Inspection on 07/12/05 for Normanton Lodge Care Home

This inspection was carried out on 7th December 2005.

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 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 23/11/06

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 7th December 2005 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 Normanton Lodge Care Home DS0000064447.V263236.R01.S.doc Version 5.0 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.V263236.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Normanton Lodge Care Home Address 75 Mansfield Road South Normanton Alfreton Derbyshire DE55 2EF 01332 332901 01332360767 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 Vacant Care Home 40 Category(ies) of Dementia - over 65 years of age (40), Old age, registration, with number not falling within any other category (40) of places Normanton Lodge Care Home DS0000064447.V263236.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. A Manager must be appointed within 3 months of the date of the change of ownership of the home. 15/06/05 Date of last inspection 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 40 older people. Most of the bedrooms are single with en-suite toilets. There are mature, accessible gardens. Normanton Lodge Care Home DS0000064447.V263236.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced. There were 39 residents accommodated in the home on the day of the inspection. Residents, visitors and staff were spoken with during the inspection. Care records were examined, plus other records relating to the staffing and management of the home. A tour of the home was undertaken. What the service does well: What has improved since the last inspection? What they could do better: Although the systems in place for the administration and safe handling of medication in the home were generally satisfactory, there were some potentially unsafe practices which required attention to fully ensure the safety and welfare of residents. Some work was needed to ensure that the home’s adult protection policy and procedures were up to date and that all staff had training in adult protection awareness and issues. There were some complaints that meals at the home were not always hot enough when served in the dining rooms. The residents records did not contain a recent photograph as required. Normanton Lodge Care Home DS0000064447.V263236.R01.S.doc Version 5.0 Page 6 A more structured approach to providing social activities for residents would give residents more choice and a better service. 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. Normanton Lodge Care Home DS0000064447.V263236.R01.S.doc Version 5.0 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.V263236.R01.S.doc Version 5.0 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 the following standard(s): 3 Generally, the assessment information was good, so that residents could be confident that the home was able to meet their needs. EVIDENCE: The care records of four residents were examined. Generally, there was detailed assessment information, including risk assessments and nutritional and tissue viability assessments. Each resident had a care plan covering all their assessed needs. The records of one recently admitted resident included the home’s own assessment of needs but did not have the assessment by the care manager. Normanton Lodge Care Home DS0000064447.V263236.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Residents’ health and personal care needs appeared to be fully met, with good liaison with other healthcare professionals and evidence of respecting residents’ privacy and dignity. Generally the administration of medication in the home was satisfactory. However, there were some practices identified that could potentially affect the safety and welfare of residents. EVIDENCE: The care plans seen were well written with clear details of the action to be taken by staff to meet the needs of residents. All the care plans had been regularly reviewed and all had evidence of the involvement of the resident or their representative. There was evidence of good practice in the records, such as consultation with residents / their representatives about their wishes regarding resuscitation, and agreement of the care plan signed by the resident or their representative. Some of the residents spoken with were aware of their care plans. One resident’s representative said they were kept involved and informed in the resident’s care. Staff spoken with were knowledgeable about the care needs of individual residents and were familiar with the care plans. Some of the care records seen contained older care plans and information Normanton Lodge Care Home DS0000064447.V263236.R01.S.doc Version 5.0 Page 10 which could be stored elsewhere to avoid possible confusion. There were no photographs of residents in the care records or the medication records. Residents spoken with said that staff respected their privacy by always knocking on bedroom doors and ensuring privacy in the toilets and bathrooms. Staff spoken with were clear on how to maintain privacy and dignity for residents. There were good records of the assessment of residents’ health care needs and of how these were met. For example, there were assessments of the risk of developing pressure sores, followed up by records of District Nurse involvement and the provision of suitable equipment. There were records of visits by the GP, dentist and optician. The home used a monitored dose medication system. Medication was securely stored in a locked trolley and cupboard. The fridge for storing medication was situated in a separate, unlocked room and was found to be unlocked on the day of the inspection. The fridge temperatures had been correctly checked and recorded daily. The Medication Administration Records, (MARs), were mostly correctly completed. One handwritten entry did not have sufficient information and had not been signed by the person writing it. The records of ordering and receipt of medication were satisfactory. It was found that one medication prescribed for a resident was being used for other residents. The home’s medication policy and procedure was in the process of being reviewed and updated in line with the Royal Pharmaceutical Society guidelines. All staff who administered medication had undergone appropriate training. Normanton Lodge Care Home DS0000064447.V263236.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 and 15 Routines in the home were flexible to reflect residents preferences and choices. However, there were not always sufficient activities offered to meet the social and recreational needs of residents. Although the standard of meals provided appeared to be generally good, the hot food was not always served at appropriate temperatures. EVIDENCE: Residents spoken with said that daily routines in the home were flexible and that they were able to get up and go to bed when they chose. Residents care records included information about residents’ preferences. Activities in the home were organised informally by care staff. Residents and staff spoke of recent visits by outside entertainers to the home. One resident spoke of the regular church service provided in the home. Residents spoken with said they would like more activities organised by the home. Resident spoken with said they were able to see their visitors in private. Visitors spoken with said they were always made welcome by staff. Residents were able to use several dining areas in the home. The dining areas were pleasant and comfortable. Two residents spoken with commented that Normanton Lodge Care Home DS0000064447.V263236.R01.S.doc Version 5.0 Page 12 hot food was often too cold when it was served in the dining rooms. One resident said that the standard of meals had become worse recently. In discussion with the acting manager, it was found that a hot trolley previously used to bring meals from the kitchen to the dining areas had not been available recently and that this was likely to be causing the problems. Generally, residents were satisfied with the quality and choice of food in the home. There was evidence that, following nutritional assessment, residents dietary needs were met. For example, by providing additional supplements, or by providing food of the right consistency. Normanton Lodge Care Home DS0000064447.V263236.