Archived: Norfolk Villa Residential Home

We carried out an unannounced comprehensive inspection on 26 September 2016. The overall rating was ‘requires improvement’. We issued a requirement notice and told the provider to take action in relation to how people's confidentiality was promoted and to how their money personal money was stored. Improvements were also required to ensure staff used people's care plans to help plan and deliver people's care in line with their needs, wishes and preferences, and opportunities for social engagement required further development. In addition, the management of people's medicines required strengthening, and further action was required to ensure the newly designed systems and processes which had been implemented to monitor the quality of the care, were embedded into practice. Following the inspection, the provider sent us an action plan, telling us how they would make improvements.

We carried out a comprehensive inspection in December 2017 and looked at whether improvements had been made for issues raised from the inspection in 2016. At the time, we found that people’s confidentiality was respected, people’s money was looked after safely and people had comprehensive care plans in place.

However, in December 2017, we found that people still did not have much opportunity to remain physically or cognitively active and that improvements were still required regarding medicines management. We also found the environment had not been assessed to ensure it was safe for all people living there and that people were not always protected from the risk of infection. We found people did not always have access to sufficient numbers of staff, people were not always treated with dignity and respect and their privacy was not always promoted. People’s needs or preferences regarding the end of their life, food and mealtimes and the décor and environment had not always been sought or respected. People had not always been involved in developing the service and the provider had not effectively monitored the service to ensure improvements were made to its quality and safety. The provider had not ensured that the culture of the service was positive, inclusive or person-centred and staff told us they did not feel valued by the provider. The provider had a limited understanding of the regulations which underpin the running of the service.

Following the inspection in December 2017 we met with the provider to discuss our concerns with them. We also took enforcement action, to impose a condition on the provider's registration. This meant on a monthly basis, the provider was requested to submit a report detailing action they had taken to ensure: people’s end of life wishes were known, the safety and temperature of the environment was assessed, infection control practices were monitored, the number of medicines people had available was monitored, people had clear information in place for ‘when required’ medicines and people’s privacy, dignity and social needs were met. The Commission had been receiving and reviewing the provider's monthly returns, which had demonstrated ongoing improvement at the service. The findings of this inspection found the information which had been provided had not always been fully accurate and did not always reflect the current regulatory position within the service.

Norfolk Villa Residential Home is a ‘care home’. People in care homes receive accommodation and nursing or personal care as single package under one contractual agreement. CQC regulates both the premises and the care provided, and both were looked at during this inspection. Norfolk Villa Residential Home provides care and accommodation for up to 19 older people, some of whom are living with dementia. Accommodation and facilities at Norfolk Villa Residential Home are situated on two floors, with access to the upper floor via stairs and/or a stair lift. There is a lounge, dining room and outside patio area, as well as some shared bathrooms, shower facilities and toilets. At the time of the inspection 13 people were living at the service.

The provider has responsibility for the management of the service and has no requirement to have a registered manager. A registered manager is a person who is registered with the Commission and has legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. However, in 2016 the provider had sought support with the running of the service, by employing an acting manager from a health and social care consultancy firm. They had recently decided to employ the acting manager permanently and they were in the process of registering with the commission

The inspection took place on 21 and 27 September 2018 and was unannounced.

The provider and manager had not always learned from information provided by previous inspections. We found some areas of improvement regarding infection control had been identified, however these were not all being monitored to ensure they improved. We found the environmental risk assessment had still not been used to assess the risk of toiletries and cleaning products being left unsecured in the home. We also found the provider’s monitoring of the service had not identified gaps in records such as people’s fluid intake not being recorded or monitored effectively. Alternative methods of communication people might require had not been considered as part of people’s care plans. Action had been taken to improve the décor and the environment and people had been involved in making some of these decisions. However, simple things, like ensuring paperwork was not left over the dining table, changing the names on people’s doors and putting unused equipment, furniture and furnishings away rather than leaving them in communal areas, had not been considered. These concerns had all been raised at the previous inspection.

