Inspection on 17/04/07 for Norton Lees Hall

This inspection was carried out on 17th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Norton Lees Hall 25/04/06

Similar services:

Snydale Care Home

Abbey The

Hawkhills

Larchfield Manor

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Norton Lees Hall 156 Warminster Road Norton Lees Sheffield South Yorkshire S8 8PQ Lead Inspector Michael O`Neil Key Unannounced Inspection 17th April 2007 09:05 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 DS0000065376.V331546.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000065376.V331546.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norton Lees Hall Address 156 Warminster Road Norton Lees Sheffield South Yorkshire S8 8PQ 0845 6027470 0114 2589731 nortonleeshall@tri-care.co.uk www.orchardcarehomes.com Orchard Care Homes.Com Ltd 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) Mrs Diane Lesley Whitehead Care Home 40 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (40) of places DS0000065376.V331546.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A specific service user named in the application dated 13.06.06 can be admitted to the home and reside at the home provided that their care needs can be met. 25th April 2006 Date of last inspection Brief Description of the Service: Norton Lees Hall is situated in the Norton Lees area of Sheffield close to local shops, other amenities and a bus route. The building is purpose built and has two floors accommodating service users who require personal care. The home is registered for 40 places. The home has a sufficient number of baths, toilets and showers. All the bedrooms are single and have en-suite toilets. The home is accessible to service users, ramps and a lift are available, and aids and adaptations are in place. The home has a pleasant enclosed garden. Car parking is available. The manager confirmed that from 17.04.07 the weekly range of fees charged for accommodation and care varied from £364-£500. Additional charges were made for services such as chiropody and hairdressing. DS0000065376.V331546.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection carried out by Mike O’Neil, regulation inspector. This visit took place between the hours of 09:05 am and 4:00 pm. Diane Whitehead, registered manager, was present during the visit. The manager submitted a pre inspection questionnaire to the CSCI prior to the actual visit to the home. Some information from the questionnaire is included in the main body of the report. The CSCI sent out questionnaires asking health professionals, residents, relatives and staff about the care and the service provided. There was a positive response and the CSCI received 2 health professional, 4 staff, 2 relative and 4 resident questionnaires back. Opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home, check the homes policies and procedures and talk to 8 staff, 3 relatives and 12 residents. The inspector wishes to thank the staff, relatives and residents for their time, friendliness and co-operation throughout the inspection process. A copy of the previous inspection report was displayed and available in the foyer of the home. Information about how to raise any issues of concern or make a complaint was on display in the foyer. What the service does well: Staff interviewed showed a good knowledge of the residents health and social needs. Residents said that the care they were receiving was good. Residents consistently added comments such as ” staff are lovely and caring ”, “staff are wonderful “, one resident also told the inspector” you won’t find any problems here”. The inspector observed that all the residents were well dressed in clean, age appropriate clothing and attention had been paid to hair and nail care. The inspector saw staff consistently treating residents in respectful and friendly way. DS0000065376.V331546.R01.S.doc Version 5.2 Page 6 A friendly, lively and welcoming feel was evident in Norton Lees Hall. Some residents were sat in groups sharing stories with each other and the sound of laughter was nice to hear. The inspector spoke with the staff about the activities they arrange. The staff showed real enthusiasm about this role and were all keen to include as many residents as possible in different types of activities. The inspector viewed the lunchtime experience for the residents as a very positive and pleasant event. Lunch was served in a pleasant relaxed manner and residents were sat at tables, which had been nicely set. The home was clean and tidy. Lounge and dining areas were domestically furnished to a high standard and felt “homely”. Relatives and residents said that the home was always kept clean. Staff said they were encouraged to attend training on various care topics and that there were good training opportunities available to them. Residents, staff and relatives said that they met regularly with the manager of the home and spoke positively about her approachability and helpfulness. What has improved since the last inspection? What they could do better: DS0000065376.V331546.R01.S.doc Version 5.2 Page 7 Some care plans must be improved to ensure that staff are able to know what to do for each resident. Residents and/or relatives need to be involved in the drawing up and evaluation of the care plans. Procedures need to be improved so that residents’ finances are fully safeguarded. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000065376.V331546.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000065376.V331546.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3.Standard 6 is not applicable to this home. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents’ assessments prior to admission took place. These enabled staff to be aware of residents needs to ensure that they could be met. This home does not provide intermediate care services. EVIDENCE: Three resident files were checked and each contained a copy of their full needs assessments. The information from the full needs assessment had been incorporated into one of the two resident care plans. DS0000065376.V331546.