Inspection on 30/06/05 for Norman Lodge

This inspection was carried out on 30th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Norman Lodge 04/04/07

Norman Lodge 13/10/05

Norman Lodge 24/02/05

Norman Lodge 10/06/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Norman Lodge 1a Glenroyd Avenue Cleckheaton Road Odsal Bradford, BD6 1EX Lead Inspector Ann Stoner Unannounced 10.00am: 30th June 2005 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 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. Norman Lodge J52 J03 S33549 Norman Lodge V230107 300605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Norman Lodge Address 1a Glenroyd Avenue Cleckheaton Road Odsal Bradford BD6 1EX 01274 691520 01274 675129 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) City of Bradford Metropolitan District Council Dept of Social Services Mr Philip Mc Dermott Care Home Only 36 Category(ies) of Old age (36) registration, with number of places Norman Lodge J52 J03 S33549 Norman Lodge V230107 300605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 24th February 2005. Brief Description of the Service: Norman Lodge is a single storey, purpose built Local Authority residential and day care resource centre for older people. In addition to day care, the home provides residential care for respite, rehabilitation, assessment and permanent service users. Nursing care is not provided. Day care is not regulated and therefore is not inspected. The residential part of the home functions from four different wings, with one wing dedicated to rehabilitation. Each wing has a lounge, dining and kitchen area, and specialist equipment to enable and encourage independent living is provided on the respite and rehabilitation wings. The layout of the home allows all the wings to function independently of each other, yet still providing interaction whenever necessary. In the home there is a hairdressing salon and a bar area selling alcoholic and non-alcoholic drinks each evening. People using wheelchairs have access to the well kept gardens and courtyards where there is outdoor seating. The home is located in the centre of a new housing estate, close to the city centre of Bradford. Local amenities include an off license, hairdressing salon, public houses, betting shop and newsagents. Norman Lodge J52 J03 S33549 Norman Lodge V230107 300605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Over an inspection year from April until March, care homes have a minimum of two inspections a year; these may be announced or unannounced. The last inspection was unannounced and took place on the 24th February 2005. There have been no further visits until this unannounced inspection. During the inspection, I looked at records, saw some areas of the home, such as bedrooms, lounges, dining rooms, laundry, toilets and bathrooms and I saw care staff working with service users. Throughout the day I spoke with the service users, staff and members of the management team. Comment cards/questionnaires are left for service users, visitors and other professionals at each inspection, thereby giving the opportunity for anonymous feedback. This inspection started at 10.00am and ended at 5.30pm, in addition to the time spent in the home, I spent time preparing for this inspection. What the service does well: What has improved since the last inspection? Following the last inspection, the home has worked hard to develop a preadmission assessment format and to bring care plans to a standard that gives staff clear and detailed information on how to deliver care. Medication practices have been reviewed and recruitment records of existing staff are now kept in the home. Norman Lodge J52 J03 S33549 Norman Lodge V230107 300605 Stage 4.doc Version 1.30 Page 6 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. Norman Lodge J52 J03 S33549 Norman Lodge V230107 300605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Norman Lodge J52 J03 S33549 Norman Lodge V230107 300605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 5 & 6. People are able to make an informed decision about the home; however, the lack of a written contract and statement of terms and conditions of the home leaves relatives and/or service users unaware of the specific rights and responsibilities of both the home and the service user. The home’s pre-admission assessment forms the basis of the care plan. Service users admitted for rehabilitation are given support and encouragement to return home. EVIDENCE: The home has worked hard to develop a pre-admission assessment process, which is thorough, detailed and shows that the person is suitable for the home. Staff spoke of the difficulty they had experienced with a service user admitted on an emergency basis. Although emergency admissions are rare, the home should justify how they are able to meet the person’s needs. They do this on an informal basis when the initial telephone request is made, but a record of how they arrived at their decision to accept the referral should be kept within the person’s records. Norman Lodge J52 J03 S33549 Norman Lodge V230107 300605 Stage 4.doc Version 1.30 Page 9 One assessment form showed that the service user’s family had been involved and offered an introductory visit to the home, and another service user said that she visited the home twice before making her decision regarding admission. The home has produced a statement of purpose and service user guide, however without the contract and statement of terms and conditions, the requirements of the Care Homes Regulations 2001 are not met. Two requirements have been made to address the above issues. There is an information pack about the home in bedrooms; one service user had obviously read the pack and was able to identify key information from it. A multi-disciplinary team that includes care staff, physiotherapists and occupational therapists provide a rehabilitation service, with dedicated facilities, to support service users to regain independence and eventually return home. Service users were aware of the need to join in daily living activities to achieve their ultimate goal of