Inspection on 15/05/07 for Norlington Care Home

This inspection was carried out on 15th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Norlington Care Home 10/09/09

Norlington Care Home 19/09/07

Norlington Care Home 03/10/06

Norlington Care Home 18/05/06

Norlington Care Home 14/11/05

Norlington Care Home 01/06/05

Norlington Care Home 11/02/05

Norlington Care Home 22/06/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Norlington Care Home 19 Stourwood Avenue Southbourne Bournemouth Dorset BH6 3PW Lead Inspector Chris Gould Unannounced Inspection 15th May 2007 10:00 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 Norlington Care Home DS0000055350.V337851.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. Norlington Care Home DS0000055350.V337851.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norlington Care Home Address 19 Stourwood Avenue Southbourne Bournemouth Dorset BH6 3PW 01202 422064 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) Norlington Care Limited Mrs Carolyn Mary Jolliffe Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Norlington Care Home DS0000055350.V337851.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. No more than 20 service users in need of nursing care may be accommodated. 3rd October 2006 Date of last inspection Brief Description of the Service: The Norlington Care Home is registered to provide personal care for up to 37 older people, 20 of whom can require nursing care. Mrs June Tempany and her son Mr Gary Tempany own the home. The Commission for Social Care Inspection has registered Carolyn Jolliffe as the manager. Norlington Care Home is situated on the edge of Southbourne and is close to local shops and amenities such as libraries, churches etc. and also to the sea and cliff top walks. There are single and double rooms on the ground, first and second floors. A lift provides level access to all areas of the home. There is a large lounge and lounge/dining area in the original part of the home. At the rear of the home, on the ground floor, are a small quiet lounge and a conservatory that can be used as a dining area. The fees for the home as provided to CSCI at the time of inspection range from £450 to £520. The fees for people requiring continuing care are negotiated on an individual basis. Additional charges include hairdressing, chiropody and newspapers. See the following website for further guidance on fees and contracts. http:/www.csci.org.uk/about_csci/press_releases/better_advice_for_people_c hoos.aspx Norlington Care Home DS0000055350.V337851.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors undertook this unannounced key inspection over eight hours on one day in May 2007. A tour of the premises took place and three staff files, five residents care records and relevant documentation and policies and procedures relating to the running of the home were inspected. Eight residents, three visitors to the home and the staff on duty were spoken with. Carolyn Jolliffe the registered manager, June Tempany and Gary Tempany were available throughout the inspection. The Annual Quality Assurance Assessment form had been completed and was provided to the Commission for Social Care Inspection on the day of inspection. New legislation has made it a legal requirement for all registered adult services to fill in an Annual Quality Assurance Assessment. The completed assessment is the main way that the Commission for Social Care Inspection will know how well the service is delivering good outcomes for the people using it. What the service does well: Norlington Care Home provides a clean, well-maintained comfortable home where residents’ privacy and dignity are respected. All the residents and visitors spoken with commented positively about the laundry service and the cleanliness of the home. A visitor commented that staff are ‘very good and attentive’ and that their relative ‘is a 100 happy’. People are only admitted following an assessment and the home has confirmed by letter they are able to meet the assessed needs of the prospective resident. The home has a recruitment procedure and training programme that enables the staff working at the home to acquire the knowledge needed to provide the care required by the residents. Residents living at the Norlington Care Home can be confident that their complaints will be listened to and staff training and the home’s procedures protect them from abuse. The minutes of the recent families meeting identified that communication was good and everyone was in agreement that they knew whom to contact if necessary. A programme of social activities is provided and in April included a visit by an entertainer, an Easter bonnet craft afternoon and celebration lunches for the Easter weekend and St George’s day. Norlington Care Home DS0000055350.V337851.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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. Norlington Care Home DS0000055350.V337851.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 Norlington Care Home DS0000055350.V337851.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): 3. The home does not provide intermediate care therefore standard 6 is not applicable. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admissions only take place when the home is confident that they are able to meet the assessed needs of the prospective resident. EVIDENCE: The care records for two recently admitted residents viewed contained a pre admission assessment of care needs including information from professionals previously involved in providing their care. Discussion with staff confirmed that they were aware of the resident’s needs at the time of their admission. Norlington Care Home DS0000055350.V337851.R01.S.doc Version 5.2 Page 9 Copies of letters provided to the prospective resident advising them that following assessment the home is able to meet their needs were seen. The home identified that the present assessment format needed reviewing and has developed a new form that is to be implemented. Norlington Care Home DS0000055350.V337851.