Inspection on 18/03/09 for Norfolk Lodge

This inspection was carried out on 18th March 2009.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Norfolk Lodge 03/08/09

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 19/06/2009.

CARE HOMES FOR OLDER PEOPLE Norfolk Lodge 32 Kings Lynn Road Hunstanton Norfolk PE36 5HT Lead Inspector Jane Craig Key Unannounced Inspection 18th March 2009 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 Lodge DS0000072808.V374574.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 Lodge DS0000072808.V374574.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norfolk Lodge Address 32 Kings Lynn Road Hunstanton Norfolk PE36 5HT 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) 01485 532383 ARMS Associates Ltd Mrs Sylvia Ince Care Home 23 Category(ies) of Dementia (23), Old age, not falling within any registration, with number other category (23) of places Norfolk Lodge DS0000072808.V374574.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other categories - Code OP Dementia - Code DE The maximum number of service users who can be accommodated is 23 New Service 2. Date of last inspection Brief Description of the Service: Norfolk Lodge is registered to provide personal care to up to 23 people older people who may have needs associated with dementia. In September 2008 the home was bought by ARMS Associates Limited, who also own two other care homes nearby. Norfolk Lodge is set in secure and well-maintained gardens in a residential area of Hunstanton. It is close to local amenities, including shops and the sea front. The home is a two-storey building. It has a mix of single and shared rooms, most of which have en-suite facilities. Bedrooms on the first floor are accessed by a stair lift. Communal rooms comprise two lounges and a dining room. There are assisted bathrooms on both floors. Information about the home is available to anyone thinking of moving in. At the time of the visit the weekly fees ranged from £387 for people funded by social services to £470 for people who fund their own care. Extra charges were made for toiletries, hairdressing, newspapers, activities provided by external entertainers, transport and escorts to hospital and other appointments. Norfolk Lodge DS0000072808.V374574.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 no stars. This means that people who use the service experience poor quality outcomes. This is the first key inspection of this service. The inspection includes information we have gathered about the service since its registration in September 2008 and an unannounced visit to the home. The visit was carried out on 18th March 2009 by one regulatory inspector. At the time of the visit there were twenty two residents living at the home. We met with some of them and wherever possible asked about their views of Norfolk Lodge. We spent time observing daily routines in the home and how staff interacted with residents. Three residents were case tracked. This meant that we looked at their care plans and other records and talked to staff about their care needs. We also received six surveys from residents. We talked to the registered manager, the responsible person for ARMS Associates Ltd, and several members of the staff team. We looked around the home and viewed a number of documents and records. What the service does well: What has improved since the last inspection? What they could do better: Norfolk Lodge DS0000072808.V374574.R01.S.doc Version 5.2 Page 6 Residents must be assessed before they are admitted to the home. In the case of an emergency this should be as soon as possible after their admission. This is to ensure that staff understand the residents needs and can be sure they have the skills to provide appropriate care. All residents must have care plans to instruct staff how to support them to meet their personal and health care needs. The plans must be reviewed and changed when the residents needs change. They should be detailed enough to ensure that staff know exactly how the resident prefer to be supported. Residents must also have assessments and plans to identify and reduce any risks to their health and safety. These must be kept under review. The practices for storing, recording and administering medication must be made safer. Residents should have care plans to support them to meet their individual social care needs. The level and range of activities should be further developed to ensure that all residents social and recreational needs are met. The staff should have clearer guidance and procedures to make sure that they know exactly how to report poor practice or suspected abuse to outside agencies. There should be an audit of the environment to ensure that all areas in need of redecoration and renewal are identified. An action plan, with timescales, should be drawn up to show when work is to be carried out. In order to protect residents and themselves, staff must have appropriate training in health and safety topics. 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 Lodge DS0000072808.V374574.R01.S.doc Version 5.2 Page 7 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 Lodge DS0000072808.V374574.R01.S.doc Version 5.2 Page 8 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): 1, 2 and 3 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents received sufficient information about the home but the lack of information about new residents could result in staff not understanding their needs. EVIDENCE: There was a combined statement of purpose and service users guide. The document contained comprehensive information about the home and told residents about the service they could expect to receive. It was given to anyone moving into the home. People funding their own care had a contract with the service. Both the contract and service users guide included information about a weekly amenities charge of £5 for toiletries and a contribution to activities. The Norfolk Lodge DS0000072808.V374574.R01.S.doc Version 5.2 Page 9 schedule of fees indicates that this charge is negotiable. At the time of the visit only residents who had moved in since the current owners took over were being charged. The manager told us that she usually assessed residents before they were admitted to the home, which helped her to ensure that she fully