This inspection took place on 27 June 2018 and was unannounced. Our last inspection was in September 2016 where we rated the service as ‘Good’ but made two recommendations about staffing levels and the caring nature of staff. At this inspection we identified breaches of the legal requirements in relation to staffing levels, person centred care and governance. You can see what action we told the provider to take at the back of the full version of the report.

Norfolk House 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 House accommodates up to 76 people in one purpose built building. Care is provided across three floors which each have their own communal facilities and dining areas. One floor provided residential support to people living with dementia. Two floors provided nursing care to people with a variety of long term conditions and disabilities. At the time of our inspection there were 61 people living at the service.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. 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.

There were not sufficient numbers of staff at the home to keep people safe. On a unit for people living with dementia, we identified a lack of staff presence to ensure people were kept safe. There were also shortfalls in relation to support and monitoring of staff medicines practice on one floor. Medicines were managed, stored and administered safely throughout the rest of the service.

Care was not always provided in a person-centred way. Care plans lacked detail, particularly around the support required for people living with dementia. Important information about people’s backgrounds and their preferences with relation to end of life care were also missing. The provider carried out checks and audits but these had not identified and addressed the concerns identified on this inspection in a proactive manner. People also told us that they did not have regular contact with management.

People’s healthcare needs were met by trained and competent nursing staff. We saw evidence of staff liaising with healthcare professionals where required and these staff had the support and training required to support them in their roles. The provider carried out checks on new staff to ensure that they were suitable to be working in an adult social care setting. Staff felt supported by management and we saw evidence of regular meetings to involve staff in the running of the service. The home environment was tailored to people’s needs, but for those living with dementia interaction with the home environment was limited due to staffing levels. Staff ensured the environment was clean and there were robust processes in place to reduce the risk of the spread of infection.

Staff were kind, caring and committed to their roles. Care was provided in a way that involved people and staff offered day to day choices to them. Regular reviews were carried out to identify any changes to people’s needs and the provider conducted surveys to gather feedback from people and relatives. Regular meetings took place to provide people with opportunities to make suggestions and we saw examples of recent suggestions being actioned by management. There was a complaints policy in place and management recorded and responded to complaints appropriately.

Risks to people were assessed and staff implemented plans to reduce hazards to people. People’s independence was promoted by staff who were knowledgeable about how to empower people. Where incidents had occurred, appropriate actions

The inspection took place on 29 September 2016 and was unannounced.

Norfolk House is a purpose built care home with nursing which can accommodate up to 76 people. On the day of the inspection there were 59 people living at the service, some of whom were living with dementia.

There was a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act and associated Regulations about how the service is run.

At our last inspection of Norfolk House in September 2016 we found four breaches of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At this inspection we found the provider had made improvements.

Staffing levels within the service had increased and people told us that staff responded promptly to requests for support. However, some people told us that the responsiveness and flexibility of staff at busy times was reduced. Whilst staff were generally attentive to people’s needs and spoke to people kindly, we observed occasions where interaction with people was lacking.

Risks to people had been assessed and staff had taken appropriate action to reduce these risks. There were plans in place to ensure that people would continue to receive their care in the event of an emergency. Appropriate checks on staff were completed before they started work, to help ensure only suitable applicants were employed. Staff understood safeguarding procedures and were aware of the whistle-blowing policy. Medicines were managed safely and people received their medicines in line with their prescriptions.

People were supported by staff who had the skills and experience needed to provide effective care. Staff had induction training when they started work and ongoing refresher training in core areas. Staff received regular supervision which gave them the opportunity to discuss their performance and training needs.

People’s legal rights were protected as the registered manager and staff understood their responsibilities in relation to the Mental Capacity Act 2005 (MCA) and Deprivation of Liberty Safeguards (DoLS). Staff routinely asked for people’s consent prior to supporting them.

People enjoyed the food provided and could have alternatives to the menu if they wished. People’s nutritional needs had been assessed and action was taken where substantial changes to people’s weight was noted. People were supported to stay healthy and to obtain medical treatment if they needed it. Staff monitored people’s healthcare needs and sought advice from healthcare professionals if they became unwell.

Staff understood the importance of respecting people’s privacy and dignity. Relatives told us they were welcomed to the service and there were no restrictions on the times they could visit. People had opportunities to take part in activities at the service and to go out to local places of interest.

Assessments were completed prior to people moving into the service and this information was used to complete detailed care plans. Records of people’s care were regularly reviewed and people and their relatives were involved in the process. Details of people’s life histories and preferences were recorded and used by staff to prompt discussion.

Quality assurance audits were completed and actions were addressed where improvements were required. There was a system in place to deal with people's comments and complaints had been addressed.

