Inspection on 04/04/07 for Norman Lodge

This inspection was carried out on 4th April 2007.

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 13/10/05

Norman Lodge 30/06/05

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 Linda Trenouth Key Unannounced Inspection 4th April 2007 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 Norman Lodge DS0000033549.V326047.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. Norman Lodge DS0000033549.V326047.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norman Lodge Address 1a Glenroyd Avenue, Cleckheaton Road Odsal Bradford BD6 1EX 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) 01274 691520 01274 675129 anne.jones@bradford.gov.uk City of Bradford Metropolitan District Council Department of Social Services *** Post Vacant *** Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35), Physical disability (2) of places Norman Lodge DS0000033549.V326047.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The places for PD are for service users aged 55 and over Date of last inspection 13th October 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 people who require respite, rehabilitation, assessment, and long-term care. 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. 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. The fees charged are £465.68 with additional charges for toiletries, hairdressing, daily papers and certain activities. Norman Lodge DS0000033549.V326047.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example, Choice of Home and “Lifestyle.” An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent,” “good”, “adequate” and “poor.” The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk I visited the home unannounced and stayed for approximately 7 hours. The inspection process also included gathering information and evidence before and after the visit to decide the overall judgement. I met with people living in the home and spoke with the manager and staff. I watched how people interacted with each other and with staff. The main purpose of this inspection was to make sure that the home continues to provide a good standard of care. During the visit I looked at the records, watched staff working, and talked to people living and working at Norman Lodge. I also looked around some of the building. Comment cards were sent out to people living at the home, relatives, visitors, and social and health care professionals, to give them opportunity to comment on the service. Feed back from the questionnaires returned is included in this report. The manager was on annual leave on the day of the inspection and therefore feedback was given to the deputy manager of the home. Requirements and recommendations made during this visit, and those outstanding from previous inspections can be found at the end of the report. Norman Lodge DS0000033549.V326047.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Norman Lodge DS0000033549.V326047.R01.S.doc Version 5.2 Page 7 People living at the home are not provided with contracts or statements of terms and conditions of residency, which means that people are not informed of their rights and responsibilities. The staffing levels are not always enough to meet the needs of all the people living at the home. Where staff make handwritten entries on medication records, these should be checked and countersigned by another person. All the above were raised at the previous inspection. Staff must be continually vigilant and update records and review risk assessments, to make sure that all staff are aware of any changes and that the needs of all people using the service are being met. The lack of activities for less able people in the home must be addressed. Staff must be given enough time, guidance, and confidence to provide meaningful activities, which will help people to be active and mentally stimulated through the day. 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. Norman Lodge DS0000033549.V326047.R01.S.doc Version 5.2 Page 8 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 Norman Lodge DS0000033549.V326047.R01.S.doc Version 5.2 Page 9 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 and 6. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Whilst the service user guide tells people what the service can provide there are no written contract or statement of terms and conditions, which means people, are unaware of their specific rights and responsibilities. People’s needs are assessed before they move in to make sure that their needs can be met by the home. EVIDENCE: Norman Lodge DS0000033549.V326047.R01.S.doc Version 5.2 Page 10 The questionnaires returned by people using the service and case tracking of four people confirmed that they did not have a contract, this included people who are now living at the home permanently. The lack of a written contract and statement of terms and conditions of residency leaves individuals unaware of their specific rights whilst living at the home. I spoke to two people living at the home who told me that they had the opportunity to stay at the home on short stay before moving in permanently. They said that they felt they were well aware of what the home had to offer and were able to make a decision and choice to live in the home. Individuals moving into the home were well assessed. All the case tracking confirmed that there was good and thorough assessments which makes sure that the home can meet all their social, health and care needs. Norman Lodge DS0000033549.V326047.R01.S.doc Version 5.2 Page 11 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. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The care planning and risk assessments have improved making sure that essential health needs are not overlooked. The health and care that a person receives is based on their individual needs. The principles of respect, dignity, and privacy are put into practice. EVIDENCE: The case tracking confirmed that the staff have improved care planning. One person has high dependency needs, the care plan was stepped up to monitor nutrition, fluids and monitor pressure care and recorded how frequently the person is turned. The plans recorded more detail and instructions, which helps make sure there is better consistency and continuity in the care carried out by the staff. Norman Lodge DS0000033549.V326047.R01.S.doc Version 5.2 Page 12 The district nurses’ recommendations are put into practice and the GP is regularly involved with the care. Other care plans I saw showed that staff had begun to make instructions clearer within the care plan. However risk assessments must be updated regularly to make sure staff are aware of how to safely meet all the person’s needs. The homes own medication policies were available but staff should make sure they follow the guidance. A second signature should be recorded where the MAR (Medication Administration Records) sheet is hand written. Those people who wish to self-administer their medication are encouraged to do so and they are appropriately risk assessed, which means that people can retain their independence managing their own medications safely. Norman Lodge DS0000033549.V326047.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. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The majority of people living in the home felt that the activities are very good but activities for less able people are limited. The mealtime is relaxed and informal and food is consistently well praised by the people living at the home. EVIDENCE: The main focus of the inspection was on a unit that cared for people who live at the home permanently. The environment was comfortable, clean, and warm and people looked well cared for and relaxed in the care of the staff. The staff were busy with various duties throughout the morning and caring for one person who was very poorly. The staff said that this was a typical morning and that their main priority was to make sure people were comfortable and cared for. They said that they did not have time generally to provide activities. Norman Lodge DS0000033549.V326047.R01.S.doc Version 5.2 Page 14 I spoke to a relative who confirmed that staff are very busy and said she had difficulties finding staff if she wished to talk to them. She also felt there was a lack supervision and stimulation for the people who are more dependent on the staff. Mt observations throughout the morning confirmed this and after discussion with some of the more able people it wasn’t clear what activities they could choose from and what was provided. It was apparent from staff that there were some activities in the day centre, but there was no information about these and little planning of daily activity for those individuals who remained on the unit. The majority of the questionnaires returned were from people who stayed at the home for a short length of time. They were generally happy with the variety and choice of activities. I stayed for lunch and dined in the “Salts unit,” the meal was relaxed and unhurried and comments from people living at the home are very favourable. Questionnaires returned were also very positive about the food. However there was no menu available for people to read and a lack of information on the notice board. The home must display a daily or weekly menu to inform people of the range of food and choices available. Norman Lodge DS0000033549.V326047.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. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People living at the home and their relatives felt confident that their concerns were taken seriously and dealt with. EVIDENCE: People I spoke to and questionnaires returned confirmed that everyone felt able to raise concerns and are confident that they will be taken seriously. The majority of questionnaires returned confirmed that they knew who to complain to. Others stated they had not needed to complain. The Adult Protection Team had informed the manager of an adult protection issue at the home. This was promptly investigated by the manager who acknowledged there needed to be some changes made to the recording of information in the care plans and transfer information shared with other agencies. Staff had attended adult protection training and felt they were able to raise concerns about any poor practice. Norman Lodge DS0000033549.V326047.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, 20,21,22,23,24,25 and 26. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The home is comfortable and people live in a safe environment. EVIDENCE: The lay out and design of the home allows for small clusters of people to live together in a non-institutional environment. Each unit separates into smaller groups of bedrooms with separate lounge, dining, and kitchen areas. I toured the Salts unit, which provides accommodation for 9 people. I visited two people in their bedrooms who told me that the home was very comfortable and that they felt their bedrooms provided everything they needed and were well maintained. They felt the cleanliness and hygiene standard of the home Norman Lodge DS0000033549.V326047.R01.S.doc Version 5.2 Page 17 was good. They said that they had been able to personalise their rooms bringing along many photographs and personal memorabilia. They also confirmed they could lock their door if they wished. I spoke to a relative who confirmed that on her visits to the home it was always clean and fresh and well looked after. The bedrooms visited were well furnished and decorated. The bathrooms and toilets were clean and provided all necessary facilities. The toilet and bathroom door locks were working and there were appropriate alterations to the bathrooms for people with mobility problems i.e. grab rails and hoists. Norman Lodge DS0000033549.V326047.