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. Shortfalls in the completion of care plans and risk assessment documentation does not ensure that the health and personal care provided is safe and meets the resident’s individual needs, potentially placing them at risk. EVIDENCE: Five residents care records were read and the content was found to be variable. An activities of daily living assessment is undertaken to inform the development of a care plan. The records viewed contained a lot of information but it was not always easy to identify the actual care being provided. One action plan gave conflicting advice relating to eye care as new instructions had been added but the old procedures had not been removed or changed in any way to inform that the task was no longer relevant. Norlington Care Home DS0000055350.V337851.R01.S.doc Version 5.2 Page 11 One resident required an appliance put on to a limb but as no one at the home had the experience to undertake the task until training had been provided the daily record said that it was not to be used. This was not clear in the care plan. The appliance was put on and when it was removed a skin tear was noted. An assessment and care plan identifying how the skin tear was managed was not available. A wound assessment and care plan was in place in one resident’s file viewed. The resident had three wounds, with two of them being assessed as a ‘minor injuries wound’. The main wound had been reviewed and redressed but this information was not available relating to the minor wounds. One resident’s care plan identified an infection and the action to be taken but there was no clear outcome recorded. The care plans are often based on routine rather than on individual assessment and need. A number of the care plans viewed stated that the resident was to be turned three hourly but the turn charts do not demonstrate that this is the actual care provided. There is limited information to record the time the resident is sat out of bed or the pressure relieving care that is provided during this time. One resident’s care plan states that they are to be encouraged to mobilise for 10 minutes every hour assisted by one carer. On visiting the resident and in discussion with the staff it was identified that this task is no longer relevant to the actual care required by the resident. One care plan says to offer a bath but the manual handling assessment says to bed bath. One highly dependant resident visited at 11:50 on the morning of the inspection was still in bed in a very poor condition needing to be washed, dressed and sat out of bed. When sat up the resident has increased independence when eating and drinking. The mid morning drink and biscuit had been provided while the resident was in bed and lying on their side. There was no evidence in the resident’s records viewed to suggest that the resident or a representative had been involved in the process of developing the care plan. An inspection had taken place by the CSCI pharmacy inspector in March 2007 when a number of requirements were made. Since the pharmacy inspection procedures, practices and auditing process have been reviewed. Systems have been changed to ensure that the residents’ medication does not run out and it can be given as prescribed. The new system was demonstrated as working when medication was delivered to the home on the day of the inspection. During this inspection there were no discrepancies found between the medication administration records and the medication still in the blister packs, bottles and cartons. The medicine refrigerator records showed that since the pharmacy inspection the temperature had remained within normal limits and had not dropped below 2°C. Norlington Care Home DS0000055350.V337851.R01.S.doc Version 5.2 Page 12 The care records viewed contained a medication care plan including the resident’s preference for taking medication. The care records did not always provide clear guidance to indicate when prescriptions marked ‘as needed’ or ‘prn’ should be given when the resident is unable to request the medication. The directions for eye drops do not always state whether they are to be administered to one eye or both. Staff induction includes respecting residents privacy and dignity. This was confirmed when speaking with staff. Staff were seen knocking on doors and waiting for an answer before entering residents’ rooms. Residents spoken with said that they were always addressed in the way they had requested and the staff are very polite. The admission document includes the resident’s preferred form of address. Screens are provided in the bedrooms used by more than one resident. Norlington Care Home DS0000055350.V337851.R01.S.doc Version 5.2 Page 13 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. The home tries to be flexible and offer choices however there are times due to restrictions on the service when not all the residents are provided with the opportunity to retain control over their lives or to have their social needs met. EVIDENCE: The records viewed were variable in the information they included relating to the social history of the resident. Further work is still required in this area as a full picture of the person’s past family, work and social history will assist with planning for their future care. A healthcare assistant is allocated to provide social activities each afternoon. Regular residents meetings take place and a ‘families and friends‘ meeting was held in April. Minutes of the meetings are recorded. A monthly newsletter is produced and copies are available in the reception area. Norlington Care Home DS0000055350.V337851.R01.S.doc Version 5.2 Page 14 There is a programme of group activities available but there was limited evidence of how the social needs are met for the residents where these activities are not appropriate. During April the activities included a visit by an entertainer, an Easter bonnet craft afternoon and celebration lunches for the Easter weekend and St George’s day. Money provided by fund raising activities undertaken by residents, their families and staff is available to provide social activities for the residents. A record is maintained of all visitors to the home. Visiting arrangements are included in the revised Service Users Guide. Open visiting is encouraged after 10:00 am except by arrangement. Visitors spoken with confirmed that they were always made welcome by the staff. Those residents who were able to articulate a view confirmed that they were able to make choices about such matters as what they ate and at what time they had breakfast. One resident said ‘I need help to get up and go to bed so it really depends on the staff’. Residents are able to “personalise” their bedroom with additional items of their choice. This was confirmed when visiting residents’ bedrooms. Residents are asked at what time they would like their breakfast and this is entered in the ‘night time care plan’. Residents confirmed that they are provided with a choice of lunch and evening meal. The menus viewed appeared well balanced and nutritious including the provision of five pieces of fruit and vegetables each day. There were adequate fresh fruit, vegetables and dry store items available. Residents are provided with breakfast, lunch, evening meal and a snack in the evening with soft diets pureed in separate piles to aid presentation. Residents agreed that the food supplied is good. Norlington Care Home DS0000055350.V337851.R01.S.doc Version 5.2 Page 15 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 good. This judgement has been made using available evidence including a visit to this service. The systems in place provide residents with the confidence that their complaints will be listened to and acted upon and they are protected from abuse. EVIDENCE: The annual quality assurance assessment completed by the registered manager identifies that twenty-one complaints have been received by the home in the past twelve months. The complaints had been well documented, investigated and action taken to address identified issues. The complainants had been satisfied of the outcome following the investigation. A recent survey for residents and their relatives undertaken by the home confirmed that they know whom to contact ‘if things go wrong’. The registered manager undertakes an audit of complaints every three months. The home has an adult protection policy that has been reviewed to clearly provide the actions that would be taken if an adult protection issue were reported in line with the local multi agency ‘No Secrets’ guidelines. As seen in the staff training files and confirmed when talking to staff they have now received training and been provided with a copy of the home’s prevention of abuse policy. Norlington Care Home DS0000055350.V337851.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. The standard of the environment is good providing the residents with a comfortable, clean and well maintained place to live. EVIDENCE: The home is well decorated and comfortably furnished. A full time and a part time person are employed to ensure that the home is well maintained and to assist with implementing the ongoing refurbishment plan. In the past twelve months refurbishment has included decorating the dining room, fitting a new hairdresser’s basin in the ground floor bathroom, a new en-suite toilet in a resident’s room and decorating residents bedrooms. There are plans to upgrade two bathrooms in the near future. An assessment of the home is due to be undertaken by an occupational therapist in June 2007. Norlington Care Home DS0000055350.V337851.R01.S.doc Version 5.2 Page 17 A fire risk assessment is in place together with an action plan. The home is working towards meeting the recommendations. Dorset Fire and Rescue Service were due to visit a few days after this inspection. Low level lighting is now provided in all rooms and this forms part of the monthly monitoring undertaken by the home. A number of bedrooms still have fluorescent strip lighting. The resident’s preference for this type of lighting has been included in the individual care records. On the day of inspection the home was clean and no malodours were noted. All residents and visitors spoken with commented positively about the laundry service and the cleanliness of the home. Designated staff are employed to attend to the laundry and the cleaning of the home. All staff have received infection control training and been provided with a copy of the revised infection control policy. This was confirmed when talking to staff. Norlington Care Home DS0000055350.V337851.R01.S.doc Version 5.2 Page 18 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. The recruitment process and staff training provided ensures that the care of residents is provided by staff that are generally competent and knowledgeable. However the number and skill mix of staff available at times during the day are not sufficient to ensure that the individual needs of the residents are fully met. EVIDENCE: Staff rosters are maintained showing which staff are on duty at any time during the day and night. In addition to care staff the Norlington employs staff to cover housekeeping, cooking, maintenance and administration. The call bell system is monitored three monthly to ensure calls are being answered within an acceptable time. The completed annual quality assurance assessment, reading care plans, visiting residents and talking with staff identified that the home has a high number of residents highly dependant on staff to meet their needs. Staff expressed concern that at times during the day there are not enough staff on duty. As discussed previously a resident was waiting to be washed, dressed and sat in a chair until late in the morning and another resident said that his Norlington Care Home DS0000055350.V337851.R01.S.doc Version 5.2 Page 19 choice of time to go to bed and get up was restricted due to his dependence on staff. One member of staff said that there have been times when residents have had to wait until after lunch to be washed. At the time of inspection of the 32 residents 26 required help with dressing and undressing, 16 of these needing two people to help with their care. A number of residents if there care plans are to be met require regular moving to prevent the development of pressure ulcers whether in bed or sat in a chair. Fifteen residents need help, supervision or prompting to eat meals. A visitor commented that staff are ‘very good and attentive’ and that their relative is a 100 happy’. Of the twenty-seven care staff employed at the Norlington Care Home ten have achieved at least a level 2 NVQ in care and seven are at present undertaking the training. Three staff records viewed evidenced all the relevant checks and information had been obtained prior to the member of staff commencing at the home. Training records of two recently appointed members of staff contained documentation to evidence that an induction had been undertaken using the Skills for Care induction standards. The care staff have all received manual handling, infection control and health and safety training. A manual handling update was held at the home on the afternoon of the inspection. The home has a number of residents diagnosed with dementia and all care staff have received recent relevant training. This was confirmed by reading training files and talking with staff. A training