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Archived: Norfolk Villa Residential Home Inadequate

Inspection Summary


Overall summary & rating

Inadequate

Updated 20 June 2019

The overall rating for this service is ‘Inadequate’ and the service is in ‘special measures’. Services in special measures will be kept under review and, if we have not taken immediate action to propose to cancel the provider’s registration of the service, will be inspected again within six months. The expectation is that providers found to have been providing inadequate care should have made significant improvements within this timeframe. If not enough improvement is made within this timeframe so that there is still a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. This service will continue to be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement so there is still a rating of inadequate for any key question or overall, we will take action to prevent the provider from operating this service. This will lead to cancelling their registration or to varying the terms of their registration. For adult social care services the maximum time for being in special measures will usually be no more than 12 months. If the service has demonstrated improvements when we inspect it and it is no longer rated as inadequate for any of the five key questions it will no longer be in special measures.

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 insp

Inspection areas

Safe

Inadequate

Updated 20 June 2019

The service was not safe.

People did not always have risk assessments in place relating to significant health risks.

People were not always protected from the risks of cross infection because areas requiring improvement were not all being monitored.

People�s risks relating to the environment had still not all been assessed.

People were not always protected from the risk of fire or legionella.

Effective

Requires improvement

Updated 20 June 2019

The service was not always effective.

People�s fluid intake was not recorded in a way that enabled it to be monitored effectively.

The environment was not always looked after in a way that showed people respect.

People received support from staff who knew them well and had received training.

People were supported by staff who had received training in the Mental Capacity Act and who promoted choice whenever possible.

Caring

Requires improvement

Updated 20 June 2019

The service was caring.

People were looked after by staff who treated them with kindness and respect.

People and visitors spoke highly of staff. Staff spoke about the people they were looking after with fondness.

People felt in control of their care and staff listened to them.

People said staff protected their dignity.

Responsive

Requires improvement

Updated 20 June 2019

The service was not always responsive.

People�s needs regarding how they may need information presenting had not always been assessed or recorded.

Care records were written to reflect people�s individual needs and were regularly reviewed and updated. However, these did not always reflect people�s needs and preferences relating to their culture or nationality.

People received personalised care and support, which was responsive to their changing needs.

People were involved in the planning of their care and their views and wishes were listened to and acted on.

People knew how to make a complaint and raise any concerns.

Well-led

Inadequate

Updated 20 June 2019

The service was not well led.

The provider and manager had increased the amount of checks to monitor the service but had not identified the gaps identified at the inspection.

The provider and manager had not used all the information from the previous inspection report to ensure concerns identified were acted upon.

The culture in the service had improved but the provider did not have clear values and aims against which they monitored the service.

Staff were motivated and inspired to develop and provide quality care.