Inspection on 16/10/07 for The Normanhurst Annexe

This inspection was carried out on 16th October 2007.

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 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 27/04/06

The Normanhurst Annexe 30/11/05

The Normanhurst Annexe 10/08/05

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 De La Warr Parade Bexhill-on-sea East Sussex TN40 1LB Lead Inspector June Davies Key Unannounced Inspection 10:00 16th October 2007 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 The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 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. The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Normanhurst Annexe Address De La Warr Parade Bexhill-on-sea East Sussex TN40 1LB 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) 01424 217577 01424 734650 Normanhurst@btinternet.com www.normanhurst.com Mr David Lewis Mr Robert Hebbes Mrs Janet Mellor Care Home 18 Category(ies) of Dementia (18) registration, with number of places The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The maximum number of residents to be accommodated will be eighteen (18) The people accommodated will be aged sixty five (65) or over on admission Only service users who have a dementia type illness are to be accommodated 27th April 2006 Date of last inspection 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 Care 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 Annexe cares for up to 18 residents with a dementia-type illness. All bedrooms are centrally heated, two of which have en-suite 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 home’s literature states that it ‘aims to provide residents with the appropriate degree of care to assure the highest possible quality of life within the home’. The home provides personal care and support to residents who are both privately funded and those who are funded by Social Services. The home’s fees range between £410.72-£580.00 per person per week. Additional costs are charged for hairdressing (£4 - £30), chiropody (£10 - £13), manicure, pedicure, newspapers, guest meals, external telephone calls, faxes and e-mails (£ variable). Prospective residents/representatives are provided with written information regarding the services and facilities provided at the home. Copies of these documents are kept on display in the reception area alongside a copy of the most recent inspection report. The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place over a period of 6.5 hours. Evidence used in this report was gained via the Annual Quality Assurance Assessment, Surveys to Residents, discussion with Deputy Manager, two staff and four residents on the day of the inspection. The inspector also looked at all documents relevant to the standards inspected and carried out a tour of the building. Observation also took place in the dining room and communal lounge of staff interaction with the residents. What the service does well: All residents have a pre-admission assessment to ensure that the home can meet the needs of any new resident wishing to come into the home, and that staff are appropriately qualified to meet those needs. Staff respect the residents’ privacy and dignity, and this was confirmed by those residents who completed resident surveys and residents spoken to on the day of this inspection. All residents were happy with the activities on offer in the home, and the contact they have with the community. The food in the home is very good, and the residents praised the choices and quality of food they are given. Both residents and visitors to the home have clear guidelines as to how to make a complaint and this information is prominently displayed in the main entrance hall. The home is very well presented. It is clean and provides a homely comfortable home for the residents. Laundry facilities within the group of homes is good and residents reported that they were pleased with the way their personal laundry was returned to them. There are sufficient staff on duty at all times to meet the assessed needs of the residents. All staff in the home have been well trained in all aspects of health and safety. There is evidence of ongoing training to ensure that all new staff receive the appropriate training and that other staff are able to update their training. The home is well managed, with the manager and deputy working together to ensure there is a sharing of knowledge and skills. The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 Page 6 Personal belongings brought into the home by the residents are well recorded. What has improved since the last inspection? What they could do better: Residents must be given clear information as to the number of the room they will occupy when coming to live in the home and the fees that will be charged and by whom they will be payable. Staff must record in detail what personal hygiene tasks have been carried out with residents that require help with the personal hygiene. All care plans should be reviewed on a monthly basis, with the resident and or their relative/representative signing up to these changes. Residents must have their weight recorded on a monthly basis and any concern regarding gain or loss must be reported to the resident’s doctor. All visits or appointments with health care professionals must be recorded in the residents care plan. Residents records must be kept individually this also refers to daily reports, which should not be kept collectively in daily diaries. All rooms in the home must have an accessible call bell facility so that residents are able to call for assistance in an emergency. More staff need to obtain their NVQ level 2 in Care to ensure that they have basic knowledge and skills to meet assessed needs of the residents in the home. For the residents safety wheelchairs should not be used without footrests in situ. The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 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 The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1, 2, 3 and 6 Quality in this outcome area is good. The homes statement of purpose and service user guide is good. They provide prospective residents with the information they need to make a decision about moving into the home. Pre-admission assessments are generally good and gain sufficient information on which to base a care plan. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Statement of purpose and service user guide has been reviewed and gives clear information to prospective service users. The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 Page 10 While viewing care plans the inspector noted that in three of the four care plans viewed while there was a contract and a statement of terms and conditions, these did not state the number of the room that the resident would be occupying or the fees payable or by whom, and only one contract was signed. The registered manager ensures that she obtains pre-admission assessments prior to the resident moving into the home, it was noted however that in one case where the resident was an emergency referral the pre-admission assessment had not been completed fully. Generally information contained on pre-admission assessments gave good information on which to base a care plan and for the manager to assess whether the home could meet the assessed needs of that resident. The home does not offer intermediate care. The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 and 10 Quality in this outcome area is good. While care plans are informative, staff need to be more vigilant in keeping records up to date, to ensure that all the assessed needs of each resident is met. The health needs of residents are fairly well met and there is evidence of good multi-disciplinary working taking place. The systems for medication administration are good with clear and comprehensive arrangements being in place to ensure residents medication needs are met. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Four care plans were examined as part of case tracking and showed that they contain good information covering the following areas:- a personal profile, The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 Page 12 communication, mobility (including risk assessments for the prevention of falls and pressure area care), eating and drinking, nutritional screening assessments and health and social care needs. It was noted however that daily record sheets for each resident are kept on a separate file, but there are also a daily diaries were information regarding residents is also kept collectively. In daily record sheets it was noted the personal care is not always mentioned and there was no detail of the personal care given. While it is acceptable to keep individual daily records separate from the care plan, by keeping a daily diary with residents names collectively this does contravene the Date Protection Act 1998 and this will be mentioned further on in this record and in the report under Standard 14. Care plans are reviewed but this is not done on a monthly basis for instance dates of review in two care plans were February, April, May, July, September and October. As mentioned previously staff do not state on daily records how they are maintained the personal hygiene of the residents. The deputy manager stated that staff are aware to check for pressure areas, and any concerns are passed directly to the district nurses, who will then visit the home to assess residents for pressure relieving equipment. The home does consult with the continence nurse where a resident needs assessment; she then visits the home and assesses the resident for continence aids. Where there are issues regarding the psychological health referral in the first instance this is made via the General Practitioner to the Consultant Psychiatrist, and an appointment will be made for the resident to visit the consultant or receive a visit from the Community Psychiatric Nurse. On the day of this inspection some of the residents went over to The Normanhurst Care Home to take part in an exercise programme. One residents commented that she enjoys doing the exercises in Normanhurst Care Home. While care plans do have charts for nutritional screening this does not take place on a regular monthly basis. Of the four care plans viewed no weights had been recorded since March 2007. Residents are able to keep their own G.P. if they home is within the G.P.’s catchment area, and there are a several General Practitioner surgeries from which a resident can choose if they come into the home outside of their General Practitioners catchment area. There was evidence in G.P. visits page and professional visits page that residents are able to have access to opticians, chiropodists, dentists etc., but these forms need to be kept up to date as there were big gaps from one chiropody visit to the next. Medication is well managed in the home and there were no errors found. Requirements have been met from the previous inspection in that all policies and procedures are in place relating to Medication general policy, Prescription Drug policy and procedure, Medication Error policy and procedure and homely remedies policy