The registered manager provided good leadership for the service. Relatives told us the service was well run and that the registered manager was open and approachable. Staff told us the registered manager provided good leadership and promoted a positive culture at work. They said they felt the service had improved since the registered manager had been in post. People an

This inspection was carried out on 15 September 2015. Norfolk House is a purpose built care home with nursing, situated on the outskirts of Weybridge in Surrey. Some of the people using the service are living with dementia. The service can accommodate up to 76 people, over three floors, and all rooms have en-suite facilities. On the day of the inspection there were 58 people living at the service.

On the day of our visit there was not a registered manager in post. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. 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. There had not been a registered manager at the service since January 2015. A new manager had started at the service, they told us that they were in the process of submitting their application to us. They had only been at the service for one week.

There were not sufficient numbers of staff deployed around the service to meet people’s needs.

Risk assessments for people were undertaken. Each risk assessment gave staff information on how to reduce the risk but they were not in any detail. These included risks of poor nutrition, choking and falls.Staff had a good understanding of people’s risks. Not all of the information around risks had been kept together to ensure that staff had all of the information in one place.

Staff had knowledge of their responsibilities under the Mental Capacity Act 2005 (MCA), and the Deprivation of Liberty Safeguards (DoLS). The Care Quality Commission (CQC) monitors the operation of the Deprivation of Liberty Safeguards (DoLS) which applies to care homes. However MCA assessments had not always been completed appropriately for people.

Staff did not always have the most up to date guidance in relation to their role. The service clinical training had not been completed by all of the nurses. 

There were complete pre-employment checks for all staff. This included full employment history and reasons why they had left previous employment. This meant as far as possible only suitable staff were employed.

There were up to date policies for staff in relation to people’s medicines. Peoples medicine charts were completed clearly and accurately. Peoples medicines were managed safetly and they had them when they needed them.

One to one meetings were undertaken with staff and their manager however appraisals had not taken place for all staff. Staff did say that they felt supported.

People’s personal history, individual preferences, interests and aspirations were all considered in their care planning. Care plans were reviewed every month to help ensure they were kept up to date and reflected each individual’s current needs. However there wasn’t always a plan of care around every idenfied need. For example in relation to challenging behaviour.

There was a programme of activities in place which people said they enjoyed. However there were times at the weekend when no activities took place.

There were instances of staff not being as caring as they could be. There were times when people had no meaningful conversations with staff. Other people and relatives felt that staff were kind and considerate. People were treated with kindness and compassion by staff throughout the inspection. One person said “I have fun with the carers, staff are caring in every way.”

People and relatives said they felt their family members were safe. Staff understood what it meant to safeguard people from abuse and how to report any concerns.

Staff gave examples of where they would ask people for consent in relation to providing personal care. We saw several instances of this happening during the day.

People and relatives said that the food was good. People were encouraged to make their own decisions about the food they wanted. People’s food and nutrition was carefully monitored and maintained.

People had access to health care professionals as and when they required it. We saw several examples of visits from health care professionals on the day of our visit.

People and relatives had the opportunity to be involved in the running of the service. Residents and relatives meetings were held and the minutes showed discussions about the décor of the service.

There was a complaints policy which people and relatives had knowledge of and knew how to access this.

Audits of systems and practices were carried out and were effective. Where concerns had been identified these were being addressed. Incidents and accidents were recorded and there was an analysis of this. For example in relation to falls.

Staff said they felt supported or motivated in their jobs. Regular staff meetings took place and staff contributed to how the service ran. Meetings were minuted and made available to all staff.

Annual surveys were sent to the people, relatives and staff which were used as a way of improving the service.

During the inspection we found one breach of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.

We visited this home on the 1 July 2014 and found the registered provider was compliant with the outcomes we inspected at that time.

Since that inspection we received concerns about the number of staff on duty and that this had led to inadequate care being delivered for people. In response those concerns we carried out this inspection on the 15 August 2014 to specifically review the staff levels and whether this met people's needs.

We spoke with 10 people who used the service, seven relatives who were visiting, nine member's of staff and the registered manager.

Although the registered manager told us they had experienced some staffing difficulties mainly in June and July this year they had now recruited new staff who were starting to work.

The vast majority of people, relatives and staff we spoke with told us there were enough staff to meet people's needs. People's comments included, " I'm comfortable here and the staff are very good." " It's home from home and I like it here." and " The staff always come when I need them." relatives said, " It is good care here and there are enough staff." and " They always look after X very well I have no complaints."

However, two relatives we spoke with disagreed with these positive views and despite earlier complaints to staff and management remained unsatisfied. They felt there were inadequate staff to meet their family member's particular needs at all times. The registered manager assured us that they would offer any relatives a further opportunity to meet in order to discuss their views and attempt to resolve their concerns.

We visited Norfolk House to look at the care and welfare of people who used the service.

Our inspection team was made up of two inspectors. We asked our five questions; Is the service caring? Is the service responsive? Is the service safe? Is the service effective? Is the service well led?