People did not always have risk assessments in place relating to significant health needs. One person had not been referred to an external professionals to ensure staff had guidance on how to keep them safe. People were not always protected from risks such as legionella. When people required the amount they drank monitoring, records had not been completed in a way that would enable staff to identify any concerns. No-one had been allocated to monitor these records to ensure people were regularly drinking enough. People’s culture and language had not always been reflected in their care plans or how this might affect the way they wanted to be supported. These gaps had not been identified or addressed as part of the manager’s or the provider’s quality monitoring system.

The way people and staff talked about the service and the things they were now able to do, showed the culture of the service was changing. People felt more involved and shared with us things the staff, manager and provider had done to make them feel valued and important. However, there were no clear values or aims for the service against which the provider could monitor the performance of the staff team or the culture within the home or staff team.

People now had more opportunities to remain physically and cognitively active and it was clear people and staff were enjoying them. Group and individual activities had been developed according to people’s interests and preferences. People told us the food had improved and staff told us there was a lot more choice available now.

People and staff told us there were enough staff to meet their needs and we saw staff had time to spend with people. People’s privacy and dignity were respected and people told us they were treated with respect. People now had end of life care plans in place and an end of life ‘champion’ had been identified who would share best practice with the staff team.

People told us they felt safe using the service. Staff had received training in how to recognise and report abuse and people also had access to information about how to report concerns. People were supported to access healthcare professionals as and when needed.

People received support from staff who knew them well and had the knowledge and skills to meet their needs. People and their relatives spoke highly of the staff and the support they gave. People were supported to maintain important relationships and visitors were always w

Improvements were also required to ensure staff used people’s care plans to help plan and deliver people’s care in line with their needs, wishes and preferences, and opportunities for social engagement required further development. In addition, the management of people’s medicines required strengthening, and further action was required to ensure the newly designed systems and processes which had been implemented to monitor the quality of the care, were embedded into practice. Following the inspection, the provider sent us an action plan, telling us how they would make improvements and during this inspection we looked to see if action had been taken.

Norfolk Villa Residential Home is a service which provides care and accommodation for up to 19 older people, some of whom are living with dementia. Accommodation and facilities at Norfolk Villa Residential Home are situated on two floors, with access to the upper floor via stairs and/or a stair lift. There is a lounge, dining room and outside patio area, as well as some shared bathrooms, shower facilities and toilets. On the day of the inspection 15 people were living at the service.

The provider had responsibility for the management of the service and has no requirement to have a registered manager. A registered manager is a person who is registered with the Commission and has legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run. However, in 2016 the provider had sought support with the running of the service, by employing an acting manager from a health and social care consultancy firm. The acting manager is referred to as the manager throughout the report.

We carried out an unannounced comprehensive inspection on 05 December 2017 and 08 December 2017.

People continued to live in a service which was not effectively assessed and monitored by the provider to ensure its ongoing quality and safety. Despite, the provider employing a consultancy firm to manage the service on their behalf, the provider did not have effective systems and processes in place to monitor the ongoing standard of the service, and to help ensure the service met regulations.

The provider had a limited understanding of the regulations which underpin the running of the service, in particular, the regulation relating to good governance. The continued rating of requires improvement since 2015 demonstrated the provider did not continuously learn and improve the service.

People lived in a service which did not continuously and positively adapt to changes in practice and legislation. For example, the provider and manager did not know about the CQC’s changes to the Key Lines of Enquiry (KLOEs). They were also not aware of the Accessible Information Standard (AIS). The AIS is to ensure services fully meet people’s information and communication needs, in line with the Health and Social Care Act 2012. Both of these came into effect from 01 November 2017.

People lived in a service which did not have a positive, inclusive and person-centred culture. The provider told us the ethos of the service was to offer a homely and family ordinated service. Whilst, these values were seen to be embedded into staffs practice, staff told us they did not feel the provider demonstrated these values.

The provider had not always notified the Commission of significant events which had occurred in line with their legal obligations. For example, the approval of Deprivation of Liberty Safeguard (DoLS) applications.

