Inspection on 15/08/05 for Norton Grange

This inspection was carried out on 15th August 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Norton Grange 04/01/10

Norton Grange 30/09/07

Norton Grange 02/10/06

Norton Grange 29/03/06

Norton Grange 10/02/05

Norton Grange 08/07/04

Norton Grange 16/02/04

Norton Grange 01/10/03

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Norton Grange 46 Tern Grove Kings Norton Birmingham B38 9DN Lead Inspector Monica Heaselgrave Unannounced Inspection 15th August 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Norton Grange DS0000033520.V262900.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. Norton Grange DS0000033520.V262900.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Norton Grange Address 46 Tern Grove Kings Norton Birmingham B38 9DN 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) 0121 458 5292 0121 458 1143 Birmingham City Council (S) John Christopher Wilkins Care Home 20 Category(ies) of Old age, not falling within any other category registration, with number (20) of places Norton Grange DS0000033520.V262900.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. That the home is registered to accommodate 20 people over 65 years who are in need of care for reasons of old age. Registration category will be 20 (OP) That minimum staffing levels are maintained at 3 care staff throughout waking of 14.5 hours. That additional to above minimum staffing levels there must be two waking night care staff. That Mr Wilkins completes NVQ level 4 in care by June 2005. Date of last inspection 10th February 2005 Brief Description of the Service: Norton Grange is a care home, owned and managed by Birmingham City Council. It is located in a residential area of Birmingham, set back from a main road where public transport can be accessed. Shops and community facilities are not located near to the Home. The Home was a purpose built two-storey building. The top floor is now not used. Accommodation and care is provided on the ground floor. All bedrooms are for single occupancy, with toilets and bathrooms for communal use. Facilities are split into two units, each with a dining room and kitchen. There are separate lounge areas where people can choose to socialise. A separate corridor has the laundry, store rooms, staff room and office accommodation. There is a separate Asian Elders Day Centre operating from the Home, this has it’s own facilities. At the front of the Home there is a ramped access and parking space for a number of vehicles. To the rear and sides are garden areas, which are utilised by service users. Norton Grange DS0000033520.V262900.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced inspection took place over 6 hours. The Inspector looked around the building, and inspected a number of records to include care plans, risk assessments, daily notes, fire safety records, accident book and staff rotas. Records pertaining to Health and Safety were also inspected, these including gas safety, electrical appliances, water temperatures, infection control, safe storage of hazardous substances, food hygiene and manual handling assessments. The manager, two assistant managers, two care staff and eleven service users were spoken to. The Inspector observed some aspects of the daily care routine. A copy of the Home’s fire procedure was taken for reference. What the service does well: What has improved since the last inspection? Progress continues to be made with general re-decoration in the Home. Risk assessments are now incorporated into the service users’ care plans which ensures their safety is promoted. There is a rolling programme of activities for service users. Since the last inspection, the manager has introduced one day a week as ‘key worker day’. Service users and their key workers can plan and undertake an activity of their own choice, with support. Norton Grange DS0000033520.V262900.R01.S.doc Version 5.0 Page 6 The manager and his team have further developed policies and procedures, and these are now made accessible to all care staff. Since the last inspection all staff have been nominated for food hygiene training. The manager has developed a draft fire procedure to ensure the safe evacuation of service users in the Home. 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. Norton Grange DS0000033520.V262900.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 Norton Grange DS0000033520.V262900.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): 1, 3, 4 The Statement of Purpose does provide service users with all the information they need to make an informed choice about living in the Home. There is comprehensive assessment information prior to admission which ensures service users’ needs are known, and can be met. EVIDENCE: The manager provided the Commission with a Statement of Purpose prior to this inspection. This does not clearly state that there are not separate toilets for male and female service users. A few female service users in the Home stated that this ‘worries’ them, and they find it upsetting if the toilet door is left open when in use, as is the case where some individuals suffer with dementia. Prospective service users now have a choice as to whether or not this feature of the Home is one that might influence their