understood what care the resident needed. A new assessment document had been introduced but had not yet been used. The last resident to come into the home had been admitted in an emergency and had not had an assessment by the manager. There were no preadmission assessments from health and social care professionals and no assessments had been carried out within the first three weeks of their stay. This meant that staff had no baseline information about their strengths and needs to draw up meaningful care plans. Standard 6 is not applicable, as Norfolk Lodge does not provide intermediate care. Norfolk Lodge DS0000072808.V374574.R01.S.doc Version 5.2 Page 10 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 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Not all residents health and personal care needs were met. Medication was not managed safely. EVIDENCE: We looked at three sets of care files as part of the case tracking process and some others in less detail. None of the care plans or associated records were completed in full. One resident who had been admitted recently did not have an entry on their care records until five day after their admission. Daily records after that period highlighted a number of needs but there were no care plans in place to address these. Care plans to support residents with their personal care were not detailed enough to ensure that staff provided consistent care in the way the resident Norfolk Lodge DS0000072808.V374574.R01.S.doc Version 5.2 Page 11 preferred. For example, the only directions on one plan were, needs to be assisted. Care plans had not been reviewed for several months and it was not clear what information was still relevant. The plans we saw did not address needs that had recently been highlighted in the residents progress notes. For example, there were no care plans to support one resident who was increasingly depressed and agitated. There were no care plans to help staff to manage aggressive behaviour, although those staff we spoke to all said they would use the same strategies. There was no evidence that residents or their relatives were invited to be involved in planning or reviewing care. The care files we saw included health and safety risk assessments associated with manual handling, pressure sores and nutrition. One person was assessed as being at very high risk of poor nutrition. The advice on the assessment form, which was to seek dietetic advice, had not been actioned and there was no plan to direct staff how to minimise the risk. The recent daily notes indicated that the resident was eating a normal diet but the assessment had not been revised. There were several other risk assessments we saw that had not been reviewed and changed as the residents needs changed. There were some notes on the files to show that residents were referred to various health care professionals if they were not well. One resident confirmed that staff looked after him and called the doctor if he was not feeling well. However, care plans were not updated to include advice from the professionals, which meant that any care or treatment they prescribed might not be incorporated into daily care routines. There was a lack of records on some files to show that advice was sought as soon as a need was identified. None of the files we saw contained any specific care plans to support residents who had needs associated with dementia. Care records for residents who had other mental health needs showed a lack of understanding. A number of residents needed assistance to stand or transfer from chair to wheelchair. Throughout the day we observed staff lifting residents using underarm lifts. This type of lift is no longer taught because of the high risk of injury to both the resident and staff. Several residents had bed rails in place. None had been assessed to find out whether the use of bed rails was appropriate. There were no assessments to show that the bed rails used were suitable for the resident, the bed and the mattress. There were no ongoing maintenance checks to ensure that the rails were safe. Norfolk Lodge DS0000072808.V374574.R01.S.doc Version 5.2 Page 12 All staff who handled medication had completed an in-depth training workbook. However, there were some indications that the training was not being put into practice. Most medication was stored in a trolley in the dining room. However, we found several packets of medication, which should not be stored at low temperatures, in the kitchen fridge. We also found four full packets of night sedation in a kitchen cupboard. These belonged to residents who were no longer at the home. Most medication was administered from a monitored dose system (MDS) but some residents had a number of packets of tablets not in the MDS. Staff had decanted a weeks supply of these into dosette boxes. Although this had been done in an effort to make administration safer, there were a number of risks attached to this practice and we discussed these with the manager at the time of the visit. There were no records of medicines received into the home and the records of medicines returned were retained by the pharmacy. There were some gaps on medication administration record (MAR) charts but the corresponding tablets had been removed from the MDS. Because of the lack of complete records it was not possible to confirm that residents were receiving their medicines as they were prescribed. It also meant there was no audit trail, which increased any risk of mishandling. There were some handwritten entries on MAR charts. These were not signed and witnessed to evidence that they were checked for transcribing errors. Some of the entries did not give complete instructions on dosage and time to be given as stated on the medicine containers. This increased the risk of residents receiving the wrong dose at the wrong time. There were no care plans or specific instructions to direct staff when to give medicine that was prescribed when required. This could increase the risk of residents receiving more, or less, medication than they needed. Some medicines were prescribed in a variable dose, such as one or two tablets. Staff did not record how many had been given, which meant that they would not be able to monitor how effective the dose was. There were no controlled drugs at the time of