Inspection on 23/05/05 for Northview Lodge Nursing Home

This inspection was carried out on 23rd May 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

Northview Lodge Nursing Home 24/12/09

Northview Lodge Nursing Home 17/11/08

Northview Lodge Nursing Home 15/03/07

Northview Lodge Nursing Home 11/10/05

Northview Lodge Nursing Home 16/11/04

Northview Lodge Nursing Home 08/07/04

Northview Lodge Nursing Home 19/03/04

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

CARE HOMES FOR OLDER PEOPLE Northview Lodge Nursing Home Northview Road Castletown Sunderland SR5 3AF Lead Inspector Katie Tucker Unannounced 23 May 2005 10:00pm 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. Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Northview Lodge Nursing Home Address Northview Road Castletown Sunderland SR5 3AF 0191 5168605 0191 5168601 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) Southern Cross Healthcare Services Limited Mrs Lynn Bell Care home with nursing 45 Category(ies) of MD Mental Disorder (30) registration, with number DE(E) Dementia - over 65 (15) of places PD Physical disability (10) DE Dementia (8) PD(E) Physical dis - over 65 (7) Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 16/11/04 Brief Description of the Service: Northview Lodge is a two-storey purpose built nursing home, which was originally designed to provide care for older people with dementia-type illnesses. At the beginning of 2002 the ground floor was converted to provide care for younger adults with acquired brain injury and mental health needs. In July 2004 the upstairs unit was converted to provide a smaller higher staffed unit for older people with a dementia-type illness and a small unit for younger adults with very complex mental health needs. There is a car park and main entrance to Northview Lodge at the front of the building. Access to this entrance is level. Both floors have dining rooms, lounges, bathrooms, toilets and bedrooms. a passenger lift serves both floors. The administration office is located on the first floor with an additional office area on the ground floor. The home is off the Western Way at the Castletown junction. A short walk from the home is an industrial/business estate with food retailers and a range of stores. The local bus routes provide transport to the local estates and the city centre. Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine unannounced inspection was carried out during the night and completed at a follow up visit during the day. An inspector spent 5 hours during the night at the home and spoke to the 1 service user who was up and the staff. At the subsequent visit the inspector spoke to the manager, the majority of staff, 2 visitors and 17 service users. A sample of assessments, care plans and risk assessments, medications records and staff files was examined. The staff were asked about the service user plans, the protection of vulnerable adults procedure, access to training and any changes to working practices, as were the service users. The general maintenance of the building was checked. Also the outcome of complaints and Protection of Vulnerable Adults investigations were used in putting together this report. Northview Lodge provides a service for people with a dementia-type illness (memory loss) and acquired brain injury as well as for people with mental health needs. Some of the people have difficulty making their views known. Therefore staff practice, attitude and approach were observed and judgements were made on how well the approaches that were used were working. This type of observation formed a part of the inspection process as well as what people said and was backed up through the examination of records, comments made by service users, staff, relatives and the manager. During this inspection key standards were focused on but not all were checked. What the service does well: The service is well run. Practices are based on up-to-date research and the manager is constantly promoting the rights of the people who live at Northview Lodge. Over the last year groups of people from the younger adults units have been on holiday to Spain and more recently Turkey. The manager is in the process of organising a weekend a way in England for people from the dementia care unit. Northview lodge is divided into three units and staffing levels in all three units is beyond that seen elsewhere. Southern Cross Healthcare has instructed the manager that she must staff at sufficient levels to meet all the needs of the people using the service. The manager felt that she would be heavily criticised by the Southern Cross Healthcare if she were found not to be meeting people’s needs. Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 Page 6 The manager has been working in partnership with a local hospital trust and an occupational therapist works part-time at the home. The hospital has now agreed to support her to recruit a full-time occupational therapist. Also Southern Cross employs a team of specialists including a psychiatrist and neuro-rehab psychologist. This level of healthcare support has greatly enhanced the care that people receive and allowed staff to develop their skills and ability to meet people’s needs. The manager should be commended for the pro-active approach she uses to assessing individuals. What has improved since the last inspection? What they could do better: The manager is aware that the assessment records that she developed for people with dementia have to be completed for all of the people on the dementia care unit. Doors were being wedged open with furniture as people did not wished to feel trapped in their bedrooms. This is a fire safety hazard and the manager is going to work with the fire brigade to find suitable means for keeping the doors open but which protect people in the event of a fire such as door guards. Staff particularly those on night shift have access to training but this could be widened through the use of distance learning. To make it easier for staff to complete courses and look up information the manager agreed that providing Internet access on the computer would help staff to up date their knowledge. Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 Page 7 Staff at CSCI are working with Southern Cross Healthcare personnel department to make sure proper procedures are followed when taking up Criminal Records Bureau (CRB) checks. 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. Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 The manager adopts a pro-active approach to admissions and this ensures that the needs people have can be met at Northview Lodge. However at times the level of recording does not sufficiently demonstrate that the ongoing needs of people are being reviewed. EVIDENCE: The manager ensures that a lot of detail is recorded when assessment of people’s needs are undertaken prior to admission being agreed. She is adept at ensuring that agreements are reached, around meeting people’s complex physical and mental healthcare needs and conditions of residency, prior to admission. She appropriately contacts CSCI to discuss the complex needs people may have and the impact this may pose for other service users prior to their admission to Northview Lodge. Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 Page 10 The manager has collaborated with a neuro-rehab psychologist and elderly psychologist to design an appropriate and comprehensive assessment tool for the dementia care unit. This tool was seen to be very useful and it was agreed that it would be introduced. Southern Cross Healthcare also uses an assessment form, which is based on the Roper Tierney and Logan nursing model. This tool is suitable for those people who are able to communicate fully and have general nursing needs. The tool does not allow staff to demonstrate that they could meet the needs of the people who wish to use Northview Lodge. On the dementia care unit when staff have been conducting reviews and up-dating the assessments they have continued to use this assessment record. Thus the files contained insufficient information about people’s dementia care needs. The manager discussed that staff had used the new tool for people moving to the unit but that they had not recognised the need to use this tool for all service users in the dementia care unit. The manager developed a specific assessment tool for the younger adults units when this service was opened in 2002. The tool is very comprehensive and provides space for a wide range of information to be recorded. However at times staff are self-limiting the amount of information they record and this can lead to some important information being lost. The manager is aware that for some staff this is a new type of recording and is supporting people to develop the necessary skills. When people have a dementia-type illness the generation of life histories is crucial for assisting staff to work with these people. People with dementia tend to revert to previous routines and patterns of behaviour. By understanding how people have lived and their lifestyles, what often seems to be unusual behaviour when seen in the context of what people previously did becomes perfectly reasonable. Thus staff can work around a routine such as, a person who has always worked nightshift may have what seems to be a disturbed sleep pattern but in fact it is the norm for this person. Therefore staff can ensure that meals and activities are provided during the night. Over the last six months staff have been completing life histories for all of the people with dementia. These are written in a narrative style and give a real sense of the person. The manager is now in the process of having them all typed up so they can be put in each person’s file. Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 9 and 10 Staff have a wide range of information about how to meet the health and personal care needs of individuals. The staff strive to ensure that their practices are in line with current good practice and that mechanisms are in place assist them meet the needs of people. EVIDENCE: Staff are developing a wide range of care plans and risk assessments. Often it was found that the actions that staff should take to meet particular needs are continually repeated in various care plans. Alternative the care plan or risk assessment would be about one aspect of a person’s care but the monitoring and evaluation would refer to another aspect of their care needs. This type of inconsistent recording can led to staff missing the important actions that need to be taken, or inconsistent and unhelpful approaches being used. The manager said that staff are planning to revisit the style they use to complete care plans to help with this issue. Also they were finding that care plans and risk assessments were completed for the same needs. At times language staff are using does not accurately reflect the actual nature of a person’s needs. Terms such as ‘aggressive’ were used. These do not tell the reader exactly what happens and how challenges are displayed. Therefore staff will not be able to plan full strategies to deal with this potential. The Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 Page 12 manager and staff recognised this shortfall. The manager has been assisting staff to develop recording skills and this is becoming evident in the detail of recordings made. The manager and staff have developed a system for auditing the medication. It was found that this type of auditing has allowed staff to readily follow-up any discrepancies in recording and administering practices. The check of the medication confirmed that all was in order and auditable trials of medication could be completed. The staff are very aware of the side effects of medications and new developments. The staff work in partnership with the local GP’s so current knowledge can be shared. Staff were aware of the research showing the use of neuroleptic medication (used for mental health needs, behavioural issues and anxiety) in the elderly population often exacerbated anxiety and agitation rather than reducing these symptoms. Staff were also following guidance around routinely using pain relief for people who were prescribed this for chronic pain but could not express verbally when they were in pain. By adopting this type of approach to current practice the quality of life people in Northview Lodge have will continually be at an optimum. The service users described the staff ‘as a great bunch’. People said they found them to be extremely supportive and helpful. Service users described how staff were available but not overbearing. Throughout the visits staff worked with people in a sensitive manner and allowed people to maintain as much independence as they could. The manager has worked closely with the regional consultant for people with Huntingdon’s Disease and each month the community nurse from this team visits Northview lodge. Also practices have been developed so the SHO’s (hospital doctors) conducted three monthly reviews at the home. Thus people being seen by this team are readily seen and can easily get access to other services. The manager actively promotes these types of protocols for all of the service users. Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13 and 14 Service users from all units are given access to a wide range of appropriate and stimulating activities. This is an area that the staff at Northview Lodge are continually extending. Families and friends are actively encouraged to be a part of the team. EVIDENCE: When the inspection was commenced the majority of people from the younger people’s units had gone on holiday to Turkey. The majority of the remaining people had chosen to go to bed and one person was up. Service user plans showed that individual’s had agreements in place around the times that they wished to retire and the only restriction in place for the younger adults unit was that this was not after 1am. One person was up on the dementia care unit but they were sound asleep in a chair. Staff were confident that if people chose to stay up this would not be a problem and during the night people were offered hot drinks if they had woken and could not get straight back off to sleep. Therefore the decision was made to pop back to Northview Lodge for a daytime visit. The manager and staff have been reviewing how the introduce more risk taking strategies with the people on the dementia care unit. Service users from the other two units regularly go out unaccompanied to the local shops and use local community facilities. People go to local colleges and routinely make Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 Page 14 chooses about their lifestyle. However staff have found promoting a greater level of independence for those on the dementia care unit more of a challenge. However it was evident that staff are developing the confidence and skills to make decisions around risk-taking. In the service user plans evidence was found to show that people could bathe independently if they retain this capacity and can choose not to be checked as often at night. The manager is continuing to look at how further action can be taken to promote this level of independence. Service users made choices about the activities that they completed. Staff worked in partnership with people and consistently asked for service users opinions on all of the units. Visiting professionals and relatives spoke extremely highly of the service offered at Northview Lodge. One relative said ‘the staff are brilliant ‘ they described how they had been so moved by the way the staff valued and cared for the people at the home that they had started to fund raise for the home. They were proud to say that so far they had raised £2000. Relatives said they could visit whenever they wanted and did so frequently. They said ‘I always find the staff are happy to see me, ask how I am and take a real interest. Also they always let me know how my relative is, inform me of times they are not well and really seem to care’. Their main topic of conversation on the two younger adults units was the trip to Turkey. People had returned that week and thoroughly enjoyed the trip. Many had experiences and fulfilled dreams they never thought they would such as riding camels. Others who had not gone had said they had been asked but chose not to go. The people on the dementia care unit regularly go on trips as well and plans were being made for them to go on a weekend break. The manager found that on the whole people on the holidays had been helpful and pleased that service users were being given this type of opportunity. Service users said ‘it is great to get out and about and do things other people take for granted’. Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 The manager and staff have constantly demonstrated a good understanding of protection of vulnerable adults procedures and are aware of the actions they need to take to protect individuals. However, Southern Cross Healthcare’s employment procedures are not as robust as they need to be and did not support the good practice carried out by the manager. EVIDENCE: Southern Cross Health Care has agreed to adhere to the Multi Agency Protection Panel for Vulnerable Adults Procedures developed by Sunderland Social Services Department. The manager is aware of the procedures that he needs to follow and has been involved in protection of vulnerable adults investigation. The staff discussed their knowledge of procedures and had been on the local authority training. This training equips staff with a good understanding of how to use the local authority procedures and all staff need to have this knowledge. The staff and manager have consistently demonstrated a good knowledge of the procedures and when to implement them. Also the manager is part of the panel organised by the local authority for developing practice in this area. Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 Page 16 Last year staff have raised an issue around practices adopted at the home, which may have inadvertently impacted on service users. Initially the advice offered by Southern Cross healthcare to the manager about action she should take was flawed and the investigation was not completed as quickly as would have been expected. The company has dealt with procedural concerns and the issues investigated. The manager has dealt with all other issues raised either the complaints or protection of vulnerable adults route in a competent and appropriate manner. Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 Page 17 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 Southern Cross Healthcare and the manager are constantly reviewing the environment and within the constraints of the design of the building ensure it meets current models of good practice. EVIDENCE: Northview Lodge unit on the ground floor for younger adults is divided into two sections. This allows service users the option to choose which area of the home they live in but still mix when they want. Relatives and service users made very positive comments about these changes when they were made last year. Since the last inspection a tea making facility has been provided on one of these units and service users were very positive in their comments about this developments. Major refurbishment works were completed lat year on upstairs to develop a smaller unit for people with a dementia-type illness and create a unit for younger adults upstairs. Throughout the changes the manager has demonstrated a desire to develop a very high standard service for people with Dementia-type illness. The reduction to a smaller sized unit for people with a Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 Page 18 dementia-type illness was based on research produced by Stirling University. The way the lounges and corridors were altered made them more interesting and has allowed service users to use the facilities more productively. The manager is now planning to develop a kitchenette upstairs on the dementia care unit so as to allow people to retain their skills around making drinks and snacks. The overall maintenance of the building is to a satisfactory standard. Northview employs a handyperson and any minor faults are rectified in prompt manner. The décor and renewal of furniture is regularly reviewed and action taken appropriately. Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 Page 19 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 and 30 The staffing levels at the home very clearly meet the personal, social and emotional needs of the service users. Training is available for staff and staff are actively encouraged to become life long learners. EVIDENCE: Routinely 2 qualified nurse and 7 carers are provided on the downstairs unit during the day. On the 15-place unit for dementia care 1 qualified nurse and 3 carers are provided during the day. On the 10-place unit for younger adults 1 qualified nurse and 2 care staff are provided during the day. During the night 3 qualified nurses and 4 care staff are provided. The staffing levels for nights have been increased since the last inspection and these levels are much higher than many provided elsewhere. Although some reasons for this are that on the younger adults unit specific placing contracts are in place for particular people this is not the case in the dementia care unit. The manager has been allowed to meet not only the personal care needs of people within the home but also the emotional and social needs. Southern Cross Healthcare again should be commended for this practice. During the inspection 2 qualified were on duty and 3 carers. One of the staff nurses had rang in to say they were unwell and only 28 people were at the Northview Lodge as the remainder were on holiday. These staffing levels still meet the needs of those who were in the home. Also staff were provided in sufficient numbers to meet the needs of the service users on the holiday. Southern Cross Healthcare paid staff for all of the time they were accompanying people on the holiday, which again is very good practice. Staffing levels meet those normally seen during the second visit. Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 Page 20 Some discussion centred on cover for shifts. The manager does not like to use agency staff as she feels that staff not having knowledge of the service users complex needs could adversely affect the quality of the service. Thus she covers gaps when needed. Although she is very clear on the requirements of the Working Time Directive and ensures staff do not breach this directive she does not follow this practise in relation to herself. Staff discussed and commended the manager for her dedication to Northview lodge and willingness to cover a night shift after working the day if shortages had occurred. The manager described how this was occasional and she did like to work on all shifts at times to see how the home was being operated. However the impression gained from staff was that this was a more frequent event. The manager was made aware that CSCI would not see this as an admirable practice and she undertook to develop strategies that allowed her to monitor practice but made sure she worked within the requirements of the Working Time Directive. The night staff discussed the range of training that they received. They said the manager arranges mandatory training in one-day batches so those on their days off do not have to keep coming in for various updates. Thus staff felt the manager really considered their needs as well as the homes. Also NVQ assessors come during the night to assist and assess the staff completing this award. Only new starters at the home do not hold an NVQ award and a number are doing level 3. Also 6 staff have now started NVQ level 4. Up dating practice was discussed with the nurses and night staff did tend to find this more difficult. It was felt that if access to the Internet was available they could look up current research and use various websites to complete distance learning and PREP (continuing professional development for nurses) work. Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 Page 21 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) 38 The fire safety precautions do not sufficiently ensure service users safety needs are not compromised. EVIDENCE: On the whole the health and safety needs of service users and staff were being met. However some of the people on the dementia care preferred their doors open. Currently items of furniture are being used to wedge the doors open and this compromises people’s safety. The manager was made aware that this practice is unsafe and alternatives needed to be found. She undertook to discuss this issue with the Fire Authority as a matter of urgency. Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 2 15 x COMPLAINTS AND PROTECTION 3 x x x x x x x STAFFING Standard No Score 27 4 28 x 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x x x x x x 2 Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 Page 23 NO 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 3 Regulation 14 (2) 12 (2) Schedule 3 (3) (q) Requirement The manager must fully introduce the newly developed dementia specific assessment tool. The assessment process must include individuals’ rights, decision-making skills and outline where they are limited.(reqired at the last inspection -timescale 19.04.05) Care plans must set out in detail the actions that staff need to take to meet service users needs. The system of writing care plans must be reviewed and action must be taken to ensure that they are not repetative. The manager must work with staff to develop risk-taking strategies and assessments with the service users. The manager must ensure her own shifts are in line with Working Times Directives. A robust system for CRB disclosures that come back with a show must be in place, which Timescale for action 24.10.05 2. 7 15 (2) 24.10.05 3. 4. 27 29 18 19 (5) (b) 1.08.05 26.09.05 Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 Page 24 5. 38 23 (2) (n) is not reliant on the good will of the individual to produce their form.(required at the last inspection - timescale 22.03.05) Doors must not be wedged open with furniture. 23.05.05 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. Refer to Standard 30 Good Practice Recommendations Night staff should be given access to distance learning via the use of the Internet. Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Baltic House Port of Tyne, Tyne Dock South Shields NE34 9PT 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 Northview Lodge Nursing Home B52 B02 S18202 Northview Lodge V219554 24 May 2005 Stage 4.doc Version 1.30 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. 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