Inspection on 27/04/06 for The Normanhurst Annexe

This inspection was carried out on 27th April 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 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 Brassey Road Bexhill-on-sea East Sussex TN40 1LB Lead Inspector Niki Palmer Unannounced Inspection 27th April 2006 10:10 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.V289815.R01.S.doc Version 5.1 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.V289815.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Normanhurst Annexe Address Brassey Road 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 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.V289815.R01.S.doc Version 5.1 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 30 November 2005 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 £352-£540 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.V289815.R01.S.doc Version 5.1 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 Thursday 27 April 2006 and lasted approximately six hours. 13 residents were accommodated on the day of the inspection. The inspection began with discussions with the Registered Manager of the home in respect of progress made since the last report. In order to gather evidence on how the home is performing, individual discussions took place with three residents over the lunchtime period, the Inspector having been invited to join them for a meal. In addition, three care staff were spoken with during the visit. Two care records were examined in some detail for case-tracking purposes, both of which were female. Other records and documentation inspected included: the home’s preadmission procedures, medication practices, provision of activities, quality assurance systems, complaints procedure and the systems in place to safeguard residents from harm, neglect and abuse. The environment and some individual rooms were spot-checked. A pre inspection questionnaire was received following the site visit to the home and 10 service user surveys were sent to the home prior to the inspection, six of which have been returned. Following the inspection, telephone contact was made with two relatives and two Community Psychiatric Nurses (CPN’s) to gather further feedback on the home. In order that a balanced and thorough view of the home is obtained, this inspection report should to be read in conjunction with the previous inspection report carried out on 30 November 2005. What the service does well: The Normanhurst Annexe provides residents with a good standard of personal care, which is delivered by an experienced, kind and caring staff team. Comments received include: ‘staff are approachable, attentive and provide good care’ and ‘all the staff are wonderful, I have no complaints’. The home is managed by an experienced and competent person, who has a good level of understanding of the needs of residents with a dementia type illness. The Normanhurst Annexe DS0000021255.V289815.R01.S.doc Version 5.1 Page 6 Activities and the provision of food are managed well by the home. The home has an adequate complaints procedure in place to ensure that all complaints made directly to the home will be dealt with within 28 days. Feedback from residents and visitors to the home is sought on a regular basis. What has improved since the last inspection? What they could do better: Many requirements from the previous inspection report are outstanding, particularly in relation to medication and Adult Protection. These shortfalls have the potential to place residents at risk. In order to support residents who have additional complex behavioural needs associated with dementia, the home is required to provide training to staff. This will not only be of help to residents, but staff also. A number of the home’s policies and procedures are outdated and unknown to staff. The home is required to ensure that these are updated as a matter of priority and accessible to staff. The home’s recruitment procedures have been an ongoing concern over recent inspections with the exception of the last report. On the day of the inspection the Inspector was refused access to these files. The home’s reluctance to allow the CSCI access to staff recruitment records potentially jeopardises the health, safety and welfare of residents. The Normanhurst Annexe DS0000021255.V289815.R01.S.doc Version 5.1 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 Normanhurst Annexe DS0000021255.V289815.R01.S.doc Version 5.1 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.V289815.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. This home has good systems in place to assess prospective residents. This ensures that no one is admitted to the home, whose needs cannot be met. EVIDENCE: Of the six service users’ survey forms that were returned to the Inspector, three stated that they either did not have, or were unsure of whether they or their relative (as some forms had been completed on behalf of residents by a family member), had been provided with a written contract on admission to the home. The Registered Manager explained that all residents are provided with their own copy, which once signed are kept within individual care records, two of which were seen during the inspection, but that family members are not routinely given a copy. It is recommended that the home offer residents’ family members/next of kin a copy of the home’s terms and conditions of contract. The Normanhurst Annexe DS0000021255.V289815.R01.S.doc Version 5.1 Page 10 Only one person has been admitted to The Annexe since the last inspection. The Registered Manager completed a thorough assessment prior to admission alongside the individual and family members in order to determine the level of support that the person required. A good level of information was gathered at this time including a personal profile, detailed personal care needs, use of medication and a falls risk assessment. Intermediate care is not provided. The Normanhurst Annexe DS0000021255.V289815.