Below is a summary of what we found. The summary is based on our observations during the inspection, speaking with people who used the service, the staff who supported them and from looking at records.

If you want to see the evidence supporting our summary please read the full report.

Is the service safe?

From our observations we saw people were treated with respect and dignity by the staff. People that we spoke with told us the staff were kind and helpful.

Systems were in place to make sure that managers and staff learned from events such as accidents and incidents, complaints, concerns, whistleblowing and investigations. The provider reported safeguarding alerts to the local authority and notified CQC. They had worked cooperatively with social services during recent alerts that had been sent to them by the home. This reduced the risks to people and helped the service to continually improve.

The registered manager set the staff rotas, they took people’s care needs into account when making decisions about the numbers, qualifications, skills and experience required. This helped to ensure that people’s needs were always met. The registered manager told us they still used some agency workers but planned to be fully staffed by August so would no longer need this help.

Is the service effective?

People’s health and care needs were assessed with them and their families. We saw that people and their relatives had been encouraged to be involved in writing their plans of care.

Specialist dietary, mobility and equipment needs had been identified in care plans where required.

The premises had been adapted to meet the needs of people with physical impairments. Regular health and safety checks were in place that ensured corridors and stairs were clear of clutter during the home’s refurbishment.

Is the service caring?

People were supported by kind and attentive staff. We saw that care workers showed patience and gave encouragement when supporting people.

People who used the service, their relatives, friends and other professionals involved with the service completed an annual satisfaction survey. Where shortfalls or concerns were raised these were addressed.

People’s preferences and interests had been recorded and care and support had been provided in accordance with people’s wishes.

Is the service responsive?

People benefited from some activities in and outside the service regularly arranged by staff.

We saw the complaints policy displayed on the notice board. People could be assured that if a complaint had been received there was a system in place which would ensure their complaint would be investigated and appropriate action taken.

Is the service well-led?

The service worked well with the local authorities that had placed people at the home. This ensured people received their care in a joined up way.

The service had a quality assurance system and records seen by us showed that identified shortfalls were addressed.

Staff told us they were clear about their roles and responsibilities. Staff had a good understanding of the ethos of the home and that quality assurance processes were in place. This helped to ensure that people received a good quality service at all times.

We spoke with ten residents or their relatives on the day of this unannounced visit, and with others prior to our inspection. We also liaised with the local authority's quality monitoring manager, and with senior staff at the Elmbridge locality team. We were also accompanied by a CQC specialist advisor.

We received a number of positive comments about the home, especially the ongoing refurbishment which had improved the environment for residents. However, we also noted some health and safety matters, related in the main to the refurbishment, that needed to be addressed.

During this follow up visit in March 2014 we found recruitment records for staff now contained all the relevant information required by regulation.

We reviewed the staffing levels and found more work was needed. However, comments from residents and relatives were mainly positive, and included "Staff are very helpful", "I'm quite content with everything here", and "They seem to be nice people." The manager was on leave on the day of this visit so some areas we identified for improvement were passed on to senior staff for their attention.

We also reviewed record keeping and found some areas of good practice. These included the new electronic care planning system, and the new method of recording of food and fluid intake of residents.

This was a follow up visit to check improvements in staff recruitment records since our previous visit in July 2013. We did not speak to residents or relatives on this occasion in relation to recruitment records, though during our last visit feedback on more general issues had been positive.

During this follow up visit we found that whilst improvements had been made, there were still shortfalls related to staff recruitment records.

We spoke with ten residents, three relatives and a visiting health professional during our inspection. We asked people a range of questions related to their experiences at Norfolk House. Responses were, in the main, positive and included “I think they do a good job” and “All staff are helpful.”

We asked people if staff gained their consent before supporting them with care and treatment. Responses were all positive and included “Yes, they are very courteous.” We asked people if they received the care they needed and if staff looked after them well. Responses varied from “Yes, reasonably” to “Very well.” We asked people about the meals at Norfolk house and we were told that “On the whole it is good.” Other comments included “Very nice” and “Excellent.”

All those we spoke to who were able to answer the question on safety, confirmed they felt safe living at Norfolk House. We asked people if they would know who to report to if they had any complaints, and those who were able to answer this question said they would speak to staff or the manager. On the overall quality of the service, responses ranged from ‘”Alright” to “First class.”

We interviewed ten residents and one visitor during our visit, using a standard format with questions related to the regulations we intended to cover during our inspection.

In answer to our questions, people told us that staff were respectful towards them and that they got the care they needed when they needed it.

They told us they felt safe living in this home, and said staff appeared to be well trained for the work they were asked to do.

We were told that the home was kept clean and fresh, and that the overall quality of the care was good. Some added positive comments about the help they received, and one described the care as ‘personalised.’

We received a number of complimentary remarks about the meals, the care, and the staff. One person, summed up the general comments we received from the residents about staff when they told us: “They never walk past you without a smile or a greeting.”