going home. One person said, “I have gained so much confidence in such a short space of time”, another described how she had been encouraged to climb stairs in the physiotherapy room, and another person said, “We are here to try and help ourselves, so that we can go home.” The home now has some places for assessment, but there are no systems in place to show what is being assessed, who is to assess, and how the assessment should be conducted, monitored and reviewed. The registered manager said that he has asked the care management team for an assessment tool, but has been unsuccessful. A recommendation has been made to address this. Norman Lodge J52 J03 S33549 Norman Lodge V230107 300605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8 ,9, & 10. The health care needs of residents are met and care plans provide clear and detailed instructions for staff to follow. Residents are treated with respect and their privacy is upheld. Assessments for service users to hold their own medication are not clear. EVIDENCE: The home has worked hard to improve the level of detail recorded in care plans. The care plans sampled showed clear and precise instructions for staff to follow. One person’s personal cleanliness plan showed her preferred time for having a bath, how she liked a bubble bath, and gave clear instructions on staff actions. This service user confirmed that care was given in line with her care plan. Another person’s care plan gave staff instructions on prompting a service user to dress and stated that she liked to wear her necklace, which is of great sentimental value to her. Care plans are evaluated and there was a thorough ‘person centred’ evaluation in one plan. Nutritional and pressure area care assessments were in the care plans sampled and there were good, easy identifiable records of medical treatments, and visits of health professionals. Service users confirmed that their health care needs are met. Norman Lodge J52 J03 S33549 Norman Lodge V230107 300605 Stage 4.doc Version 1.30 Page 11 The assessment process for service users wanting to self medicate was sampled. Although informal processes are in place to question the cognitive ability to self medicate and monitor medication compliance, this is not formally recorded and reviewed. A requirement to address this has been made. One service user who holds her own medication was able to show how this is stored securely in her own room. Throughout the day staff respected the privacy and dignity of service users. One service user said that she held the key to her bedroom door and, for extra privacy, locked it from the inside when undressing. Another person confirmed that she had been offered a key but did not want one. A care worker was able to describe how she respects the dignity of a service user with memory loss, and confirmed that the core values of privacy and dignity are included in the induction programme. Norman Lodge J52 J03 S33549 Norman Lodge V230107 300605 Stage 4.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 & 15. Service users are encouraged to make decisions and choices about their lifestyle. They are helped to keep contact with family and friends and visitors are welcomed at the home. A good, varied and nutritious diet is provided. EVIDENCE: Service users confirmed that their choices are respected and gave examples of the choices that they make, which include choices around bedtimes and times for getting up in a morning, choices of menu, and whether to join in activities or not. One person said, “You can go out and wander around if you want.” Another person said, “There is always something going on, and you can join in or sit somewhere quiet to read or watch TV.” Service users can join in the daily activities in the day centre and throughout this inspection a variety of activities took place. One person’s care plan showed that she goes to the Salvation Army luncheon club each week, and local Church meeting every second Wednesday. This person confirmed that this is standard practice and that the home arranges the Access bus for her. Most impressive, was the fact that one service user has recently been involved in the recruitment and selection processes of new staff, and in the organisation’s system of quality assurance. On the morning of this inspection, this service user was visiting another establishment to monitor standards and to speak to service users. On Norman Lodge J52 J03 S33549 Norman Lodge V230107 300605 Stage 4.doc Version 1.30 Page 13 her return, she said, “I feel complete, it made me feel young again, important and living life like I used to”. Service users confirmed that visitors are welcome, are offered a drink and can speak to them in private. One visitor was extremely complimentary about the home. Menus are on the dining tables, and the meal served corresponded with the menu. Service users said that the meals were ‘lovely’ and confirmed that alternatives are always available. One person’s care plan showed that she had an allergy to pork and pork derivatives; the cook was aware of the products that this person was allergic to. Norman Lodge J52 J03 S33549 Norman Lodge V230107 300605 Stage 4.doc Version 1.30 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,17 & 18. Complaints are taken seriously and service users are safe. EVIDENCE: Information on how to make a complaint is displayed throughout the home. All service users said that they would complain if they needed to and staff knew how to deal with a complaint. The home has a copy of the Multi-Agency Adult Protection procedures, and although some staff are waiting for training on adult abuse, they explained how they would deal with any suspicions of abuse. The registered manager said that abuse is a ‘live’ agenda item and discussed regularly at meetings; this includes both staff meetings and service user meetings. Information on advocacy, with contact telephone numbers, is in the service user guide. Norman Lodge J52 J03 S33549 Norman Lodge V230107 300605 Stage 4.doc Version 1.30 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19, 20, 21, 22, 23, 24, 25, & 26 The home is safe and