Staff spoke highly of the manager, and felt respected, supported and valued by them. The manager was open and transparent, and worked in partnership with key organisations for the benefit of people, for example the local safeguarding team. The manager was able to tell us of their understanding of the Duty of Candour. The Duty of Candour means that a service must act in an open and transparent way in relation to care and treatment provided when things go wrong. The provider, although open and transparent, did not know what the Duty of Candour was. This demonstrated the provider did not effectively keep his professional knowledge and development up to date.

Overall people received their medicines safely. However, monitoring checks had not always identified when improvements were required, in respect of stock control and the risk assessment of topical medicines (creams).

Whist people did not complain about the numbers of staff, the provider had not continually assessed the staffing needs at the service, to ensure they met with people’s changing care needs.

People did not live in an environment which had been effectively assessed to ensure its safety. Areas in the service, such as this kitchen were accessible to people, however risks associated with this had not been assessed to ensure people’s safety. The temperature of the service was not effectively monitored to ensure it met with people’s preference.

People were not always protected by infection control practices. Practices were not in line with infection control guidance. People did not always live in an environment which was free from odour. Two people’s bedrooms smelt of stale urine, and tobacco smoke drifted through the lounge from the outside smoking area, which was used by people and staff. Although, people did not comment about the smell of smoke, inspectors found the smell to be overpowering.

People were protected in the event of a fire. Staff had undertaken training, and the fire system was checked in line with manufacture guidelines. Moving and handling equipment was checked and serviced as required. However, the call bell system which was an old system was not serviced to ensure it was in good working order. This meant there could be an unnecessary risk of it breaking down.

People told us they felt safe, with one person telling us “I feel safe living here”. People were protected from abuse because staff knew what action to take if they suspected someone was being abused, mistreated or neglected. People’s personal money was safely managed. People told us they felt confident to complain, with one person telling us, “I will speak up if I have any concerns, I’ll speak to (the manager). People were supported with decisions relating to their care and advocates were appointed when necessary. People’s human rights were protected.

People who had risks associated with their care needs had these managed to ensure their ongoing safety. People were supported to eat and drink enough. Whilst, people were complimentary of the food, the manager told us that some people had commented about the quality of the meals in a recent quality questionnaire. So action was being taken to make improvements. The mealtime experience required improvement to ensure it met with people’s preferences.

Overall, people lived in a service which had been designed and adapted to meet their needs. However, signage was not always present to help ordinate people to where they were, this meant people may become anxious and get lost.

People’s care and support needs were assessed to ensure their needs were met. People received a co-ordinated approach to their care. People’s care records recorded when advice had been sought from external health and social care professionals, such as district nurses and social workers.

People were not always supported to live heathier lives. People who chose to smoke were joined in the smoking area by staff who worked at the service, who also smoked. This did not promote and encourage people’s day to day, health and wellbeing.

People received care from staff who had undertaken training to meet their needs. Staff told us training opportunities were good, but they would prefer more face to face training, rather than ELearning. Staff received an induction prior to commencing their role to introduce them to the provider's ethos and policy and procedures. Staff who had no experience in the sector completed the care certificate. The care certificate is a nationally recognised qualification for care workers new to the industry.

People were not always treated with dignity and respect. People did not always have their correct name on their bedroom door, and in one person’s bedroom, their continence aids were visible in large numbers. People’s privacy was not always promoted because staff did not always knock on people’s bedrooms doors, prior to entering them. People’s confidentiality was respected. Conversations about people’s health and social care needs were held in private.

People told us, “I like living here”, “The staff are so good” and “They are lovely people”. Staff displayed a kind approach in their care of people, and spoke fondly of the people they cared for. Special occasions, such as people’s birthdays were remembered and celebrated. People’s communication needs were considered and staff adapted their approach to ensure they met people’s individual needs. People’s equality and diversity was respected.

People continued to not always have the opportunity to take part in organised social engagements. A recent quality questionnaire, completed by people living at the service had also identified people wanted more to do, but staff told us they did not have the support of the provider to make this better.

