Inspection on 23/11/06 for Normanton Lodge Care Home

This inspection was carried out on 23rd November 2006.

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

Other inspections for this house

Normanton Lodge Care Home 03/12/09

Normanton Lodge Care Home 29/10/08

Normanton Lodge Care Home 07/12/05

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Normanton Lodge Care Home 75 Mansfield Road South Normanton Alfreton Derbyshire DE55 2EF Lead Inspector Rose Veale Unannounced Inspection 10:00 23 November 2006 rd 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 Normanton Lodge Care Home DS0000064447.V319031.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. Normanton Lodge Care Home DS0000064447.V319031.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Normanton Lodge Care Home Address 75 Mansfield Road South Normanton Alfreton Derbyshire DE55 2EF 01773 811453 01332 360767 care@normanton-lodge.com 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) Normanton Lodge Limited Frances Dring Care Home 43 Category(ies) of Dementia - over 65 years of age (43), Old age, registration, with number not falling within any other category (43) of places Normanton Lodge Care Home DS0000064447.V319031.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th December 2005 Brief Description of the Service: Normanton Lodge is situated in South Normanton, near to the M! motorway at junction 28. The home is a large converted older building with several newer extensions. The home provides accommodation and personal care for up to 43 older people. Most of the bedrooms are single with en-suite toilets. There are mature, accessible gardens. The fees at the home range from £335 to £400 per week, depending on the assessed needs of the residents. This information was provided by the manager in the pre-inspection questionnaire received on 20th November 2006. Normanton Lodge Care Home DS0000064447.V319031.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was unannounced and took place over 7 hours. The inspection visit focused on assessing compliance to requirements made at the previous inspection and on assessing all the key standards. There were 39 residents accommodated in the home on the day of the inspection. Residents, visitors and staff were spoken with during the visit. Some residents were unable to contribute directly to the inspection process because of communication difficulties, but they were observed during the visit to see how well their needs were met by staff. Records were examined, including care records, staff records, maintenance, and health and safety records. A tour of the building was carried out. A questionnaire had been completed and returned prior to the inspection and information from this has been included in the body of this report. The registered manager was available and helpful throughout the inspection. What the service does well: What has improved since the last inspection? All of the requirements made at the last inspection had been met, resulting in improvements to medication procedures, the complaints procedure, staff training, and residents’ records. Special locks had been fitted to external fire doors to ensure residents safety. The manager had completed the registration process with CSCI. Normanton Lodge Care Home DS0000064447.V319031.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Normanton Lodge Care Home DS0000064447.V319031.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 Normanton Lodge Care Home DS0000064447.V319031.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 and 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The information available about the home and the needs assessment process was sufficient so that residents had confidence the home could meet their needs. EVIDENCE: The care records of 5 residents were examined. All the records included assessments of the needs of the residents, including assessments from hospital and/or social services where applicable. The home had completed assessments including manual handling, nutrition, tissue viability, and risk assessments. Residents spoken with said that their needs were met at the home. Standard 6 did not apply to this service. Normanton Lodge Care Home DS0000064447.V319031.R01.S.doc Version 5.2 Page 9 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 good. This judgement has been made using available evidence including a visit to this service The care plans lacked detail, regular reviews and resident involvement so it was not clear that residents’ needs were fully met. EVIDENCE: The 5 care records seen all included a care plan. The care plans mostly covered all of the assessed needs of the residents but did not include sufficient detail. For example, one plan about personal hygiene did not include specific details of the assistance required with bathing; one resident had been assessed as at risk of developing pressure sores but there was no specific care plan detailing the action to be taken by staff to reduce the risk. There was no evidence of regular review of care plans. One care plan had been amended recently in parts where the resident’s condition had changed. There was no evidence of the involvement of residents / their representatives in care plans. There was a form in each record for residents / representatives to sign and comment on care plans but none of these had been completed. Normanton Lodge Care Home DS0000064447.V319031.R01.S.doc Version 5.2 Page 10 Residents spoken with said their needs were met at the home and that staff were competent to meet their needs. Staff training records showed that staff had received training appropriate to the needs of residents, such as manual handling, safeguarding adults, and control of infection. Staff spoken with said they would like training in the care and support of people with dementia. Staff spoken with were knowledgeable about the care needs and preferences of the residents. Records were kept of the input of other healthcare professionals, such as GP, District Nurse, chiropodist and optician. Residents spoken with said the GP was called promptly when needed. Residents spoken with said that staff respected their privacy and dignity, for example, by knocking on doors before entering, and calling residents by their preferred name. Visitors spoken with said that staff were “patient” and treated residents with respect. It was observed that there was a good rapport between residents and staff. Promotion of residents’ privacy and dignity was included in staff induction training. Medication was securely stored in the home. At the last inspection it was found that the fridge used for medication was unlocked. At this inspection the fridge