Archived: Norfolk Villa Residential Home

Updated 20 June 2019

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

The inspection took place on 21 and 27 September 2018 and was unannounced. The inspection was carried out by two inspectors and an expert by experience. An expert by experience is a person who has personal experience of using or caring for someone who lives with dementia.

Prior to the inspection we reviewed the records held on the service. This included the monthly reports submitted by the provider detailing improvements they had made within the service. We also reviewed notifications. Notifications are specific events registered people have to tell us about by law.

During the inspection we spoke with nine people and two visitors. We reviewed five people’s records in detail. We also spoke with six staff and reviewed one personnel record and the training records for all staff. Other records we reviewed included the records held within the service to show how the quality of the service was monitored. This included audits, minutes of meetings and policies and procedures.

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 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