People’s care plans were detailed and provided information about their healthcare needs. Staff, were knowledgeable about how to meet people’s needs and were able to describe how they delivered people’s care in line with their care plans. However, care plans relating to people’s end of life care were not always personalised

We undertook this comprehensive inspection on the 22 September 2016. We undertook this inspection to confirm that the service now met legal requirements. The inspection was unannounced.

The service provides care and accommodation for up to 19 older people, some of whom are living with dementia. On the day of the inspection 14 people were living at the service.

Accommodation and facilities in Norfolk Villa are situated on two floors, with access to the upper floor via stairs. There are some shared bathrooms, shower facilities and toilets. Communal areas include a lounge, a dining room and an outside patio area.

There was a registered provider; the service did not require a registered manager in post. The registered provider had sought the advice and expertise of a consultancy firm and they had employed an acting manager. The acting manager is referred to as the manager throughout the report. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At this inspection we found improvements had been made to the systems and processes in place to support good governance. We found people were safe, and care provided appropriate to people's needs. However, we continued to have minor concerns regarding medicine management and although care plans and risk assessments were in place, these required greater personalisation. Our findings were already incorporated into the manager’s plan for the next 6 months.

Medicine management had improved significantly however we found verbal orders from doctors were being taken by staff over the telephone which could be misunderstood and had the potential to cause risk to people. We also found hand written entries on people’s medicine charts were not always checked by a second person which might cause errors in the medicine they received. Clarity was required where people were on a variable medicine dose so the rationale for giving a certain dose was clear and consistent. The staff immediately put systems in place to address this during the inspection.

Staffing levels met people’s needs, were flexible, and staff had received training to meet people’s needs. Staff had a good knowledge of people’s care plans and had been involved in developing these alongside people where they wished to be involved. Staff were supported and learning and recent changes to the processes in place were being embedded through staff meetings and supervision.

People’s human rights were respected. People were central to decisions about their care and treatment and their consent was asked for prior to any interventions. The Mental Capacity Act (2005) was better understood and staff knew when restrictions in place might amount to a deprivation of liberty.

People enjoyed a healthy diet. There were systems in place to ensure essential information regarding allergies and preferences were known. People’s weight was monitored and where there were concerns and specialist advice was needed, prompt referrals were made.

People had access to their doctor when they were unwell and specialist care when required. Referrals had been made promptly and external professionals involved in people’s care.

Staff were caring and kind. Although further work was required to embed end of life care planning and discussions; staff cared for people compassionately and people had pain free, dignified deaths.

Staff had good knowledge of people, they talked about people with fondness and they did special things which made people feel they mattered. For example buying their favourite foods and celebrating dates which were meaningful to them.

Care plans were more organised, clearer and reflected people’s needs and risks. However, further work was required to make care plans more individualised and people's personal confidential information was not always stored securely.

Activities were minimal in the home. People told us when activities occurred such as musicians, they loved these, and this was an area the manager wished to develop further with the support of the registered provider.

Complaints processes were in place and managed promptly. People told us they had no concerns and would talk to staff if they did.

The manager had worked alongside the staff team to develop systems and processes which made the care at Norfolk Villa safer and the atmosphere and culture better. Audits were identifying issues and these were being actioned. The structures for a quality service were in place but these required further consolidation and embedding into practice through on going supervision and staff training.

Although there was significant change, we have rated the service as ‘requires improvement’ because it is too early to be certain the service will maintain full compliance in the future. Norfolk Villa is required to continue to send the Commission monthly progress reports until May 2017 so we can continue to monitor progress.

The service provides care and accommodation for 19 older people, some of whom are living with dementia or who may have physical or mental health needs. On the days of the inspection 17 people were living at the care home.

Accommodation and facilities in Norfolk Villa are situated on two floors, with access to the upper floor via stairs. There are some shared bathrooms, shower facilities and toilets. Communal areas include a lounge, a dining room and an outside patio area.

