Care Home: Norfolk House

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What the care home does well The AQAA states "personal care is delivered according to each service user`s plan of care" this was evidenced by the signing of the carer plans by the service user /relative to demonstrate their involvement. The acting manager has amended the daily shift plans to make them more explicit. We were told this has been implemented to make people more accountable for what they do, to take responsibility for carrying out specific duties, to help improve the systems that they follow and help in monitoring the delivery of care services in the home. Care staff spoken to supported this new way of working, saying they felt supported and more responsible for what they are doing and feel they can discuss issues they feel unsure about with the acting manager. What has improved since the last inspection? We were told the company has introduced the "Nutmeg" system on their intranet. This has enabled the chef to devise balanced and nutritious menus with the aid of the Nutmeg guidelines that break down the fat, carbohydrate and protein value of all foods incorporated into any dish. The result is displayed by means of a colourful graph that determine if meals are well balanced. We were told that this system is very helpful and beneficial to menu planning and in helping to ensure service users choose and enjoy a healthy and nutritious diet and maintain good health. The home has created an album of activity photographs, which in itself has created another activity as it provides a visual reminder of enjoyable pastimes and as a topic for discussion which encourages service users to talk about what has gone on in their daily lives at the home. Their records demonstrated that they have responded in a positive way to complaints and allegations received, and they have taken ownership of any mistakes/failures that have occurred and have taken steps to raise staff awareness of the issues that can lead to complaints and allegations being made against the home. Improvements have been made to the garden to include a new pagoda area where service users can sit and relax Many of the service users told us they were looking forward to spending time out there when the weather gets warmer. CARE HOMES FOR OLDER PEOPLE Norfolk House 39 Portmore Park Road Weybridge Surrey KT13 8HQ Lead Inspector Mavis Clahar Unannounced Inspection 26th February 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Norfolk House DS0000017628.V358003.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. Norfolk House DS0000017628.V358003.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norfolk House Address 39 Portmore Park Road Weybridge Surrey KT13 8HQ 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) 01932 820300 01932 821001 norfolk.house@schealthcare.co.uk Ashbourne Homes Ltd Mrs Elizabeth Werrett Care Home 76 Category(ies) of Old age, not falling within any other category registration, with number (76), Physical disability over 65 years of age (3) of places Norfolk House DS0000017628.V358003.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 52 beds providing nursing care for elderly people from the age of 60 years. 24 residential beds including up to three service users in the category PD(E). 1 person aged 56 years or above may be admitted for short term convalescent residency at any time. 29th November 2006 Date of last inspection Brief Description of the Service: Norfolk House is a purpose built home situated in central Weybridge, providing nursing and personal care to seventy-six older people. Accommodation is provided over three floors, with six spacious lounges and, three dining rooms. The majority of the bedrooms are single with a few double rooms. All bedrooms have en-suite facilities. Passenger lifts and stairs serve the first and second floors. The home is served by good transport system, the railway station is close by, and the home is easily reached from junction 11 of the M25. The home has its own transport in the form of a mini bus in which service users can enjoy visits to many of the local attractions such as Hever Castle, Polsden Lacey and Gamshaw mill. To the rear of the property is a large garden with patio area, whilst the front of the property is laid out for car parking. Fees at this home are in the range of £449.17 to £750.00 per week (Nursing) and £318.46 to £650 per week (Residential care). Costs for hair dressing, chiropody and personal toiletries newspapers and magazines are borne by the individual service user. Norfolk House DS0000017628.V358003.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This unannounced site visit, which forms part of the key inspection to be undertaken by the Commission for Social Care Inspection, (CSCI) was undertaken by Mrs Mavis Clahar on the 26th February 2008 and lasted for seven hours; commencing at 09:30 hours and concluding at 16:30 hours. The CSCI Inspecting for Better Lives (IBL) involves an Annual Quality Assurance Assessment (AQAA) to be completed by the service, which includes information from a variety of sources. This initially helps us to prioritise the order of the inspection and identify areas that require more attention during the inspection process. This document was received by CSCI and is referred to throughout the report. The registered manager of the home has resigned and a deputy manager from another home within the Ashbourne Homes Limited is managing the home. The majority of the service users spoken to were able to express their thoughts and feelings about the care they receive. The information contained in this report was gathered mainly from observation by the inspector, speaking with a number of service users, and with care staff. Further information was gathered from records kept at the home. The first part of the inspection was spent discussing and agreeing the inspection process with the manager, followed by a tour of the home, which included time spent in discussion with service users, care workers and the Chef. The manager and staff are aware of the Laws regarding equality and diversity and this was reflected in the staff mix. All service users in this home are Caucasian and reflect the population of the area in which the home is situated. All records sampled were up to date with care plans being signed by the service users or by relatives. A number of requirements and recommendations of good practice were issued on this visit Please see Environment outcomes for full disclosure. The final part of the inspection was spent giving feedback to the acting manager about the findings of this visit. The inspector would like to thank all the service users and care staff that made the visit so productive and pleasant on the day. Norfolk House DS0000017628.V358003.