programme for staff on the care of people with diabetes has been commenced. A member of staff is given the opportunity to shadow the community diabetic nurse when she holds the series of clinics for the newly diagnosed diabetic. All care staff now have a training plan developed following appraisal. Norlington Care Home DS0000055350.V337851.R01.S.doc Version 5.2 Page 20 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 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of the home and the quality assurance system ensures that the residents are consulted on whether the service provided meets their needs. However the omission of a full risk assessment and management plan has the potential for residents to be put at risk from falling or causing harm to themselves. EVIDENCE: Carolyn Jolliffe, the registered manager is a first level nurse and has completed the Foundation Degree in Care Home Management. The registered manager has attended a number of courses for clinical updating and is looking at how Norlington Care Home DS0000055350.V337851.R01.S.doc Version 5.2 Page 21 she can access personal clinical supervision. June and Gary Tempany, directors of the Norlington Care Home are closely involved in the management of the home. A deputy matron has been recently appointed and will commence in post in June. The deputy matron will provide support to the registered manager and assist with the further development of care documentation and the monitoring of the care provided. There was evidence that apart from having an open door policy the manager has also arranged meetings for staff, residents and their families to have a say in the way the home is run. The minutes of the recent families meeting identified that communication was good and everyone was in agreement that they knew whom to contact if necessary. The home has introduced a self-monitoring programme including care records, medication, accidents, complaints and infection control. Surveys have been used to gather the views of the residents and their relatives or representatives. The responses were generally very positive and the issues identified had been dealt with as appropriate. The registered manager is to extend the surveys to other people who are involved in the running of the home and care of the residents including GP’s, social services, chiropodist and district nurses. Regular residents meeting are held and a monthly newsletter produced. A families meeting was held recently that was not very well attended but as it was the first one it is hoped that future meetings would be more successful. The registered manager completed and has returned the Commission for Social Care Inspection, Annual Quality Assurance Assessment and will now use the document as part of the home’s quality monitoring programme. All gas installations, central heating, electrical wiring and appliances and equipment used to meet service user needs have been checked. Policies and procedures are available relating to health and safety, Control of Substances Hazardous to Health (COSHH), infection control, manual handling and first aid. Fire training, drills and fire safety checks have been completed as required. An accident book is maintained and analysed monthly. An accident to a resident identified in their care records had been recorded in the accident book. Staff have received training in health and safety including manual handling and first aid. Bed rails are in place for a number of residents. An assessment is undertaken but they record the conclusion and not how this was reached. The Department of Health document Safe Use of Bed Rails was discussed with the registered manager. The daily record and completed accident forms for one resident identified that although bed rails were fitted they had fallen out of bed. A risk assessment Norlington Care Home DS0000055350.V337851.R01.S.doc Version 5.2 Page 22 had not been undertaken to look at whether the bed rails are appropriate or if there are alternative ways of managing the risk. Norlington Care Home DS0000055350.V337851.R01.S.doc Version 5.2 Page 23 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 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Norlington Care Home DS0000055350.V337851.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15(1) Requirement The registered person shall ensure that residents care plans contain sufficient detail to provide clear guidance to staff on the actions to be taken to meet their care needs. The care plans must be reviewed and updated to ensure they relate to the actual care being provided and are focused on the individual needs of the resident. Timescale of 31/08/06 not met. 2. OP8 12(1)Sch 3 The registered person must ensure that proper provision is made for the health care and where appropriate treatment of residents. Residents with all grades of wound must have a wound care assessment and care plan that clearly documents the treatment provided. Timescale of 31/08/06 not met. 3. OP9 13(2)Sch The Registered Person shall DS0000055350.V337851.R01.S.doc Timescale for action 31/08/07 31/08/07 31/08/07 Version 5.2 Page 25 Norlington Care Home 3 make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received in the care home including: The care records must provide clear guidance to indicate when prescriptions marked ‘as needed’ or ‘prn’ should be given when the resident is unable to request the medication. The directions for eye drops must always state whether they are to be administered to one eye or both. 4. OP12 16(m)(n) The registered person must consult residents about their social interests and provide facilities and resources to meet their needs. Timescale of 28/02/06 not met 31/08/07 5. OP27 18(1)(a) The registered person must review the staffing at the home to ensure that at all times the number and skill mix are appropriate to meet the needs of residents. 31/08/07 6. OP38 13(4)(c) The registered person must 31/08/07 ensure that bedrails are only used after a full, documented risk assessment has been carried out to determine if their use is the most appropriate method of managing the risk for the individual resident. Norlington Care Home DS0000055350.V337851.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Norlington Care Home DS0000055350.V337851.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Poole Office Unit 4 New Fields Business Park Stinsford Road Poole BH17 0NF 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. 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