preferences. Following the inspection, the Statement of Purpose was updated, and therefore this standard is now met. Norton Grange DS0000033520.V262900.R01.S.doc Version 5.0 Page 9 There is a structured format for the assessment of service users. This consists of a pre-admission visit to the service user to determine the level of care and support required. This assessment included the consideration of ‘risks’ and how these were being managed, such as ‘has a tendency to fall’. This risk would direct the manager to put in place the requirements for the risk to be managed within the care home. This would include ‘how to get them up’, and which aids may be required. Other examples included information such as, ‘requires support with meals, give one item at a time, and remove salt and pepper as pours on food’. The assessment included specialist and clinical guidance from professionals involved in the assessment of the individuals’ needs. Assessments are reviewed monthly. This is good practice and ensures that as more information comes to light, this is added to the service users’ care plans. A formal review or assessment takes place six monthly which includes the service user, key worker, family and other professionals who are involved in the care of the individual. Norton Grange DS0000033520.V262900.R01.S.doc Version 5.0 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 10 Care plans identify most aspects of health, personal and social care needs and the action to be taken to meet these needs. Improvements are needed to ensure that care is delivered in accordance with the service user’s plan. Some aspects of privacy and dignity are compromised. EVIDENCE: The care planning element within the Home is good, it is consistent with the assessment of needs, and sets out in good detail the action that needs to be taken, to ensure all aspects of health care needs are met. This included monitoring weight loss, food and fluid intake and contact with dietician. Care plans, known as individual service statements (I.S.S), also identified particular reference to the management of falls, or the risk of persons with dementia who may have a tendency to wander. Risk assessments for these areas are now incorporated into the service users I.S.S, this has been developed since the last inspection in February 2005. The risk of pressure sores and their treatments is recorded and received on a continuing basis. The Home has no service user who is at risk in this area. Norton Grange DS0000033520.V262900.R01.S.doc Version 5.0 Page 11 Individual service statements are reviewed by care staff monthly and updated to reflect changing needs. Personal care routines are recorded, but it is difficult to ascertain the service user’s choice in this area. For instance, one entry stated’ ‘baths weekly’, but in discussion with care staff this person has dementia. There is no information to how this routine was adopted, and therefore more frequent baths may be the preference. One ‘goal’ for another service user was to go out shopping. On checking the daily progress records for this person for the previous month, he had been out only on one occasion. One service user stated that she does not always have help with her personal care. In discussion with the manager it was stated she does not require this level of support, and is very reluctant at attempts to encourage her self-help ability. This information is recorded in her care plan, but her response to it was not forthcoming and needs to be made clear in her daily records. It is important that the details or goals in care plans or I.S.Ss are specific and measurable. This will enable care staff to record in daily progress records in more detail which aspects of the care plan have been complimented. For instance, whether someone have been out or why they haven’t, whether a personal care routine was followed or not, and the reason for this. Where the service users are unable to determine their choices for themselves, opportunities should be created for them, and their response to this recorded clearly. This will enable staff to determine whether the care delivered appears to meet someone’s needs or not, and will greatly enhance the monitoring of the care plan and service delivery. Some service users spoken to are not keen to share toilet facilities with male service users. Their experiences of service users appear to relate to personal habits, and for some, a degree of confusion or dementia. This has resulted in toilet doors being left open when in use, which they find upsetting. Issues regarding privacy and dignity for both parties need to be explored further. Where someone requires support to protect his or her dignity, this must be clearly addressed in the care plan. At the previous inspection a requirement was made in relation to partitioning from ceiling to floor in the toilet areas. This work has not yet commenced, and remains and outstanding requirement. Norton Grange DS0000033520.V262900.R01.S.doc Version 5.0 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Social activities were varied, well planned and suited the preferences of most service users. More consideration is needed when planning for service users with dementia. There are good opportunities for service users to maintain contact with