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are treated well by care staff, however the home struggles to meet the health and personal care needs of residents with complex cognitive needs. The systems in place for the administration of medication remain poor. EVIDENCE: Significant work has been carried out by the Registered Manager to update the home’s care planning procedures. All residents now have a personalised plan of care, which covers the following areas: - a personal profile, 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. Two individual plans of care were examined in some detail as part of the case-tracking process. The first one was found to be suitably detailed and provide care staff with sufficient information to meet the assessed needs of residents, however the home is required to ensure that all care plans are signed and dated by the person responsible for the planning and review. The Normanhurst Annexe DS0000021255.V289815.R01.S.doc Version 5.1 Page 12 The second however, was more complex. Prior to the unannounced inspection, a family member contacted the Inspector to raise concerns regarding the way in which their relative was being cared for by the home. Despite the home having sought appropriate specialist advice in relation to managing and working with a person with complex cognitive needs, through speaking in detail with staff and observing their interactions with residents, it became apparent that the home struggles to meet the needs of residents with behaviour that can be challenging. Despite staffing levels being increased in order to allow for one to one support, the Inspector did note that all staff spoken with appeared to find the increase of work difficult. They used words such as ‘exhausting’, ‘stressed’ and ‘unfair on other residents’. Staff spoken with said that they had received training specific to dementia some time ago, but had not attended any training regarding working with challenging behaviour. The home is required to arrange for additional dementia and challenging behaviour training for care staff in order to support them in their role. A sample of the home’s medication procedures and records were seen. The home uses a Nomad (pre-packed) system, which can be easily monitored. Whilst it was pleasing to note that records were mostly maintained, it was disappointing to find that requirements made at the previous inspection remain outstanding. This includes having a medication error policy and procedure in place, a policy for the use of homely remedies and to liaise with General Practitioners regarding some medicines being prescribed on a PRN (as and when) basis. In addition the home is required to ensure that all handwritten entries are countersigned in order to minimise any errors that could potentially be made. Each of the residents spoken with said that staff treat them at all times with dignity and respect. Indeed this was evident on the day of the inspection. Each of the residents are addressed by their preferred term and have easy access to private areas within the home. Relatives and other health professionals spoken with following the inspection commented ‘the staff are approachable, attentive and provide good care’ and ‘all the staff are wonderful, I have no complaints’. The Normanhurst Annexe DS0000021255.V289815.R01.S.doc Version 5.1 Page 13 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, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Activities, maintaining contact with friends/relatives and the provision of food are managed well. EVIDENCE: All of the service users’ survey forms that were received by the Inspector confirmed that activities are managed well by the home. All events and activities are advertised in the home’s monthly newsletter, which is provided to all residents across the three homes. This also gives details of residents’ forthcoming birthdays, a crossword and poetry written by residents. Regular activities that take place within The Annexe include ball games, music, bingo, cross word/word searches and film afternoons with tea and chocolates. Since the last inspection a new large TV as been purchased for the main lounge area and the aerial reception improved. It is anticipated that a DVD player will be bought in due course. Staff, residents and relatives spoken with said that the new TV has been of great benefit, although one relative was very keen to point out that residents do not sit in front of the TV all day. This was pleasing to hear. All relatives and visitors to the home said that they are always made to feel welcome by care staff when visiting and that there are no restrictions placed on visiting times. Records of all visitors are kept within the home. The Normanhurst Annexe DS0000021255.V289815.R01.S.doc Version 5.1 Page 14 Throughout the duration of the inspection it was evident that positive relationships have been formed between residents and staff. Residents confirmed that the home encourages them as much as possible to make their own decisions and choices (to the best of their ability) in relation to many aspects of their lives. For example, when to go to bed and get up in the morning and what they would like to eat. All meals are prepared in the centrally located kitchen in the adjoining Care Home. A choice of main meal is advertised daily in the dining area of the home. Specialist diets are appropriately catered for including low sugar and vegetarian alternatives. All residents are encouraged to dine together in the pleasantly decorated dining room. The meal served on the day of the inspection looked appetising and plentiful with individual preferences being catered for. On the day of the inspection all care staff were found to be attentive to residents’ needs in the dining area. This is noted to have improved since the last inspection. There is also a small shop located within the Care Home, which sells sweets, soft drinks, biscuits, wine, beer and gift items. Whilst this facility is available to residents from The Annexe, staff commented that it is rarely used due to residents’ impaired cognitive state. The Normanhurst Annexe DS0000021255.V289815.R01.S.doc Version 5.1 Page 15 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 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has good systems in place to ensure that all complaints are dealt with appropriately, however inadequate policies and procedures fail to ensure that residents’ are protected from harm, neglect and abuse. EVIDENCE: The Commission for Social Care Inspection (CSCI) has received no complaints since the last inspection, however the home is currently in the process of investigating a complaint made by a relative. A copy of the home’s