the visit. The manager had recently received an appropriate cabinet but did not have a policy or register. The service users guide gave a commitment to core values, such as privacy, dignity and independence being promoted. During the course of the visit we observed that staff were generally polite and respectful to residents. Personal care was provided in private and we saw staff knocking on residents bedroom doors before entering. A member of staff talked about making sure the home was not like an institution and did not take away residents independence. Norfolk Lodge DS0000072808.V374574.R01.S.doc Version 5.2 Page 13 However, we also observed some issues that undermined residents privacy and dignity. For example, there were no privacy locks on two out of the three bath or shower rooms. A member of staff said they stood outside when residents were in the bath to make sure no-one went in. At lunchtime we observed some staff assisting people to eat whilst standing behind them, which was undignified and disorientating. Norfolk Lodge DS0000072808.V374574.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 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all residents had sufficient choice and control over their lives or had their social and recreational needs met. EVIDENCE: The care plans we looked at all included a brief life history of the resident, which in most cases had been written by family members. This helped staff to get to know residents better and gave them topics for reminiscence. There were no care plans to support residents to meet their individual social and recreational needs. The social care records we saw comprised a tick box to show when the resident had joined an activity. There was no information about their enjoyment or level of participation. The records showed that there was a limited range of activities. Staff said they did armchair exercises with a large group at least twice a week. There were occasional outside entertainers and on the day of the visit there was a visiting entertainer organising group games. Residents who completed surveys had mixed views about whether there were enough activities. Norfolk Lodge DS0000072808.V374574.R01.S.doc Version 5.2 Page 15 There were no records to show that staff spent regular one to one time with residents, although staff said they usually had time in the afternoon. During the course of the visit we saw staff chatting to residents. Some were very skilled at this and made every attempt to help residents who had difficulties with verbal communication. Staff told us that there was open visiting, which helped residents to be able to maintain contact with their family and friends. Residents who were safe to go out alone did so and some residents went out regularly with their family. There were few opportunities for others to go out, except to keep health care appointments. One person went out to church every week and there was a religious service in the home once a month. Staff told us they tried to give residents choice in all aspects of their daily lives and a resident told us that they often stayed in bed until late in the morning. However, there were some staff led routines, such as bathing and toileting regimes. Information about preferred routines was not recorded on care plans and it was not clear how staff gave choices to residents who were not able to verbalise their preferences. The records of meals showed that residents were offered a varied diet with two choices at each mealtime. The menu sheets were not on display and the cook told us that she went around asking residents what they preferred. She said that a number of residents were not able to tell her but she was aware of their likes and dislikes. The cook had not done any training with regard to nutrition and older people but said she was aware of healthy eating initiatives and tried to ensure that the residents had a healthy diet. The residents we asked said they liked the meals, and on the day of the visit we observed people enjoying their lunch. Most residents had their meals in the dining room where tables were set. Equipment was available to assist residents to maintain their independence. Residents did not always receive assistance in a sensitive and discreet manner, for example we observed staff standing up when assisting residents and we saw one member of staff outpacing the resident. Norfolk Lodge DS0000072808.V374574.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 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lack of clear procedures could result in safeguarding incidents not being handled appropriately. EVIDENCE: A large print version of the complaints procedure was on display in the home. The procedure stated that the service viewed complaints in a positive way and gave a good explanation of how complaints would be dealt with. The manager told us that there had been one complaint, which had been successfully resolved within 24 hours. However, there was no record of the complaint and subsequent investigation. Most staff had completed a self-study training course in protection of vulnerable adults and a member of staff said that they had discussions amongst themselves about the information. Some staff had also had also attended a talk by members of the social services adult protection team. There was an adult abuse policy but this had not been adapted for specific use in the home. For example, there were no contact details for the local authority and the service did not have a copy of the local authority procedure to refer to. Norfolk Lodge DS0000072808.V374574.R01.S.doc Version 5.2 Page 17 The staff we spoke to were aware of the indicators of abuse and all said they would report any suspected or actual incidents to the manager. The manager was clear about the role of social services as leading on safeguarding issues. Norfolk Lodge DS0000072808.V374574.