their family and local community. The routines of daily living need to be specific to the individual, and measurable, to ensure service users have real choices. There are occasions when the meals provided, fail to meet the expectations of service users. EVIDENCE: There is a well-established and varied level of social activities available to and utilised by the majority of service users. Service users’ meetings are used to explore what pursuits service users prefer. An activities list informs service users of events both within and out of the home. Wednesdays are planned as ‘key worker days’ during which staff members can undertake one to one activities with the service users. Individual service statements outline the social interests of service users. There are well-established events within the home, which has it’s own bar. Bingo, a ‘free and easy’ visiting library and ‘activity plus’ takes place regularly. Religious leaders visit regularly as does the hairdresser and the barber. On the day of inspection, service users enjoyed a ‘fish and chips’ supper. A number of service users stated they enjoy the activities on offer. Some service users have dementia, and others cognitive impairments. In sampling their I.S.S and activity records, it is not evident how Norton Grange DS0000033520.V262900.R01.S.doc Version 5.0 Page 13 choices are arrived at, or how staff ensure that their routines or preferences are promoted and protected. The inspector found that the ‘goals’ are not specific, for example one entry stated, ‘likes to go out’. It was cross-referenced with daily notes and the service user had been out once in the previous month. As stated in standard 7 of this report, more care is needed to ensure that the individuals’ experiences actually matches their expectations and preferences. Service users continue to enjoy contact with their family, and this is well documented in care notes. Via a variety of social events in the home, family, friends and the local community maintain good links with service users. Some service users stated they maintain a good degree of control over their lives, to include their religious observance, leisure time, personal relationships, finances and daily routines. Reviews showed that service users contributions are recorded in these areas. The home does try to ‘mirror’ the individual’s preferences. However, where individual service users stated to the inspector that they are not ‘happy’ with specific routines, such as the times of ‘getting up’ or the level of assistance offered for personal care, the inspector has advised that I.S.S and daily care notes need to be specific in their detail, and must record the service users response to the care. This will improve monitoring and service delivery. It will enable service users to have a greater influence over their lives. From discussions with some service users, it is evident that the quality of food, in their opinion, is variable and at times poor. This was discussed at length with the manager, who was able to demonstrate that there are many systems in place to try and resolve any complaints about the food. The inspector observed staff asking for service users comments upon their meals, this is recorded daily. Meetings between the manager and the contracted commercial services also take place regularly. Service users meetings are also utilised to explore concerns about the food. Menus were viewed by the inspector. Many of the comments related to the food being ‘overcooked’ or left too long in the hostess trolley, which service users say makes the food rubbery and hard to eat. The manager stated that he closely monitors cooking times, transport to and serving of the food to units. The manager stated he will continue to monitor this area closely, and provide feedback to service users. Norton Grange DS0000033520.V262900.R01.S.doc Version 5.0 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Service users are confident in making complaints, however in some instances no changes are apparent, leaving service users feeling they are not taken seriously. EVIDENCE: There is a complaints procedure, which is accessible by service users. Service users are well informed about how they can use it. In discussion with service users, it is evident from some of their comments that they are dissatisfied with what they see as the ‘lack of improvement’. Their comments have been made, particularly in relation to the quality of food, and the shared toilet facilities for both men and women. One service user stated, ‘they tell us to complain, but when we do, they complain, what’s the point’. Another stated, ‘I attend every residents meeting but nothing changes’. (I.e. shared toilets). Some service users have stated that they are reluctant to complain because they feel it’s always them who are the spokespersons, and they are ‘worried’ they are noted for this. The inspector spoke with other service users who did not share this view but stated, ‘you won’t get into trouble if you complain’. These points were raised with the manager. The inspector was satisfied that comments and complaints are listened to, recorded and fed back to service users. Documentation supports this. However, there is potential for improvement. In relation to the shared toilet facilities, whilst more cannot structurally be improved or facilities increased, it is the inspector’s opinion that more vigilance and supervision of service users who may require support to Norton Grange DS0000033520.V262900.R01.S.doc Version 5.0 Page 15 use the facilities, may be warranted. This may protect both their privacy and dignity, as well as those who are offended. It’s recommended that those service users who may require this level of support, are identified, and clear guidelines developed as to how this aspect of their care can be managed. This may, with time resolve the matter, whilst developing an open culture within the home which enables service users to feel confident that they are listened to, and can sometimes effect change. Norton Grange DS0000033520.V262900.