complaints procedure is on display in the main reception area and detailed within the home’s Statement of Purpose. It was pleasing to note that all service users’ survey forms identified that all residents and their relatives are aware of how to raise any concerns or complaints directly with the home. It is an outstanding requirement for the home to amend its Adult Protection policy and procedure in accordance with local multi-agency guidelines. Further work is also needed to document what constitutes abuse, how to recognise it, who to report suspected abuse to and details of PoVA (the Protection of Vulnerable Adults). Staff spoken with said that they have received in-house Adult Protection training, however this was not specific to working with people with dementia. The Registered Manager stated that she is keen to attend a ‘Train the Trainers’ Adult Protection external course. She feels that she would be better placed to teach the care staff of the home about the increased vulnerability factors that people with dementia face. No Adult Protection alerts have been raised since the last inspection. The Normanhurst Annexe DS0000021255.V289815.R01.S.doc Version 5.1 Page 16 The Normanhurst Annexe DS0000021255.V289815.R01.S.doc Version 5.1 Page 17 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 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Normanhurst Annexe presents as a warm, comfortable and homely place to live. EVIDENCE: Many areas of the home were inspected and found to be in good working order, clean and safe. A broken window in the first floor bathroom has been replaced and all carpets were found to be clean, with the exception of one resident’s bedroom, which was brought to the Inspector’s attention by the Registered Manager. It is anticipated that all outstanding carpeted areas will be replaced in due course. A bathroom on the ground floor has been completely refurbished. A new longer and wider bath has been be fitted, toilet replaced, walls re-tiled, new non-slip flooring and a new hand basin installed. In addition, a new bath hoist is in situ for residents with reduced mobility. At the last inspection staff commented that residents rarely use the bathroom on the third floor due to The Normanhurst Annexe DS0000021255.V289815.R01.S.doc Version 5.1 Page 18 the fact that they have difficulty getting in to and out of the bath. Since this time a new bath hoist has been purchased, which has made a vast difference to one particular resident who is now able to access this daily with support. All residents’ bedrooms viewed were found to be personalised and decorated to individual preferences. Residents are encouraged to bring their own possessions with them on admission to the home. One of the bedrooms has recently been redecorated and had a cupboard removed. This make the room seem larger. Another resident’s bedroom has had the carpet removed and replaced with homely, attractive non-slip flooring in order maintain cleanliness and hygiene. In addition to the above, the Registered Manager’s office has been improved. All care records are now easily accessible and better organised. The Normanhurst Annexe DS0000021255.V289815.R01.S.doc Version 5.1 Page 19 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): 27, 28 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides adequate training opportunities for staff, however the Registered Provider’s refusal to allow the CSCI access to staff recruitment records potentially jeopardises the health, safety and welfare of residents. EVIDENCE: A total of 10 care staff in addition to the Registered Manager and two domestic staff are employed to work in the home. Of the 10 carers, two have achieved at least NVQ level 2 in care, whilst one is awaiting certification and a further four are currently working towards this qualification. All of the care staff spoken with said that they feel the home is very proactive and supportive in helping them to gain further qualifications in care. Since the last inspection five members of staff have left the care home. Due to one resident’s increase in level of support (one to one), daily staffing levels have been increased to four care staff in the mornings and the afternoons. Agency carers are being used at this time. All carers spoken with commented that the additional pressures of work and reduced numbers of people employed have contributed to a reduction in staff morale. It must be noted that whilst staff morale is low at this time, on the day of inspection all care staff were open and honest with the Inspector and commented ‘I enjoy my work, we all The Normanhurst Annexe DS0000021255.V289815.R01.S.doc Version 5.1 Page 20 really get on, but at the moment we’re all so stressed’. All staff were observed to be attentive towards all residents, kind and caring. Concerns have been raised during previous inspections regarding the way in which staff have been recruited to work in the home. One of the Registered Providers met with the CSCI in August 2005 to discuss these matters. It was therefore disappointing to note that in April 2006, the Inspector received a letter from the Provider to state that he proposed to discontinue the practice of allowing the CSCI access to staff personnel records. Despite the Provider being referred to the CSCI’s legal position under the Care Standards Acts 2000 and Care Homes Regulations 2001 in a response letter, the Provider is continuing to disallow the Inspector access to recruitment records. This matter has been referred to the CSCI’s Regional Legal Advisor. The home is required to comply with the Regulations and allow the Inspector access to all records. The Registered Manager confirmed that all new members of staff employed receive an induction and ‘shadow’ other experienced staff for a period of time prior to working unsupervised. This is identified on staffing rotas, which were seen on the day of inspection. It was a recommendation of the previous inspection report for the home consult with their professional body in respect of the new Common Induction Standards issued by Skills for Care (replacing TOPPS). This has yet to be addressed. All staff have recently attended moving and handling and fire safety training. The Normanhurst Annexe DS0000021255.V289815.R01.S.doc Version 5.1 Page 21 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): 31, 33, 