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? We were told the company has introduced the “Nutmeg” system on their intranet. This has enabled the chef to devise balanced and nutritious menus with the aid of the Nutmeg guidelines that break down the fat, carbohydrate and protein value of all foods incorporated into any dish. The result is displayed by means of a colourful graph that determine if meals are well balanced. We were told that this system is very helpful and beneficial to menu planning and in helping to ensure service users choose and enjoy a healthy and nutritious diet and maintain good health. The home has created an album of activity photographs, which in itself has created another activity as it provides a visual reminder of enjoyable pastimes and as a topic for discussion which encourages service users to talk about what has gone on in their daily lives at the home. Their records demonstrated that they have responded in a positive way to complaints and allegations received, and they have taken ownership of any mistakes/failures that have occurred and have taken steps to raise staff awareness of the issues that can lead to complaints and allegations being made against the home. Improvements have been made to the garden to include a new pagoda area where service users can sit and relax Many of the service users told us they were looking forward to spending time out there when the weather gets warmer. Norfolk House DS0000017628.V358003.R01.S.doc Version 5.2 Page 7 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 summary of this inspection report can be made available in other formats on request. Norfolk House DS0000017628.V358003.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 Norfolk House DS0000017628.V358003.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): 3 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. Prospective service users and their relatives have the information needed to choose a home, which will meet their needs and service users are being assessed to ensure the home is capable to meet the needs of the service users prior to being admitted into the home. EVIDENCE: Review of service users documents and identified policies demonstrated the home has a policy and procedure on admission and discharge of service users. Within the admission policy all service users must have an assessment prior to being admitted into the home. The Manager, and in her absence, two Registered Nurses who are trained in the principles of assessment of service users’ needs based on what the care the home says it will provide carries out Norfolk House DS0000017628.V358003.R01.S.doc Version 5.2 Page 10 all pre admission assessments of service users prior to them being admitted into the home. Review of a random sample of service user’s files including one recently admitted service user, demonstrated that pre admission assessments are being carried out and relatives were being involved in the assessment process. Norfolk House DS0000017628.V358003.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): 7 8 9 10 People who use the service experience good quality outcomes in this area. This judgement has been using a range of evidence including a visit to this service. The home has a good and clear care plan in place for service users and this includes appropriate risks assessments. Which forms the basis for care based on the agreed care needs of the service users and demonstrated that trained staff met service users’ health and personal care needs. The home’s medication policy on receiving, storing and administering of medication was in place and being adhered to thereby ensuring the safety and protection of the service users. Care workers treated service users with respect and maintain their dignity and privacy when delivering personal care. EVIDENCE: Norfolk House DS0000017628.V358003.R01.S.doc Version 5.2 Page 12 One concern was received by CSCI and was directed to the providers for investigation. Records seen on the day of the visit, revealed this has been investigated and suitable actions were put into pace to prevent a repeat of the concern. The randomly selected care plans were clear and easy to read, identifying potential and actual risks to service users and detailing how these risks would be managed. The daily work sheet along with discussion with service users and care workers demonstrated that service users care needs are fully met. The service user or relative signed the care plans to indicate their involvement in deciding what care they received. It was evidenced that care staff undertaking the development and monthly review of the care plans also signed and dated them. In discussions with service users on the day of the visit they confirmed they were involved in the planning of their daily care. Information contained in the home’s Annual Quality Assurance Assessment (AQAA) states “On the residential side the service we provide enable service users to benefit from the involvement of our team of community nurses and specialist health professionals who supports us in meeting the needs of our service users”. All service users are registered with a local General Practitioner (GP) of their choice and visits are recorded, with access to specialist healthcare professionals through their GP practice as required such as sight and hearing tests which are carried out on a regular basis; and these visits are also recorded in the service user’s folder. Service users are offered access to chiropody service and weekly hairdressing facilities are available at a cost to the service users. In discussion with the registered nurse and care worker they were extremely proud of the high standard of care they provided to all service