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. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The staff are recruited in a responsible way and are well supported to do their job. There are not enough staff working at the home to make sure everyone’s needs are fully met. EVIDENCE: The home functions from four different wings, which means that sometimes there is only one member of staff working on each wing. When someone requires assistance from two staff, help has to be summoned from another wing, leaving the people on that unit unsupervised. At night there are only two staff on duty to cover all four wings, staff said that this does result in people having to wait for assistance. Staffing levels had improved since the last inspection. I spoke to a visiting relative who felt concerned that staffing levels were low and that she never seemed to be able to find staff. She felt they were all very caring but at times she was concerned that her relative was at risk of falling as she was Norman Lodge DS0000033549.V326047.R01.S.doc Version 5.2 Page 19 unsupervised and quite confused at the moment. She also felt that her relative was bored and lacked any mental stimulation. Recruitment was reviewed. The organisation has a robust recruitment policy, and those documents seen confirmed that these are followed. Staff have good induction and mandatory training. The management closely monitor staff training needs and the staff access a variety of additional training courses to meet the needs of people living at the home. Staff training is well managed and staff have undertaken training and updates in moving and handling and basic food hygiene. Other training has included first aid, adult protection and prevention of falls training. The organisation is committed to providing staff with NVQ training and the majority of staff have achieved NVQ level 2 and 3 in care. I spoke to staff and reviewed records and confirmed that staff meetings are held for all staff and minutes are recorded. Supervision and support is consistent for all staff at the home, Staff confirmed that they felt they were well supported by the manager of the home. Norman Lodge DS0000033549.V326047.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. People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The home is well managed and the health, safety, and welfare of people living at the home and staff are promoted and protected. EVIDENCE: The registered manager is going through the registration process with the CSCI. She has many years of experience working in the home, and she holds both a social work qualification and the Registered Managers Award. The manager is Norman Lodge DS0000033549.V326047.R01.S.doc Version 5.2 Page 21 committed to meeting the requirements and recommendations from this inspection. The completed pre-inspection questionnaire identifies necessary health, safety, and service checks have taken place. Evidence was provided during the inspection of safety checks being maintained in the areas of electrical, gas and water safety. There is a training matrix identifying when mandatory training updates are required. The training needs are monitored through supervision and the staff appraisal system. There are regular staff meetings and service user meetings and an open and inclusive approach promoted by the management of the home. There appeared however to be insufficient evidence of regular visits by the registered provider or their representative. The records available were outdated and did not give sufficient detail about their findings at the visit. Norman Lodge DS0000033549.V326047.R01.S.doc Version 5.2 Page 22 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 2 2 3 x x 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 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Norman Lodge DS0000033549.V326047.R01.S.doc Version 5.2 Page 23 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 OP1 Regulation 5 (1) Requirement The service user guide must include information about fees and contracts of residency to make sure that people are informed about their rights and responsibilities. This is outstanding from 30/6/05 and 31/03/06 2. OP2 5 (3) All people staying at the home must be provided with a written contract, which tells them the terms and conditions of residency, so that they are fully informed. This is outstanding from 30/6/05 and 31/03/06 3. OP27 18 (1) (a) Staffing levels must be reviewed to make sure that there are sufficient staff on duty to meet the needs of people using the service at all times. This is outstanding from 31/03/06. 04/06/07 04/10/07 Timescale for action 04/10/07 Norman Lodge DS0000033549.V326047.R01.S.doc Version 5.2 Page 24 4. OP33 26 The registered provider must visit the home regularly and provide a report on their findings. To make sure the quality of care at the home is of a good standard. 04/06/07 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 In order to ensure accurate recording of medication all handwritten entries on MAR (Medication Administration Records) should be checked and countersigned by a second person. Norman Lodge DS0000033549.V326047.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Norman Lodge DS0000033549.V326047.R01.S.doc Version 5.2 Page 26 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!