There was a registered provider; the service did not require a registered manager in post. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

At the last inspection on 12 and 17 September 2015, we asked the provider to take action to make improvements as we found care was not always safe, personalised and consistent. We found people’s consent was not always obtained prior to care being given; risk assessments did not always reflect people’s needs; there was no proper and safe management of medicines; staff did not always have the knowledge, experience and skills to support people; and the systems in place to monitor the quality of the service were ineffective. The provider sent us a plan detailing the improvements which would be made to meet the legal requirements in relation to the breaches. The provider told us they would make all improvements by the 28 February 2016.

At this inspection we found some improvements had been made, but we continued to have concerns in several areas.

People’s medicines were not always managed, administered and stored safely. We found essential checks were not routinely completed to ensure the right people received the medicine they were prescribed. We found that there were gaps in the medicine records which meant we could not be sure people had received their prescribed medicine.

People’s care records were not always reflective of people’s needs and did not always show whether people were involved in writing them. The records of people’s care were not always complete and lacked essential details to ensure care given was appropriate and as desired by the person. People’s end of life needs were not always planned with them and their end of life care planning was inconsistent. However, we saw these were being improved during the inspection.

People’s individual risk assessments were not reviewed regularly to ensure they reflected people’s current risk in relation to their health needs. People were not involved in planning how to mitigate the risks they faced while living at the service. People’s care plans and records did not reflect risks which had been identified by the service.

Not all staff had been trained in the MCA and the associated Deprivation of Liberty Safeguards (DoLS). When people did not have the mental capacity to make decisions about their care and treatment, assessments were not always evident and there was a lack of guidance in place for staff about how to support people to make decisions. However, we observed staff asking for people’s consent before providing personal care.

Good leadership and governance was not always evident. The provider had developed new audits but not all of these were effective and had not identified the issues raised during the inspection. However, the provider was working in collaboration with external services to improve the quality of care and during the inspection process, presented a plan to CQC to help ensure all aspects of people’s care was of a high quality.

There were activities which occurred at the home which people liked participating in and enjoyed. However, activities were not always personalised to people’s specific needs or interests and were infrequent.

Staff were recruited safely. Staff were receiving training and updates to meet people’s needs. Staff had received safeguarding training and understood how to identify abuse and keep people safe from harm. Staff had also worked hard to update care plans but we found they lacked the knowledge to develop care plans which reflected people’s risks and care needs, for example how to manage people’s diabetes, skin care and continence needs. The matron told us during the inspection further training in these areas had been booked.

People’s health needs were sometimes met. People could access their GP and other health professionals as required and staff sought advice however we found advice was not always followed or recorded by staff. People received a healthy diet although some people told us choice and involvement in menu planning was limited.

There was a complaints policy in place. People’s concerns were dealt with when they arose. People felt comfortable speaking to the registered provider or matron if they had any concerns.

The service was clean and infection control procedures were being implemented and followed by staff. There were systems in place to maintain the equipment and utilities at the service.

The service was working collaboratively with external agencies to improve the quality of care people received.

We found a number of breaches of the regulations. You can see what action we told the provider to take at the back of the full version of the report.

We saw people's privacy and dignity being respected at all times. We saw and heard staff speak to people in a way that demonstrated staff respected the people they cared for. One person living in Norfolk Villa said, 'They always knock on my door before they come in.' One visiting professional said, 'They have been very good at supporting the person I visit.'

We considered our inspection findings to answer questions we always ask;

' Is the service safe?

' Is the service effective?

' Is the service caring?

' Is the service responsive?

' Is the service well-led?

This is a summary of what we found-

Is the service safe?

People were treated with respect and dignity by the staff. There were enough staff on duty to meet the needs of the people receiving care at the home and some people were able to say they felt safe living at Norfolk Villa. Safeguarding procedures were in place and staff had completed training and understood how to safeguard the people they supported.

Staff training records contained all mandatory courses as required, for example staff had completed training in safe handling of medicines and manual handling. This meant the provider could demonstrate that the staff employed to work at the home had the skills and experience needed to support the people who received care in the home.

CQC is required by law to monitor the operation of the Mental Capacity Act 2005 Deprivation of Liberty Safeguards (DoLS), and to report on what we find. The DoLS apply to care homes and hospitals. No application had needed to be submitted.