users in the home. We were told on the day of the visit that no service user at present was risked assess as capable to self medicate. However, the home had a policy on selfmedication should it becomes necessary. The AQAA states “Qualified and senior care staff have all received training in the receipt, recording, storage handling and administration and disposal of medicines. All medicines are administered from a lockable drugs trolley, which is stored in a locked medication room when not in use. We keep a controlled drugs register and record fridge and medication room temperatures daily”. We evidenced this as correct during a tour of the home, when medication was checked. Care staff identified as capable to administer medication are requested to leave a sample of their signature, which is dated in the medication trolley. All service users have a recent photograph included in their personal folder and medication record, to reduce the risk of mistakes happening during medication administration. We observed that care workers wore name badges to enable visitors and service users with memory impairment to be sure of whom they are speaking Norfolk House DS0000017628.V358003.R01.S.doc Version 5.2 Page 13 with; and we also observed Service users being treated in a friendly but respectful manner by care workers. In discussion with service users who were able to understand the questions, they told us that they are treated with respect and dignity, and that they are able to make their own choice. One service user told us “I am very happy here. Everything is so nice. I have my own room; I can have as much privacy as I want”. Another service user said “We have good staff here; they do not ill treat me. I have help to choose my own clothing every day. Norfolk House DS0000017628.V358003.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): 12 13 14 15 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. Service users lifestyles matched their needs and preferences and where possible they are able to maintain contact with family, friends and the local community. Service users are able to make choices in accordance with their abilities and were provided with a balanced diet in mostly pleasant surroundings and in an unhurried way. EVIDENCE: The home employs a full time activity-co-ordinator who provides a range of activities based on the individual assessed and agreed needs, including their preferences, cultural beliefs and customs. We were told that wherever possible relatives are encouraged to participate in the planning and carrying out of service users’ activities. The AQAA states “ We are aware that by creating and maintains a stimulating lifestyle for our service users we have minimised the risk of a decline in their mental and physical health, through boredom, depression and lack of exercise, hobbies and games.” We observed the activities programme displayed in the reception area of the home, in all the three lounges used by the service users and in the dinning areas. Norfolk House DS0000017628.V358003.R01.S.doc Version 5.2 Page 15 The home is situated within walking distance of the town centre and service users are able to walk into town as they wish. The home also has their own Mimi bus, which they use to transport service users to places of interest and the theatre. The C/E Vicar holds monthly services at the home, and those service users who are able attends Church in the community. We were told by service users that they are able to have their friends and relatives visit any time it is convenient for them to visit. Fiver of the service users spoken to said they had choice in their clothing and sometimes they receive help from their key worker. On the day of inspection all service users were dressed appropriately for the weather. The AQAA states “With mealtimes playing a very important part in our service users, we believe we have created a very attractive and welcoming dinning room; our tables being dressed with freshly laundered and colour coordinated table linen every day and vases of flowers, and daily menus which includes four alternative choices to the main courses are displayed for the use of our service users.” . We observed jugs of fruit juices and squash with glasses were placed in the lounges whilst service users were present, and staff was seen offering drinks to service users. We observed a marked improvement in the décor of all the three dining areas, and in discussion with service users they said they were very pleased with the redecorations. On examining the servery areas adjacent to the dining rooms it was apparent that these areas were in need of refurbishment and requirements were made. For more in-depth information please see Environment outcomes. The inspector did not sample the lunch, but service users said the food was very good, tasty and the right amount. The inspector observed the presentation of the food was done in a way to stimulate appetite. Some service users had supplements as ordered by their GP or dietician, to maintain body weight or increase appetite. Fruit juices were served with lunch, which was served in the dinning room unless a service user requested to have their meals in their bedrooms. We observed care workers interacting in a friendly but dignified manner with service users during the lunch time, sitting down beside service users and speaking to them whilst helping them with their lunches. Norfolk House DS0000017628.V358003.