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 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Not all residents were provided with comfortable and well maintained accommodation. EVIDENCE: From a tour of the building it was apparent that a number of areas needed refurbishing. The responsible individual told us that he was aware of the work that needed to be done to bring the environment up to a good standard. Some work had already been started and more was planned. For example, new floorboards were being laid on the upstairs landing because there was a current trip hazard. There was a fix it list to show where other work was needed but this did not include all the issues we identified. Norfolk Lodge DS0000072808.V374574.R01.S.doc Version 5.2 Page 19 The gardens were well maintained and provided residents with a pleasant place to walk and sit. There was one bathroom with a bath hoist and two shower rooms, which could accommodate residents with restricted mobility. Most residents had an ensuite lavatory and there were sufficient facilities near communal spaces. The dining room had new chairs and tables. There were two lounges. Both were presented in a homely way with pictures and ornaments but both were in need of some refurbishment. One resident said the lounge was a lovely room because it had the sun on it most of the day. There was a TV in one of the lounges but this was only accessible to a few people. The other lounge was completely devoid of any stimulation on the day of the visit. Two of the bedrooms had been redecorated and the responsible person was aware that the others needed attention. The majority of residents had personalised their bedrooms with ornaments and small items of furniture to make them more homely and familiar. Those residents we asked said they were happy with their bedrooms. One told us, I have a nice view and I like to sit at the window. Another said their room was, very nice. The laundry was clean and well organised. It was adequately equipped for the size of the home. There were hand washing facilities but on the day of the visit there was no liquid soap or disposable hand towels, which made it difficult for staff to wash their hands immediately after handling dirty laundry. There were no disposable gloves or aprons in the laundry. Most areas of the home were clean and free from unpleasant odours. We noted that one bed had been made up with heavily soiled linen but this seemed to be an oversight. However, several beds were made up with combined sheets and mattress protectors that were so worn that residents were sleeping directly on the rubber. The manager had the Essential Steps self-assessment tool to audit the infection control practices in the home but this had not been done at the time of the visit. We were told that staff had completed a self-study training pack in infection control. However, during the course of the day we observed some practices that could increase the risk of spread of infection. For example, there was no hand washing soap or towels in some bathrooms and en-suites. Staff did not always change their gloves between assisting each resident. Staff wore the same apron in the kitchen as the bathroom. Norfolk Lodge DS0000072808.V374574.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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff training was not robust enough to ensure that staff had the necessary knowledge and skills to provide appropriate and safe care. EVIDENCE: The duty rosters we saw were the planned rotas and not an accurate reflection of which staff were on duty at any one time. They showed a consistent level of staff and the responsible person told us that the manager had the flexibility to increase staffing levels on a temporary basis if necessary. The staff we spoke to had mixed views about the staffing levels in the home and one said she would prefer not to comment. Several residents who completed surveys indicated that there were not always enough staff. One wrote, because of limited staff I don’t always get what I would like. Another commented, I get care and support within the confines of staff available. On the day of the visit there were no indications that there were insufficient staff to meet residents personal or healthcare needs. However, because of poor care records it was not possible to confirm this. Norfolk Lodge DS0000072808.V374574.R01.S.doc Version 5.2 Page 21 There had been no staff appointments at the home since the current registration. The responsible individual was made aware that some of the staff appointed prior to this had not had the necessary pre-employment checks. Many of the staff had been at the home for a number of years; therefore residents received care from a reliable staff group who were familiar with their needs. The consistency in the staff team also meant that there was minimum disruption to residents when the home was sold to the current owners. There were a number of induction training packages in the home and it was not clear which was to be used for new staff. The manager was aware that the training should cover the Skills for Care common induction standards. The manager told us that most staff were up to date with mandatory training and over half had NVQ level 2. However, there were no central training records so we were unable to confirm this. We were told that all training was done in-house through training packs bought in from a training company. A number of the training packages were seen. Whilst these were informative, there were no opportunities for staff to clarify or discuss the information to put it in the context of the home and the residents. Staff whose second language was English could also be at a disadvantage if the service relies solely on this type of training. None of the staff team had training from anyone qualified to teach moving and handling, emergency aid or basic food hygiene. Several staff had completed a training package in dementia care and challenging behaviour. One of the staff we spoke with told us they would like more training in this area. Some residents had other mental health needs that but there was no training available to assist staff to gain the knowledge and skills necessary to support them. Norfolk Lodge DS0000072808.V374574.