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 25, 26 Service users have comfortable, safe and clean surroundings in which to live. The Provider has not complied with previous requirements, which would greatly enhance the maintenance of the building, and comfort of the service users. EVIDENCE: A tour of the building evidenced that there are good arrangements for keeping the home clean, odour free and comfortable. Service users stated that, ‘the staff worked hard in keeping it nice for them’. Furnishings were seen to be comfortable and of good standard. A programme of good routine maintenance and repairs is evident. On the day of inspection, the manager advised that the broken skylight window in the staff toilet had been reported for repair. A number of other areas require attention, in particular, the windows are all metal framed, and require replacement. These are difficult for staff and service users to open, this impacts on ventilation. Whilst this work has been Norton Grange DS0000033520.V262900.R01.S.doc Version 5.0 Page 17 requested, the finances have not been made available to date. The registered manager must submit an action plan with timescales in relation to window replacement, as this continues to be an ongoing requirement. Partitioning walls in the toilet area remain an outstanding requirement. As above, a plan of action is required. Service users are unable to adjust the temperature of radiators. A request has been made for financing of this work, the inspector was informed by the manager that this is currently not on the priority list. This remains an outstanding requirement. Norton Grange DS0000033520.V262900.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 30 Staffing levels are not appropriate to the current needs of service users and could place them at risk. Staff continue to update their competencies and skills which equips them to meet the assessed needs of the service users. EVIDENCE: Minimum staffing levels are three care staff throughout the waking day. This is in addition to management support and ancillary staff. Rotas sampled indicated that the home is not complying with the Conditions of Registration. Shifts show on occasions either one staff less, or four hours in the shift short. Rotas show which staff are on duty during the day and night, and in what capacity. The home has two waking night staff and one sleep in manager, which complies with their Conditions of Registration. The home is currently carrying care staff vacancies of 30 hours. A new appointment is to commence on 18 August 2005, which should enable compliance with Conditions of Registration. Staff files show that all receive an induction and training to NTO specifications. This includes training in food hygiene, manual handling and health and safety. Some have received dementia training, which is specified to the work they undertake. Nominations for food hygiene training were shown to the inspector. Staff have also received accredited training in medicine awareness. Staff spoken to had the required foundation level training, and a good understanding of how to meet the needs of service users in their care. Norton Grange DS0000033520.V262900.R01.S.doc Version 5.0 Page 19 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, 32, 36, 38 The home is managed well; there is leadership guidance and direction to staff to carry out their care tasks. However, the consistency of care, as perceived by some service users needs improvement. Strategies to enable service users to affect the way the service is delivered require improvements. EVIDENCE: Since the last inspection, the manager has completed his NVQ level 4 in care; he already has the Registered Manager’s Award. He has a wide range of experience in meeting the needs of older persons. He is supported by the assistant manager who also has the Registered Manager’s Award and NVQ level 4 in care. There are good examples that indicate he manages both the daily running of the home and the management of the staff team well. These include maintaining platforms and systems that enable service users and staff to have information and be consulted. For instance, staff meetings are regular, as are Norton Grange DS0000033520.V262900.R01.S.doc Version 5.0 Page 20 service user meetings. Care plans and reviews are well established. Staff supervision is regularly undertaken, and staff receive guidance, directions and have access to training and procedures. As stated previously in this report, whilst the systems are in