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): 16 18 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. The home has a satisfactory complaints policy and procedure and training in place that evidenced that service users and relatives concerns are listened to and acted upon. Robust Safeguarding adults’ policies are in place to protect the service users from abuse. EVIDENCE: CSCI received one complaint about the home which was referred to the providers who dealt with this satisfactorily as the records demonstrated on the day of the visit. The AQAA stated the home received forty-one complaints in the last year all of which were dealt with within the home’s time frame for dealing with complaints, and none was upheld. This was verified on the day of the visit by reviewing their complaints The Acting manager told us that he is in touch with service users on a daily basis and issues raised are dealt with immediately; this reduces the incidents of formal complaints. Service users spoken to said they know how to complain and will do so if they are not happy. Their complaint is always dealt with immediately and they were satisfied with the outcomes. Norfolk House DS0000017628.V358003.R01.S.doc Version 5.2 Page 17 It was observed that the home’s guest information pack situated in reception contained a complaints procedure and policy; whistle blowing policy and the homes’ statement of purpose. It was noted that the home received a number of compliments from relatives of service users commending the staff on their kindness and understanding and for the high quality of work they perform. A copy of the most recent CSCI report was not made available for visitors to the home and a recommendation was made to rectify this and it was done immediately. In discussion with care workers, it was apparent they are aware of the homes’ policy and procedure on Safeguarding Adults and felt secure in the knowledge that if they had to use the whistle blowing procedure the manager and the Owners of the home would support them. During discussion with care workers it became apparent they did not have a full knowledge on Equality and Diversity issues relating to the service users they were responsible for. A random sample of care workers training record demonstrated that care workers are being trained to undertake the duties of meeting the service users assessed needs, thereby protecting them from abuse. Norfolk House DS0000017628.V358003.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): 19 26 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that meets the specific needs of the people who live there. The home is becoming more comfortable and has a programme to improve the decoration, fixtures and fittings. Occasionally there is slippage of timescales and maintenance tends to be reactive rather than proactive. EVIDENCE: We were told the management and staff encourages service users to see the home as their own home. It presents as a comfortable, attractive home, which has all the specialist adaptations, needed to meet the service users needs. It was noted that call bells were left within reach of each service users and service users said the bells are answered promptly. Norfolk House DS0000017628.V358003.R01.S.doc Version 5.2 Page 19 We observed during the tour of the home that all three serveries situated next to the dining rooms were in need of refurbishment, with some items such as the heated food store needing replacing with a heated food store which had doors, to enable service users’ food to be kept at the right temperature. The flooring in these areas also needs replacing. Requirements were made on this standard. It was also noted that the heated food survery in the dining room on the ground floor was dirty. An immediate requirement was made to have this clean. A further immediate requirement was made to clean the fridge freezer in the same dining room and to defrost the freezer. The flooring of the corridor leading from the kitchen to the laundry area must be replaced to ensure the safety of all persons using this passageway. A requirement was issued on this standard. The home has attractive gardens, which are well maintained and there is good access to the gardens from various parts of the home. Some service users told the inspectors that they try to go out daily weather permitting to enjoy the gardens. The home has constructed a new pagoda with paved area for the use of the service users, but some service users told us it is almost impossible to access this in a wheelchair, as there is no path and to gain access one has to be pushed up a slight incline over grass. In discussion with the acting manager this was supported. A requirement was made to review access to the pagoda area of the garden for all service users. We observed a large amount of used furniture stored on the back patio. We were told the home is waiting for them to be collected. A recommendation was made to chase the collection company as the furniture was occupying a large amount of the patio, which is for the use of the service users. The inspector noted that adverse weather would not stop service users enjoying the garden, as the windows are low enough to allow service users to view the gardens from their armchairs. It was noted that service users were able to personalise their bedrooms with small items of furniture, paintings on the wall and many family photographs. Generally, the home presents as clean, pleasant, hygienic and tidy and free from offensive odours. Random review of care workers training record demonstrated they have had training in infection control and this was evident in the storage of waste. The AQAA stated, “ staff are trained on the safe disposal of clinical waste and are provided with protective clothing to minimise the risk of spreading infection”. We observed staff wearing disposable gloves and aprons whilst undertaking tasks during the visit. Norfolk House DS0000017628.V358003.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): 27 28 29 30 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to this service. Staff in the home are trained, skilled and in sufficient numbers to fulfil the aims of the home and meet the changing needs of the service users. EVIDENCE: Review of the staff rota demonstrated the number and grade of staff on duty to provide care and attention to service users for any twenty-four period was suitable to meet the assessed care needs of the service users. The acting manager told us the home had gone through a period of loss of staffing but is now in the good position of having the correct numbers of staff to meet the needs of the service users. We reviewed the home’s programme of planned training, and staff files reviewed evidenced all members of staff have an individual training record. Over 50 of care workers have attained the National Vocation Qualification at Level 2 (NVQ L2). We were told Care workers are encouraged and enabled to undertake developmental training as well as the mandatory training. All newly appointed staff undertakes the Skills for Care Common Induction programme. The