and procedure. All medication is accurately recorded, controlled drugs are not used in the home at the present time. The The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 Page 13 medication fridge is not used at present as there are no medications that need to be kept in the fridge. It is evident from the day of this inspection the staff respect the residents’ dignity and privacy. From discussion with residents comments were – “The staff treat me with respect”. “Yes the staff make sure that I have privacy.” “I am well looked after here, the staff are very good.” “The staff make sure that doors are closed when I am washing, bathing or using the toilet.” “I am allowed to have visitors in my room if I wish to.” “I always see my Doctor in my own bedroom.” The residents have easy access to a telephone if they wish to, and there is a pay phone in the main entrance of the home. The inspector observed that all residents were individually and smartly dressed. One resident said, “The laundry service is absolutely marvellous.” The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 and 15. Quality in this outcome area is good. Activities and links with the community are good and support the resident’s social opportunities. Residents are able to maintain their autonomy and are encouraged by staff to remain as independent as possible. The complaints policy and procedure is displayed in the main entrance hall of the home and gives clear guidelines on how a complaint can be made and the complaints process. There have been no complaints received since the last inspection of this home. From the surveys received at CSCI three residents and or relatives stated that they would know how to make a complaint. Dietary needs of the residents are well catered for with a balanced and varied selection of food available that meets resident’s tastes and choices. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 Page 15 Four residents were spoken to about their day-to-day lives. All said that they were able to choose when to get up and when they could go to bed. They also talked about the activities on offer in the home. One resident said, “I went the care home next door this morning to do some exercises, we go over there quite often.” Another residents said, “The staff do something with us most afternoons. We do not have to join in if we don’t want to, but it is good fun.” On the dining room notice board there were a list of activities that the residents could participate in:- Ball games, Crossword and word search, Bingo, games afternoon, ABC and on Sundays the residents have a film with chocolates. The inspector observed that there was good one to one interaction between the staff and residents. An outside entertainer comes into the home every month. One resident said, “I always look forward to the Holy Communion Service. We also have a music afternoon and that is good fun.” The home is situated very close to the sea front and when the weather is nice, staff take the residents out for a walk. The home has an open visiting policy and visitors are welcome at any time. The local church visits the home on a regular basis. Staff confirmed that residents are encouraged to make choices as far as their levels of dementia allow them to do so. For all residents in the home the relatives/representatives have a power of attorney over their financial affairs. From carrying out a tour of the home the inspector noted that residents are able to bring personal items into the home with them. It was noted however that some daily records are kept collectively in a daily diary, much of the information was quite personal and should be kept on individual daily report sheets, this was also contravening the Data Protection Act 1998. Several residents in the dining room said, “The food is very nice here.” “We are given choices.” The menu for the week is displayed on a notice board in the dining room and verified the residents’ comments. There was evidence that residents are offered many different choices of food if they do no like the two choices offered each day. Specialised diets are catered for, which includes sugar free, fat free and vegetarian. The food is cooked in a central kitchen that also caters for the care home and the nursing home. The inspector noted that when she first arrived, breakfast was being cleared and residents are given a choice of cooked breakfast as well as cereals and toast. The lunch was seen to be nutritious and well presented and consisted of three courses. The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. Residents know their complaints will be listened and acted upon. Staff have excellent knowledge and understanding of adult protection issues, which protects the residents from abuse. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The complaints policy and procedure is displayed in the main entrance hall of the home and gives clear guidelines on how a complaint can be made and the complaints process. There have been no complaints received since the last inspection of this home. From the surveys received at CSCI three residents and or relatives stated that they would know how to make a complaint. Since the last inspection the registered manager has updated the abuse policy and procedure and this now explains what constitutes abuse and how to recognise it. The whistle blowing policy and procedure has also been reviewed. All but the newest member of staff has undertaken Protection of Vulnerable Adults training. The home also has a policy and procedure of The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 Page 17 dealing with violence and aggression that was reviewed in September of 2006. No form of physical restraint is used in the home. There have been no adult protection issues since the last inspection. Neither the registered manager or her staff handle any of the residents monies, any purchases made on the residents behalf is billed by the central office of the home to the relative /representative. The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19, 22 and 26 Quality in this outcome area is good. The standard of the environment within the home is good providing the residents with an attractive and homely place to live. Residents need to have access to call bells to ensure they are safe at all times. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is situated over three floors, the ground floor has communal rooms and some bedrooms including a communal bathroom and toilets, on the first floor and second floor there are bedrooms, communal bathrooms and toilets. The grounds of the home are pleasant but are due to undergo refurbishment with a large patio being provided for the residents. The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 Page 19 The standard of decoration and furnishings throughout the home is very good. All bathrooms are fitted with in-bath hoists and are domestic in character. Most bedrooms are have fitted carpets with just a few bedrooms having a wood effect vinyl flooring to prevent the risk of odours. The standard of maintenance throughout the home is excellent. The main office of the home confirmed that when a bedroom is vacated it is redecorated and new carpets are laid prior to a new resident moving in. It was noted however that in six bedrooms the residents did not have an emergency call bell, while the facilities were provided for a call bell to be plugged in the call bell and cord were missing. On the day of this inspection the home was very clean and tidy and there were no offensive odours. The laundry is sited in the basement of Normanhurst Care Home and caters for all the homes in the group. This laundry is excellently equipped and was seen to be very clean and tidy. All washing machines have a disinfecting and sluicing facility, and there were two large industrial tumble driers. The registered manager has policies and procedures in place for the control of infection. All staff are supplied with disposable gloves and plastic aprons, for use when dealing with personal hygiene and clearing up spillages. Hand washing facilities are sited throughout the home with liquid soap and paper hand towels being provided. The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 and 30 Quality in this outcome area is good. Staff are employed in sufficient numbers to meet the needs of the residents in the home. Staff morale is high resulting in an enthusiastic workforce that works positively with the residents to improve their whole quality of life. Staff are multi skilled ensuring a good quality of care and support. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From the staffing rota and observing the number of staff on duty in the home on the day of this inspection there were sufficient numbers of staff on duty to meet the assessed needs of the residents. Two members of staff said, “ There are sufficient staff on duty throughout the day.” There are sufficient domestic staff employed to keep the home clean, this was observed during the inspection and a tour of the building. The home employs a total of 13 care staff and two domestic staff. The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 Page 21 38 of the care staff have achieve their NVQ level 2 or above. Six further members of staff are in the process of doing their NVQ, when they have completed this will mean that 84 of the staff will have achieved an NVQ qualification. The inspector viewed three personal files, which are kept in the main office of Normanhurst homes. All files are very well kept, and showed that staff undergo a thorough recruitment process, which includes vetting via references, CRB and POVA first checks. Where staff come to work in the home from overseas, the office ensure that they have a ‘Home Office’ work permit. All staff are given a General Social Care Council code of conduct when they start employment in the home. The registered manager has ensured that the majority of her staff have received mandatory and job related training. In some cases some of the staff have missed one or two mandatory training courses, but evidence was available to show that this will be remedied before the end of December 2007. All staff receive an initial induction, which introduces them to residents, staff, the home and systems used in the home including health and safety. They then go on to complete their Skills for Care Induction Pack. From viewing the training matrix and discussion with staff all staff in the home receive more than three days paid training per year. The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38 Quality in this outcome area is good. The registered manager is supported well by the senior staff in providing clear leadership throughout the hoe with all staff demonstrating an awareness of their roles and responsibilities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: On the day of the inspection the registered manager was not on duty. The Registered Manager has been in post since July 2002. Prior to this she worked The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 Page 23 at The Annexe for 12 years. She completed her Registered Manager’s Award in March 2006 and holds an NVQ Assessors Award. The deputy