suitable for service users. EVIDENCE: There is plenty of space in the home and it was clean and tidy. Specialist equipment such as grab rails, raised toilet seats and hoists are provided. One service user on the rehabilitation wing used a handrail to steady herself as she walked along the corridor. Service users and visitors said they were pleased with the bedrooms, and service users confirmed that on admission they are offered a key to their room and the call and fire alarm system is explained to them. Staff explained how they try to prevent cross infection when laundering soiled linen and service users confirmed that their personal clothing is well laundered. One person said that her key worker hand washed a blouse again to remove a grease mark, and another person said, “My key worker will happily iron my clothes again if they are creased” Norman Lodge J52 J03 S33549 Norman Lodge V230107 300605 Stage 4.doc Version 1.30 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 29 & 30. Staffing levels are inappropriate for the home. The home’s recruitment processes are thorough and staff are expected to undertake training. EVIDENCE: The staffing levels are inappropriate for the layout of the building and the service it provides. There are times when there is only one care worker on a wing, which means that help has to be summoned when needed from another wing; which in turn leaves that area unattended. Service users are at most risk of having their needs overlooked at night, when there are only two workers on duty to cover all four wings. This is unacceptable. A requirement relating to this has been made. In the recruitment files of two new starters there was a completed application form, interview schedules and notes, two written references and a successful CRB/POVA (Criminal Record Bureau/Protection of Vulnerable Adults) check. A service user from the home had been involved in the recruitment and selection process of these new starters. This is very good practice. All staff are given a copy of their terms and conditions of employment, however this should be amended. A recommendation relating to this has been made. The registered manager confirmed that, in order to comply with regulations, employment records for all staff are now kept in the home. An induction programme was in place for the two new workers, and an existing member of staff confirmed that staff with both a permanent and casual contract, complete the Best Practice manual (based on the TOPSS induction and foundation standards). A care worker explained how she has transferred Norman Lodge J52 J03 S33549 Norman Lodge V230107 300605 Stage 4.doc Version 1.30 Page 17 theory from a training course into practice, giving examples of ‘person-centred care’. Norman Lodge J52 J03 S33549 Norman Lodge V230107 300605 Stage 4.doc Version 1.30 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 Quality assurance systems protect the best interests of the service users. EVIDENCE: On discharge from the rehabilitation unit, the home sends out a questionnaire about the home, and the service it provides, to service users and their relatives. Other service users are sent a similar questionnaire every three months, and the views of other professionals and relatives are sought annually. The deputy manager completes an action plan following feedback, and the questions are reviewed if the answers are found to be ambiguous. In addition to this, the home uses feedback following inspections and comments made at the Regulation 26 visits to improve standards. A service user confirmed that service user meetings take place, and said that the views and opinions of service users are valued and respected. Norman Lodge J52 J03 S33549 Norman Lodge V230107 300605 Stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 2 2 x 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 x x 3 x x x x x Norman Lodge J52 J03 S33549 Norman Lodge V230107 300605 Stage 4.doc Version 1.30 Page 20 Yes Are there any outstanding requirements from the last inspection? 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 1 Regulation 5 (1) Requirement The service user guide must include: The statement of terms and conditions of the home. The contract. A copy of the most recent inspection report. The registered person must give service users a contract showing the arrangements made. All service users who self medicate must have a risk assessment that shows: The factors taken into account to assess the service users cognitive ability to hold their medication. The measures taken to monitor compliance. A review of the monitoring process. Evidence that the service user understands that the medicines must be locked away. Norman Lodge J52 J03 S33549 Norman Lodge V230107 300605 Stage 4.doc Version 1.30 Page 21 Timescale for action 31.12.05. 2. 3. 2 9 5 (3) 13 (2) 31.12.05. 31.8.05. 4. 27 18 (1) (a) This risk assessment must be reviewed on a regular basis, and at the start of each stay for respite and short stay service users. The registered provider must make sure that staffing levels are approriate to the needs of the service. 30.9.05. 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. 2. Refer to Standard 3 3 Good Practice Recommendations The home should be able to show how they arrived at their decision to admit people to the home on an emergency basis. There should be an assessment tool, for those service users admitted for assessment, showing: The roles and requirements of those required to carry out the assessment. How the assessment is to be conducted. How the assessment is to be monitored. 3. 29 How the assessment is to be reviewed. The terms and conditions of employment should state that any new convictions (including motoring offences) must be reported to the manager. Norman Lodge J52 J03 S33549 Norman Lodge V230107 300605 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 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 Norman Lodge J52 J03 S33549 Norman Lodge V230107 300605 Stage 4.doc Version 1.30 Page 23 - 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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