35, 37 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ interests are safeguarded and promoted in respect of the home’s management and administration systems. EVIDENCE: The Registered Manager has been in post since July 2002. Prior to this she worked at The Annexe for 12 years. She completed her Registered Manager’s Award in March 2006 and holds an NVQ Assessors Award. She spoke in depth with the Inspector regarding the knowledge and skills she has gained through additional learning and said that on a personal level she feels more confident and assertive in managing the home. The evidence gained throughout the duration of this inspection supports this. The Normanhurst Annexe DS0000021255.V289815.R01.S.doc Version 5.1 Page 22 At the last inspection the home had begun to think about how they can receive feedback from others about the care that is provided. The first residents and families’ meeting was held in October 2005. Unfortunately since this time a further meeting has not been held, but the Manager is keen to organise another as she feels the first one was very successful. Residents’ and families’ questionnaires are given out regularly, although it must be noted that due to the cognitive abilities of the residents, they are mostly returned by family members. In addition, feedback is gained from visiting health professionals including Community Nurses, General Practitioners and CPN’s. Feedback forms are on display in the main entrance area. The results of questionnaires are published and made available to others, however it was disappointing to note that they are not easy to read and follow. This is unfortunate as the outcome of the questionnaire is very positive for the home. A recommendation has been made in respect of this. The Registered Manager confirmed that one of the Registered Providers of the home regularly visits The Annexe to talk with staff, residents and view the premises. The home is required to ensure that records of these visits are provided to the CSCI in order to measure success in meeting the aims, objectives and Statement of Purpose of the home. All residents’ personal belongings are recorded on an inventory form on admission, copies of which were seen in individual care records. The Registered Manager confirmed that either family members or a solicitor manage residents’ finances and/or hold Power of Attorney. All additional charges for example hairdressing and chiropody are billed directly from the home to family members/solicitors. Records of all expenditures are kept. As already mentioned, a number of the home’s policies and procedures were not produced on the day of inspection particularly in relation to medication and Adult Protection. The home is required to ensure that all policies and procedures are up to date and made available for inspection. Evidence provided within the homes returned pre-inspection questionnaire identified that all equipment is well maintained and regularly serviced including: fire equipment, hot water temperatures, emergency lighting, hoists and adaptations and emergency call system. The Environmental Health Officer visited the home in April 2006. A copy of the report was forwarded to the CSCI, which was very positive for the home. The Normanhurst Annexe DS0000021255.V289815.R01.S.doc Version 5.1 Page 23 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 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X 3 3 3 3 X 3 STAFFING Standard No Score 27 3 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X 1 3 The Normanhurst Annexe DS0000021255.V289815.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. Standard OP7 OP8 OP9 OP9 Regulation 15(1)(2) 18(1)(c) (i) 13(2) Sch 2 13(2) Sch2 Requirement That all care plans are signed and dated by the person responsible for their review. That dementia and challenging behaviour training is provided to all staff. That all handwritten medication administration record sheets are countersigned. That advice from resident’s GP’s is sought in respect of all residents who refuse their medication on a regular basis. This must be clearly documented [OUTSTANDING FROM TWO PREVIOUS INSPECTIONS]. That a medication error policy and procedure is implemented within the home and adhered to [OUTSTANDING]. That a policy for the use of homely remedies is in place within the home [OUTSTANDING]. That the home updates its Adult Protection policy and procedure in line with local multi-agency guidelines. It needs to state what constitutes abuse, how to DS0000021255.V289815.R01.S.doc Timescale for action 30/06/06 31/08/06 30/06/06 30/06/06 5. OP9 13(2) Sch2 13(2) Sch2 12(1)(a) 30/06/06 6. OP9 30/06/06 7. OP18 30/06/06 The Normanhurst Annexe Version 5.1 Page 25 8. 9. OP28 OP29 10. 11. OP33 OP37 recognise it and that Social Services are now the lead agency. The relevant contact details must be included [OUTSTANDING]. 18(1)(c) That at least 50 of care staff (i) are trained to NVQ level 2 in care. Section 31 That the home allows the CSCI & access to all records required to Regulation be in accordance with 19(5) Regulations under the Care Schedule Standards Act 2000 and Care 2 Homes Regulations 2001. 26 That the Registered Provider forwards records of his monthly visit to the home to the CSCI. 17 That the home’s policies and procedures are up to date, made available for inspection and known to all care staff. 30/09/06 30/06/06 30/06/06 30/07/06 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. 3. 4. Refer to Standard OP2 OP12 OP30 OP33 Good Practice Recommendations That the home offer residents’ family members/next of kin a copy of the home’s terms and conditions of contract. That the home consider making an area of the garden secure so that residents can access the garden safely in the summer months. That the home consult with their umbrella body in respect of the new Common Induction Standards issued by Skills for Care (replacing TOPPS). That the results of residents’, relatives’ and visitors’ questionnaires are analysed and made available in a format that is easy to read and understand. The Normanhurst Annexe DS0000021255.V289815.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex 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 DS0000021255.V289815.R01.S.doc Version 5.1 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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