had been moved to a more secure location and was locked. The Medication Administration Records, (MARs), were correctly completed. There were satisfactory records of the receipt and disposal of medication. Temazepam was stored correctly in the controlled drugs cupboard and records kept in the controlled drugs book as recommended. It was found that some of the entries for Temazepam in the controlled drugs book were not correct, although the number of tablets in the home and the MARs were correct. All staff responsible for administration of medication had received appropriate training. Normanton Lodge Care Home DS0000064447.V319031.R01.S.doc Version 5.2 Page 11 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 good. This judgement has been made using available evidence including a visit to this service. There was flexibility of routines, a limited range of activities, and a good choice of meals so that residents’ expectations were generally met. EVIDENCE: Residents spoken with said that routines in the home were reasonably flexible, for example, they could get up and go to bed when they chose, they could choose to rest in bed after lunch, and they could choose whether or not to join in with activities. One comment was noted that the teatime meal was too early at 4.30pm. The manager said that residents could have their tea later if they wished and that a late supper was offered. Activities in the home were organised informally by care staff and included outside entertainers, playing dominoes, a regular church service, and trips out. The home did not employ an activities coordinator and there was no structured approach to organising a range of activities to meet the needs and preferences of residents. Staff spoken with were enthusiastic about activities and had good ideas, but said there was not always time to organise activities. Some staff Normanton Lodge Care Home DS0000064447.V319031.R01.S.doc Version 5.2 Page 12 were going to come in to help with activities on a voluntary basis with some remuneration from the residents social fund. Visitors spoken with said they were able to visit at any reasonable time and were always made welcome at the home. The menus seen were varied and appeared well balanced with choices at every mealtime. The menus were displayed in the dining areas. Residents spoken with were pleased with the meals provided and the choice available. One resident commented, “You can have just what you want”. Residents were asked each day what they would like for their meals. The cook was knowledgeable about the dietary needs and preferences of residents. Normanton Lodge Care Home DS0000064447.V319031.R01.S.doc Version 5.2 Page 13 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. There were policies/procedures in place and good staff awareness so that residents were protected and their concerns effectively dealt with. EVIDENCE: The complaints procedure was seen and had been updated since the last inspection to include a timescale for responding to complaints. Residents and visitors spoken with were aware of the complaints procedure. Records were kept of complaints received with the action taken and outcome. It was found that one written complaint had not been responded to in writing and so there were no records to indicate the action taken and the outcome. The manager said this complaint had been dealt with verbally. Most of the staff at the home had received training in safeguarding vulnerable adults. Staff spoken with were aware of adult protection issues and the correct procedures to follow. Normanton Lodge Care Home DS0000064447.V319031.R01.S.doc Version 5.2 Page 14 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 home had sufficient equipment and was generally well maintained so that residents lived in a safe, clean, comfortable and pleasant environment. EVIDENCE: A tour of the building was carried out including the lounges, dining areas, bathrooms, laundry, and some bedrooms. Since the last inspection, the home had become non-smoking throughout. This was made clear in the home’s statement of purpose, service user guide, and in the statement of terms and conditions signed by residents/their representatives on admission to the home. Residents and staff who wished to smoke used an area outside at the back of the home. Since the last inspection special locks had been fitted to external fire doors so that the doors could only be opened by a code, (except when the fire alarm was activated when the code would be automatically overridden). Normanton Lodge Care Home DS0000064447.V319031.R01.S.doc Version 5.2 Page 15 This was to reduce the risk of vulnerable residents wandering outside without staff being aware. The home was clean, comfortably furnished and adequately equipped. The refurbishment of a bathroom had been completed since the last inspection. The refurbishment of a shower room had not been finished. There was an odour in a bathroom on the ground floor and the manager said this was probably due to the carpeted floor. The tiled floor of the laundry room had a gap at one side that needed completing to ensure the floor could be kept clean and hygienic. The bedrooms seen were comfortable, pleasant, and were personalised with residents’ own belongings. Residents spoken with were pleased with their bedrooms. Residents and visitors spoken with said the home was always clean and fresh. There were comments that there were some areas of the home where the décor was “tired and worn”, and that some lounge chairs were ready for replacing. Normanton Lodge Care Home DS0000064447.V319031.R01.S.doc Version 5.2 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 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 good. This judgement has been made using available evidence including a visit to this service. There were adequate staffing levels and a good staff training programme so that residents were protected and well supported. EVIDENCE: The staff rotas were seen and showed that there were 5 care assistants on duty each day from 7.30am to 9pm, and 3 care assistants on duty during the night. The manager’s hours were all supernumerary. The care staff were well supported by ancillary staff – cooks, kitchen assistants, laundry and cleaning staff. Residents and visitors spoken with said there were usually enough staff around to meet residents’ needs. Staff spoken with said that the home had been short of staff for a few months, but that recruitment of new staff meant that shifts were now generally covered. Staff spoken with said that staffing levels would be improved by having an additional care assistant working the morning shift and also by having an activities coordinator. 