial period is included within the Statement of Purpose and Service Users Guide. It is recommended that the home consider purschasing a wide-screen TV to ensure that all residents are able to see it. The reception should be clear at all times. It is recommended that the home consider making an area of the garden secure so that residents can access the garden safely. That at least 50 of care staff are trained to NVQ level 2 in care by December 2005. The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Ivy House 3 Ivy Terrace Eastbourne East Susssex BN21 4QT 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 The Normanhurst Annexe H59-H10 S21255 Normanhurst Annexe V230579 100805 Stage 4.doc Version 1.40 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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