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 On the whole, residents rights were promoted by the practices in the home. However, staff training and the procedures for the protection of vulnerable adults needed to be updated to fully ensure the protection of residents. EVIDENCE: The home had a complaints procedure which needed amending to include a timescale for responding to complaints. A record of complaints was kept with details of the action taken and the outcome. Residents spoken with were aware of a complaints procedure but had not had to use it. Residents said they were happy to go to staff with any concerns and said these were usually promptly acted on. One resident gave an example of asking for a new mattress to replace an uncomfortable one and says this was dealt with quickly. The home’s policy for the protection of residents from abuse did not include reference to the local authority multi-agency procedures for the protection of vulnerable adults and a copy of these procedures was not available in the home. Some of the staff spoken with had received training in the awareness of abuse and procedures to follow. All staff spoken with were clear on the procedures to follow if they suspected abuse and all knew of the home’s whistleblowing policy. Normanton Lodge Care Home DS0000064447.V263236.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed at this inspection as they were assessed and met at the last inspection. Normanton Lodge Care Home DS0000064447.V263236.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 29, 28, 29 and 30 Residents were well supported by a skilled and knowledgeable staff team, and were protected by the recruitment practices in the home. Individual staff training records were needed to ensure staff are fully competent to do their jobs. EVIDENCE: The staffing rotas for the home were seen. Staffing levels were satisfactory with five care assistants on the morning and afternoon shifts and three care assistants at night. Staffing levels included at least one senior care assistant on every shift. The acting manager had worked in the home for many years, but had only recently taken up her present post. She was continuing to work some hours included in the care staffing levels. It was anticipated that the acting manager’s supernumerary hours would increase over the coming weeks to meet the demands of the role. Residents and visitors spoken with said that although staff were busy, there seemed to be enough staff on duty to meet the needs of residents. Staff spoken with said that they felt that staffing levels were sufficient. Staff records were examined. All the records seen were well organised and contained all the required information. There was evidence of good practice around recruitment, such as checking on references and keeping interview notes. There was a programme of staff training at the home including induction and NVQ training. Most of the staff at the home had achieved or were working Normanton Lodge Care Home DS0000064447.V263236.R01.S.doc Version 5.0 Page 16 towards NVQ level 2 or 3 in care. Separate staff training records were not kept, although certificates relating to training completed were included in staff files. Staff appraisal forms were also kept in the files and showed that staff training and development was regularly discussed. Staff spoken with confirmed that they had undergone training as required, such as fire safety, safe handling of medicines, and moving and handling. Staff spoken with were satisfied with the training available to them. It was not clear whether all staff had received recent training in the protection of vulnerable adults from abuse. Normanton Lodge Care Home DS0000064447.V263236.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 and 38 As the acting manager had only recently taken up the post, it was too soon to make a judgement on her abilities. However, the acting manager had previously worked at the home in a senior management role and had the confidence of residents and staff. The health and safety of residents and staff appeared to be promoted and protected by practices and policies in the home. EVIDENCE: The home had recently changed ownership and the acting manager had been in post for about three weeks. The acting manager had previously worked at the home for many years and had been in the role of care services manager. She was therefore very familiar with the needs of the residents and the routines and procedures of the home. There appeared to be good support for the acting manager provided by the new owners of Normanton Lodge. The acting manager said she had already done part of the NVQ level 4 qualification Normanton Lodge Care Home DS0000064447.V263236.R01.S.doc Version 5.0 Page 18 and planned to complete this in 2006. Residents, staff, and visitors spoken with were pleased that the acting manager had taken on her new role. The home’s health and safety policy was seen and this was satisfactory. Records relating to health and safety were checked, such as the fire log book, and servicing and maintenance records. All the records seen were up to date. Staff had received training in health and safety, fire safety and first aid. Normanton Lodge Care Home DS0000064447.V263236.R01.S.doc Version 5.0 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 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 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 X X X X X X X X STAFFING Standard No Score 27 3 28 X 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X X X 3 Normanton Lodge Care Home DS0000064447.V263236.R01.S.doc Version 5.0 Page 20 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. 3. 4. Standard OP9 OP9 OP15 OP16 Regulation 13(2)(4) 13(2) 12(1)(a) 22(4) Requirement The medication fridge must be locked. Medication prescribed for one resident must not be given to others. Arrangements must be made to ensure that meals are served at an appropriate temperature. The complaints procedure must include a timescale so that complainants are informed within 28 days after the date the complaint was made of any action to be taken. All staff at the home must have training in adult protection awareness and procedures. All staff must have access to the multi-agency procedures for the protection of vulnerable adults. All staff must have individual records of all training undertaken. Residents’ records must include a recent photograph. Timescale for action 08/01/06 08/01/06 08/01/06 08/01/06 5. 6. 7. 8. OP18 OP18 OP30 OP37 13(6) 13(6) 17(2) Schedule 4 17(1)(a) Schedule 3 31/03/06 31/01/06 31/03/06 31/01/06 Normanton Lodge Care Home DS0000064447.V263236.R01.S.doc Version 5.0 Page 21 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 OP12 OP27 Good Practice Recommendations There should be a more structured programme of social activities offered to residents. The staff rota should include the designation of staff members. Normanton Lodge Care Home DS0000064447.V263236.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Normanton Lodge Care Home DS0000064447.V263236.R01.S.doc Version 5.0 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. 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. 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