home ensures that staff undertakes the mandatory training with yearly updates as necessary to maintain their competency to fulfil their duties. This was evidenced through discussion with the manager and care workers and from review of care workers training records. Norfolk House DS0000017628.V358003.R01.S.doc Version 5.2 Page 21 It was noted that one staff member had no references in their personal file. We were told this member of staff has been with the home for a long time, and the acting manager presented their supervision record, which evidenced good work history. We were told all care workers are Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) checked prior to commencing employment, and they are in receipt of terms and conditions of employment, as evidenced in their randomly selected files, which contained the information required under care Homes Regulations 2001 Schedule 2. The acting manager told us that supervision records were up to date and this was verified during random sampling of care workers files. Documented evidence indicated that the home ensures that care workers receives the mandatory training with yearly updates as necessary to maintain their competency to fulfil their duties. This was evidenced through discussion with the acting manager and care workers. In discussion with care workers some were able to give examples of how the home applied equality and diversity to the different needs and wishes of the service users in their care, and also within the diverse staff group. Staff files contained their up to date training records and it was noted that Equality and Diversity training was not done. In discussion with the acting manager he provided evidence that this aspect of training was down for discussion with the Company Trainer. A recommendation was made to include Mental Capacity Act training as well. Norfolk House DS0000017628.V358003.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): 31 33 35 38 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence including a visit to the service. The acting manager has the experience to run the home and works to continuously improve services and provide an increased quality of life for the service users. There is a strong ethos of being transparent and open in all areas of running the home. The views of service users and their relatives are actively sought in the running of the home and The service provides training on health and safety issues for all staff and service users are involved in the running of the home. Service users financial interests are safeguarded EVIDENCE: Norfolk House DS0000017628.V358003.R01.S.doc Version 5.2 Page 23 The acting manager is a registered nurse with long managerial experience in the NHS and has been a deputy manager for another home within the group of homes of which this is a member. The acting manager has demonstrated that he has kept himself updated on issues relating to care of the service users and staff in his charge. In discussion, it was evident he was knowledgeable about the training needs of the care workers to meet these identified needs. There are clear lines of accountability within the home, each member of staff spoken to on the day of inspection aware of their role and responsibilities. Regular residents meetings are arranged and minutes of the meetings are passed to the owners who will action requests as soon as possible. The home does not become involved in service users finance except for service users spending money, which the home oversees. Receipts are kept and logged for all transaction carried out on behalf of service users.. Review of documented records demonstrated that health and safety checks are routinely carried out at the home. All equipment examined on the day was properly maintained. Records indicated that fire drills, fire alarm, water temperature fridge and freezer recordings were regularly checked. Random sample of care workers’ training files demonstrated that up to date and relevant training were carried out by care workers to protect service users’ health, welfare and safety. In discussion with care workers they discussed their understanding and implementation of appropriate procedures to safeguard service users. Further more they spoke about their understanding of promoting safe working practices based on their health and safety training. In discussion with the acting manager he was able to produce evidence of records for domestic, catering, standing hoists, bath hoists, wheelchairs, fire, electricity, boiler and central hearing checks and repairs since the last inspection. We reviewed their record of Regulation 26 visits to the home as well as their record of Regulation 37 within the last six months. Norfolk House DS0000017628.V358003.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Norfolk House DS0000017628.V358003.R01.S.doc Version 5.2 Page 25 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP19 Regulation 23 (2) (c) Requirement Timescale for action 26/09/08 2 OP19 23 (2) (d) 3 OP19 23 (2) (a) The servery area on all three floors of the home needs replacing. The hot food fixed trolleys, the counter tops, the wash hand basin the under cupboard shelving and the floorings must be replaced to reduce the possibility of infection and accidents to service users and staff. The flooring along the corridor 25/04/08 from the kitchen to the laundry must be replaced to reduce the possible incidents of accidents to service users and staff Ensure there is suitable access to 25/04/08 the pagoda area for service users in wheelchairs RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000017628.V358003.R01.S.doc Version 5.2 Page 26 Norfolk House 1. 2 Standard OP30 OP19 Training on the mental capacity Act should be included in the training programme planned for this year. Chase the company employed to remove the old furniture from the patio as this is restricting the space on the patio for the service users use. Norfolk House DS0000017628.V358003.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Maidstone 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 Norfolk House DS0000017628.V358003.R01.S.doc Version 5.2 Page 28 - 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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