manager showed the inspector around the home, introduced her to the residents in the home and produced all the documents required as part of the inspection. The deputy manager described how she works very closely with the registered manager, and that she is aware of all that takes place in the home. The registered manager has a quality assurance file; within this file there was evidence that residents receive questionnaires, which are mainly filled in by the residents visitors. The deputy manager stated that the manager was very disappointed in the low number of questionnaires received back. Stakeholder questionnaires are also sent out, but this is mainly to General Practitioners, and district nurses. The inspector spoke with the deputy manager, regarding sending questionnaires out to other stakeholders, such at the chiropodist, optician, dentist, care managers, hairdresser, and entertainers who come into the home. This quality assurance system needs to be developed further to show recorded monthly monitoring of care plans and reviews, cleanliness of home, quality of food and regular monitoring of policies and procedures. Evidence was available within the main office of the home to show that regular Health and Safety and Fire Risk Assessments are carried out for the Normanhurst Annexe. Care plans show that all residents’ personal belongings are recorded on an inventory form on admission to the home. None of the residents manage their own finances; families or solicitors who hold Power of Attorney manage this. Where purchases are made on the resident’s behalf for example hairdressing, chiropody, these are billed directly to relatives or solicitors. A record of all expenditures are kept within the main office. As mentioned under Standard 30 the majority of staff in the home have received all mandatory training, with exception of some newer employees, who will have completed this training by the end of December 2007. The registered manager has ensured that the home has up to date policies and procedures in place for all health and safety matters. On inspection of the fire book in the main office it was noted that the home has not had a recent fire drill. Up to date certificates were available for all appliances used in the home. All windows are fitted with window restrictors. Hot water checks are carried out on a weekly basis. The inspector did note that wheelchairs being used in the home did not have footrests in situ. This was discussed with the Deputy Manager who confirmed that staff did not take residents out of the home without having footrests in situ. The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 Page 24 All accidents are recorded appropriately in a Health and Safety Executive accident book. The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 Page 25 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 3 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 2 X X X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 Page 26 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. Standard OP2 Regulation 5(b)(c) Sched. 4(8) Requirement The registered provider must ensure that the contract and statement of terms and conditions inform prospective residents of the number of the room they will occupy and the fees payable. Each resident and or their relative/representative should sign the contract and statement of terms and conditions. The registered manager must ensure that staff record personal care tasks rather then just stating ‘all personal care given’ this is neither adequate or helpful. Daily records when well written, help ensure a consistent approach and good quality of care for the residents. The registered manager must ensure that nutritional screening is undertaken on admission and subsequently on a monthly basis and a record is maintained, including weight gain or loss and appropriate action is taken. The registered manager must ensure that all information DS0000021255.V348342.R01.S.doc Timescale for action 03/12/07 2. OP7 15(1) Sched. 3(1)(b) 03/12/07 3. OP8 14(1)(a) (2) Sched. 3(3)(m) 03/12/07 4. OP14 15(1)(2) (a) 03/12/07 The Normanhurst Annexe Version 5.2 Page 27 5. OP22 23(2)(l) (m)(n) 6. OP28 18(1)(c) (i) relating to a resident is kept individually and not collectively to avoid contravening the Data Protection Act 1998 The registered manager must ensure that call bells with accessible alarm facilities are provided in every room in the house. That at least 50 of care staff are trained to NVQ level 2 in care. This requirement was made at the previous inspection and timescale of 30/09/07 has not been met. 03/12/07 28/01/08 7. OP33 24(1)(a)( b)(2)(3) 8. OP38 23(4)(5) The registered manager must ensure that a good quality assurance system is developed in the home to include seeking views of the external stakeholders and the monitoring of all systems used in the home. The registered manager must ensure that wheelchairs are not used without foot rests in situ. 28/01/08 03/12/07 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. OP7 2. OP8 Refer to Standard Good Practice Recommendations Care plans should be reviewed on a monthly basis and the resident and or their relative/representative should sign any changes. Records should be kept of all visits or appointments from health care professionals, nurses, doctors, chiropodists, opticians, dentists etc. The Normanhurst Annexe DS0000021255.V348342.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000021255.V348342.R01.S.doc Version 5.2 Page 29 - 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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