place, they require further development to ensure effective monitoring. It is the inspector’s opinion that although there are some features of the home that service users feel have not yet been fully resolved, there is evidence that the manager has tried to address these issues, although yet not to the satisfaction of all the service users. With improvements suggested, service users may feel that their views are acted upon. The manager has continued to ensure that all equipment and heating systems are maintained properly, certificates for these were seen. The health and safety of service users is potentially compromised because the current staffing levels being short. Risk assessments have been incorporated into service user care plans; these further promote the safety and welfare of service users. Where requirements have been made with regards to the practices and procedures, these have been met, and include improvements to care plans, risk assessments, developing activities for service users, and staff training. The management of incidents and accidents in the home meets with requirements. Safe working practices continue to be maintained, which ensure the health and wellbeing of service users and staff is promoted. The inspector viewed the proposed fire procedure which was a requirement from the previous inspection. This needs to include what fire equipment is available, how it is used, it’s location, escape routes, the importance of self closing doors and how to move service users if required. Norton Grange DS0000033520.V262900.R01.S.doc Version 5.0 Page 21 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 3 X 3 4 X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 X 2 X 2 X X X 2 3 STAFFING Standard No Score 27 2 28 X 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 4 X X X 3 X 2 Norton Grange DS0000033520.V262900.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP7 Regulation 15(1) Sch 3 Requirement The Registered Manager must ensure that care plans have specific details as to how the service users’ needs are to be met. This should include particular routines and choices made by the service users. It is important that these are measurable and reviewed to ensure the care fits with the expectations of the service users. The Registered Provider must ensure that toilets are fully partitioned. The Registered Manager must submit an action plan with timescales to be agreed. This is an outstanding requirement from 08 July 2004. Care plans must show how care needs are to be met. Care plans must demonstrate how choices for those who suffer dementia are arrived at and what opportunities are being created for them. DS0000033520.V262900.R01.S.doc Timescale for action 01/12/05 2 OP10 12(4)(a) 15/10/05 3 4 OP12 OP14 15(1) Sch 3 12(1)(a) 12(3) 01/12/05 01/12/05 Norton Grange Version 5.0 Page 23 5 OP32OP15 16(2)(i) The Registered Manager must ensure that food offered responds to the needs of service users. The current quality control measures in place must continue, with outcomes being made known to all service users. The Registered Manager must seek to resolve the concerns expressed by service users, concerning the shared toilet facilities. This should include reviewing the care plans to identify individuals who may require further assistance to protect both their dignity and that of their peers. Making suggestions as to how things might be improved may create cooperative relationships and prevent situations causing distress. The broken skylight window in staff toilet must be repaired. The Registered Manager must develop an action plan, with timescales for the replacement of windows. Timescale to be agreed. This is an outstanding requirement from 08 July 2004. The Registered Manager must ensure that radiators are altered to allow temperatures to be adjusted by the service users. An action plan with timescales must be submitted to the CSCI. This is an outstanding requirement from 08 July 2004. Staffing levels within the Home were not compliant with the Conditions of Registration. That is; there should be three care staff on duty throughout the DS0000033520.V262900.R01.S.doc 15/10/05 6 OP16OP32 24(1) (a)(b) 15/10/05 7 8 OP19 OP19 23(2)(b) 23(2)(b) 15/10/05 15/10/05 9 OP25 23(2)(p) 15/10/05 10 OP27 18(1)(a) Sec 24 30/09/05 Norton Grange Version 5.0 Page 24 11 OP38 12(1)(a) working day. The issue of improved staffing must be addressed promptly to ensure the safety of all persons within the premises. The Registered Manager must provide a written response which details the action he will take to address this issue, and the timescale within which this will be addressed. The Registered Manager must 31/10/05 ensure that the fire procedure incorporates: - What fire equipment is available and it’s location. - How to use the equipment. - Where the fire escape routes are. - The importance of self-closing doors. - How to move service users if required. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Norton Grange DS0000033520.V262900.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Norton Grange DS0000033520.V262900.R01.S.doc Version 5.0 Page 26 Norton Grange DS0000033520.V262900.R01.S.doc Version 5.0 Page 27 - 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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