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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management arrangements were not effective enough to ensure that residents received a good quality service. EVIDENCE: The registered manager has many years experience of running the home. She was a registered nurse and has the recommended management qualification. The change in ownership of the home has had minimal effect on the management and administration systems in place. The responsible individual told us that the first six months has been a period of audit and assessment to identify areas that need further development. He had completed reports of Norfolk Lodge DS0000072808.V374574.R01.S.doc Version 5.2 Page 23 visits to the home where he spoke to residents and staff and looked around the home. There was a very limited system for monitoring the quality of the service. Relatives of newly admitted residents were invited to complete a survey about the home. The manager told us she responds to any negative comments on an individual basis but does not use the survey information to plan developments of the service. There were no audits of procedures and practices. Staff received an annual appraisal and an individual action plan was drawn up with regard to training. Staff were also asked to complete a self assessment questionnaire every six weeks, which they discussed with the manager. The manager did not act as agent or appointee for anyone at the home. Residents who were able to, managed their own finances and the remainder were assisted by their families or other representatives. Some residents had small amounts of money held for safekeeping. There were records of all transactions but the manager did not always keep receipts to evidence how money was spent on behalf of residents. We checked a small sample and found the records were accurate. There was an employee health and safety handbook, which was read by all new staff. The handbook covered the main points of health and safety legislation, including responsibilities of all staff. The manager said staff had received fire safety training from an external training company a year ago and were due to be updated. There was a clear fire procedure and the fire risk assessment had been completed in February 2009. Fire safety equipment had been serviced recently. There were some certificates to evidence that equipment and installations, such as gas and electricity were serviced and maintained. Others had been misplaced and were forwarded on. Portable electrical appliances had not been tested for over a year. During the tour of the building we found caustic denture cleaner in one of the bedrooms and cleaning chemicals, including bleach, stored in the laundry. This meant they were accessible to all residents, some of whom may not recognise the products and be unaware of the risks associated with handling them. Norfolk Lodge DS0000072808.V374574.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 3 2 1 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X X X X X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 2 Norfolk Lodge DS0000072808.V374574.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 OP3 Regulation 14 Requirement New residents must have an assessment before they are admitted to the home, or as soon as possible after an emergency admission, to ensure that staff fully understand and can meet their needs. To ensure that staff have sufficient instruction to enable them to understand and meet residents needs, all residents must have an up to date and detailed care plan that addresses their health and personal care needs. Care plans must be reviewed regularly and revised whenever there is a change in the residents needs. 3 OP8 13 Risks to residents health and safety must be assessed and a plans drawn up to reduce the risks. Assessments and plans must be reviewed and updated. These would include risks associated with the use of bedrails. DS0000072808.V374574.R01.S.doc Timescale for action 30/04/09 2 OP7 15 30/06/09 30/06/09 Norfolk Lodge Version 5.2 Page 26 4 OP8 13 To reduce the risk of injury to residents and staff, appropriate and safe moving and handling techniques and equipment must be used at all times. 30/04/09 5 OP9 13 In order to provide an audit trail 30/04/09 and reduce the risk of mishandling, there must be complete and accurate records of all medication received, administered and returned. In order to reduce the risk of 30/04/09 medication errors all medication not dispensed in the MDS system must be stored and administered from original containers. In order to promote residents privacy and dignity there must be privacy locks on communal toilet and bathroom doors. 30/04/09 6 OP9 13 7 OP10 12 8 OP30 18 Staff must have appropriate 31/07/09 training to meet the individual needs of the residents and to ensure that care is delivered with regard to the health and safety of both residents and staff. Cleaning materials and other potentially hazardous substances must be stored safely. 30/04/09 9 OP38 13 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP9 Good Practice Recommendations Handwritten entries on MAR charts should be witnessed in DS0000072808.V374574.R01.S.doc Version 5.2 Page 27 Norfolk Lodge order to reduce the risk of transcribing errors. There should be clear guidance for staff when to give when required medication to ensure that residents receive medication they need. Variable dose medication should be recorded to enable staff to monitor the effectiveness of the dose. 2 3 OP12 OP14 The level and range of social contact and activities should be developed to ensure that all residents needs are met. Residents usual routines, preferences and choices should be recorded on their care plans to ensure that staff are aware and can assist them to maximise their choice and control over their daily lives. Assistance at mealtimes should be provided discreetly and sensitively. There should be a record of all complaints and the action that was taken in response. Safeguarding information and procedures should be clearer to make sure that staff know how to report poor practice or suspected abuse to outside agencies. An audit of the environment should be carried out and an action plan, with realistic timescales, should be drawn up to address areas in need of redecoration and renewal. The systems for monitoring the quality of the service should be further developed. 4 5 6 OP15 OP16 OP18 7 OP19 8 OP33 Norfolk Lodge DS0000072808.V374574.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE 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 Lodge DS0000072808.V374574.R01.S.doc Version 5.2 Page 29 - 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. 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