4 staff records were examined. 3 recently recruited staff had made applications for Criminal Records Bureau, (CRB), disclosures but these had not been received back by the home. Confirmation of POVA First checks were in place, (a check that the person is not included on the register of those unsuitable to work with vulnerable adults). The manager said that these 3 staff were working under supervision at all times. This was confirmed by one Normanton Lodge Care Home DS0000064447.V319031.R01.S.doc Version 5.2 Page 17 of the new members of staff and other staff spoken with. 3 of the records seen did not include a full employment history as required. Staff induction and training records were seen. There was a comprehensive staff induction programme that followed the Skills for Care guidance. New staff were helped to work through the induction programme over a period of about 12 weeks. A new member of staff confirmed that they were working through the induction programme and that they always worked under the direct supervision of more experienced members of staff. The staff training programme had been plotted onto a matrix which showed that most staff had received training in manual handling, safeguarding adults, basic food hygiene, first aid, and fire safety training. A few staff had received training in dementia awareness. Staff spoken with said they would like more training about how to care for people with dementia. Staff spoken with were pleased with the training programme and said that they were encouraged and supported to take part in training. 13 out of 23 care staff had already achieved NVQ Level 2 in care and another 4 staff were working towards the qualification. The home had therefore exceeded the National Minimum Standard of 50 of care staff with NVQ Level 2 or above. 4 of the 13 staff with NVQ Level 2 were working towards achieving Level 3. Normanton Lodge Care Home DS0000064447.V319031.R01.S.doc Version 5.2 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 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 good. This judgement has been made using available evidence including a visit to this service. The home was well organised and there were good systems in place so that the health and safety of residents and staff was promoted and protected. EVIDENCE: Since the last inspection, the manager had completed the registration process with CSCI. The manager was working towards NVQ Level 4 and hoped to complete this by the summer of 2007. Residents, visitors and staff spoken with were positive about the manager. They said she was approachable and staff commented that she was “strict but fair”. A comprehensive quality assurance policy/procedure had been recently introduced and had not been fully implemented. The manager had started Normanton Lodge Care Home DS0000064447.V319031.R01.S.doc Version 5.2 Page 19 residents meetings. The manager said she gave residents’ relatives and representatives the opportunity to raise any concerns directly with her when they visited or at care reviews. A questionnaire had been sent out to staff asking about satisfaction with their work and with the home. No formal surveys of residents / their representatives had been carried out. It was not clear whether visits were carried out as required under Regulation 26 by the provider or their representative as no reports were available for inspection. The manager said that the provider and the area manager visited regularly. The home kept personal money for most of the residents. The records seen were well kept and included 2 signatures for all transactions. Money was kept in a safe with access only by the manager and the administrator. One record was checked against the money held and was correct. The home’s health and safety policy was seen at the last inspection and was satisfactory. A sample of records were checked and found to be satisfactory: the water system maintenance records, including a check for the presence of Legionella; the last inspection of the Environmental Health officer; and the maintenance of the hoists used in manual handling. The fire log book was checked and it was found that although fire practices were recorded, the names of staff attending had not been noted. The manager said that weekly tests of the alarms were used as fire practices and included the night staff as the alarms tests took place at different times. Normanton Lodge Care Home DS0000064447.V319031.R01.S.doc Version 5.2 Page 20 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Normanton Lodge Care Home DS0000064447.V319031.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard OP7 OP29 Regulation 15(2)(b) 19(1)(b) Requirement Care plans must be kept under regular review. Staff must not be employed at the home unless a satisfactory CRB disclosure and POVA First check have been obtained. Staff must not be employed at the home unless a full employment history has been obtained. The registered provider must make arrangements for visits to be made to the home in accordance with the regulation. Timescale for action 31/01/07 31/12/06 3. OP29 19(1)(b) 31/12/06 4. OP33 26(2)(3) (4)(5) 31/01/07 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. 2. Refer to Standard OP7 OP7 Good Practice Recommendations Care plans should be reviewed and updated at least monthly. Residents / their representatives should be involved and consulted in the planning and review of care. DS0000064447.V319031.R01.S.doc Version 5.2 Page 22 Normanton Lodge Care Home 3. 4. 5. 6. 7. 8. 9. 10. 11. OP9 OP12 OP16 OP19 OP19 OP30 OP33 OP33 OP38 The Controlled Drugs book should include a correct running total of the stock balance of Temazepam. There should be a structured programme of social activities developed in consultation with residents/ their representatives. Written records should be kept of the response to all complaints with details of the action taken and the outcome. The tiled floor in the laundry should be completed. Refurbishment of the shower room should be completed so that residents have more choice and availability of facilities. All staff should have training about the care and support of people with dementia. The quality assurance system should include surveys of residents / their representatives. The quality assurance system should include a report of the findings of surveys undertaken with details of the action taken to address issues raised. The fire safety records should include the names of all staff involved in fire practices. Normanton Lodge Care Home DS0000064447.V319031.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Normanton Lodge Care Home DS0000064447.V319031.R01.S.doc Version 5.2 Page 24 - 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!