Is the service effective?

People's health and care needs were assessed with them, and they were involved in writing their care plans where possible. Specialist dietary, mobility and equipment needs had been identified in care plans when required.

The people we spoke with told us that they felt that staff were kind and caring. People told us that they were happy with the care and support that had been delivered and their needs had been met.

The visitor and professionals we spoke with were able to confirm that they were able to see people in private and that visiting times were flexible.

The staff spoken with had a clear understanding of the care and support needs of the people living in the home. The relative spoken with said, 'Can't fault the care they give mum.' Staff had received training to meet the needs of the people living at the home.

Is the service caring?

Those people who were able to talk with us said that they were supported by kind and attentive staff. We saw that the staff showed patience when supporting people.

People using the service had completed questionnaires on their satisfaction of the service provided. Residents meetings were held to discuss any shortfall identified.

Is the service responsive?

There were regular activities arranged within the home and a local retailer had visited and set up a shop in the home so people were able to purchase items. One person said, 'It is like having a shopping mall in the home- it is great!' We looked at how complaints had been dealt with and we found that the responses had been open, thorough, and timely. People could therefore be assured that complaints were investigated and action was taken as necessary.

Is the service well-led?

The service worked in partnership with key organisations, including the local authority and safeguarding teams to support care provision and service development.

The service had recently been visited by the commissioning authority and the information from the registered provider showed the home was continuingly improving and had taken on board the recommendations suggested. This included the employment of a consultant who was assisting with the further development of records and care plans for people.

Staff had a good understanding of the ethos of the home and quality assurance processes were in place. Staff told us they were clear about their roles and responsibilities.

We found improvements had been made to people's care. People's needs were assessed and people received care and support from the staff to maintain their well-being.

We found improvements had been made to the cleanliness of the home with more detailed cleaning schedules to reduce the risk of infection and cross contamination between people.

We found that there have been improvements to the way medicines were managed and handled in the home.

We found the provider had taken steps which ensured the premises and environment were safe by securing loose furniture and ensuring the bells on the exit doors were working so staff would be alerted when people left the premises.

We found audits were in place to review the quality of the service being provided. Residents meetings took place and there was a system to raise complaints evident at Norfolk Villa. People were able to have their views and concerns heard.

We found that although improvements had been made to the standard of record keeping, further work was required in this area to ensure an accurate record was kept of the care and support people needed and received.

People told us "They look after us here" and "Staff are pleasant, they talk and joke with you. We found staff consulted with health care professionals about someone's care when they needed too. We looked at the care records of four people and found they did not accurately reflect the care people received, they were not detailed and they were nor personal to each person. This may affect the care that staff were providing and put people at risk.

We found staff had a good awareness of how to protect vulnerable people and understood what constituted abuse.

We found the home was superficially clean but there were areas which were not and there was not a robust system in place to monitor the cleanliness of the home.

We found that medicines management had improved since out last visit but there were gaps in recording and some medication was not kept securely.

There were areas of the home which were not safe because the home was not using the security measures it had in place to keep people safe. This meant they had access to areas that posed a risk to them and they could leave the building unnoticed.

We found that the systems in place to monitor the quality of the service and support the staff were not sufficient. Records related to people's care were not accurately kept.

We talked with six people who lived at the home. They told us 'It's marvellous here, staff are always popping in to ask how I am keeping' and 'They are the loveliest group of staff'.

We spoke with six staff who told us that us that they had sufficient training in all areas to help them do their jobs well.

People told us that staff always asked for their consent before providing care. We looked at the care provided and records relating to three people. Records relating to people's care were not detailed or personal to each person. This may affect how care is provided.

Medication systems were not robust and people may not have received pain relief medication when it was prescribed.

People using the service and staff on duty felt there were sufficient staff on duty to meet their needs. Staff had not followed their training to ensure the safety of people using the service and staff.

Some parts of the home were not safe for people using the service and some areas of the home were not clean.

Auditing systems undertaken by the management of the home were in place to monitor the service. Some parts of the auditing had not identified shortfalls in the quality of care provided.