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The residents’ health, social and personal care needs were generally well documented in the care plans meaning that the resident’s needs could be met. A range of health care professionals visited the home to assist in maintaining the health care needs of residents. Residents themselves said that the care they were receiving was good and added other positive comments. Three relatives interviewed confirmed that they felt the needs of their relative were being met. Medication storage and other procedures protected the residents’ health and welfare. Residents’ privacy and dignity was maintained. DS0000065376.V331546.R01.S.doc Version 5.2 Page 11 EVIDENCE: Three resident care plans were checked. Two previous requirements made had been met. Nutritional risk assessments were completed in each plan and there was only one care plan in use for each of the residents. The residents’ health, social and personal needs were generally well recorded and the care plans identified that a range of health professionals visited the home to assist in maintaining the residents health care needs. The care plans were not adequate however because • The social interests were not recorded for one resident whose specific diversity needs needed such detail recording. • There was no evidence to suggest that the resident or their relatives were involved in the drawing up or the reviewing of the care plans. (Previous requirement not met) • More specific detail about the residents’ personal care needs was needed. • Staff, when writing the residents daily notes, were not being reflective of the information actually recorded in the residents care plan. (Previous requirement not met) The other positive outcomes in this area have enabled an overall quality rating of “good” to be made under Health and Personal Care. However, the inspector discussed the shortfalls in the care plan documentation with the manager and advice was given on how to improve the care plans for each resident. Staff interviewed showed a good knowledge of the residents health and social needs. Health care professionals said that staff at the home communicated well with them and felt that the standard of care delivered at the home was good. Residents said that the care they were receiving was good. Residents consistently added comments such as ” staff are lovely and caring ”, “staff are wonderful “, one resident also told the inspector” you won’t find any problems here”. Relatives made comments such as “the staff are caring” and “the care at Norton Lees Hall is good “. The inspector observed that all the residents seen were well dressed in clean, age appropriate clothing and attention had been paid to hair and nail care. Medicines were securely stored around the home in locked cupboards. DS0000065376.V331546.R01.S.doc Version 5.2 Page 12 The inspector observed a staff member dispense medication to residents in a safe and hygienic way. Medicine Administration Records (MAR) checked were completed with staffs’ signatures. Staff said they had received medication training. The inspector saw certificates of this training. All the residents and relatives spoken with said that the staff were respectful and friendly. They commented on the hardworking and kind nature of the staff team. The inspector saw staff consistently treating residents in respectful and friendly way. DS0000065376.V331546.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents had a choice of lifestyle within the home and they were able to maintain contact with family and friends ensuring that they continue to be involved in community life. Meals served at the home were of a good quality and offered choice to ensure residents receive a healthy balanced diet. EVIDENCE: Residents said they were able to get up and go to bed when they chose, and were seen to walk freely around the home and into the garden, if able. Relatives spoken to said they were able to visit at any time and were made to feel very welcome. A friendly, lively and welcoming feel was evident in Norton Lees Hall. Some residents were sat in groups sharing stories with each other and the sound of laughter was nice to hear. Staff and residents were preparing for a trip to a DS0000065376.V331546.R01.S.doc Version 5.2 Page 14 concert hall on the afternoon of the inspection and the anticipation and excitement in the home was very evident. Residents said they enjoyed the activities available at the home, whilst other residents said that they chose not to join in with the activities arranged. Activities were advertised around the home. The inspector spoke with the staff about the activities they arrange. The staff showed real enthusiasm about this role and were all keen to include as many residents as possible in different types of activities. Residents said that they had a choice of food and that the quality of food served was good. The inspector viewed the lunchtime experience for the residents as a very positive and pleasant event. Lunch was served in a pleasant relaxed manner and residents were sat at tables, which had been nicely set. The inspector sat for a while with the residents at lunch. The Residents said that they enjoyed their lunch. DS0000065376.V331546.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures are in place to enable residents and relatives to feel confident that any concerns they voice will be listened to. Staff had an understanding of the procedures to be followed should they suspect any abuse at the home, so helping to ensure residents are protected from abuse. EVIDENCE: Complaints procedures were displayed in the home. Residents and relatives said that if they had any concerns that they would feel comfortable in talking to the manager and they knew that the problems would be dealt with immediately. Staff interviewed had received training on adult protection and were aware that there were procedures in place to report any concerns. There was regular staff training on the protection of vulnerable adults. DS0000065376.V331546.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,21,24 and 26. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment within the home was well maintained and clean providing a comfortable, safe environment for residents. EVIDENCE: The home was clean and tidy. Lounge and dining areas were domestically furnished to a high standard and felt “homely”. Bathrooms were clean and bright. Bedrooms checked were comfortable and homely. Residents said their beds were comfortable. Bed linen checked was clean and in a good condition. DS0000065376.V331546.R01.S.doc Version 5.2 Page 17 No unpleasant odours were noticeable in the home. Relatives and residents said that the home was always kept clean. A staff member said that they had received training on the safe handling of hazardous substances and the inspector saw that soap, paper towels and plastic aprons had been made available in the laundry. (Previous requirement met) Window restrictors were fitted to all windows checked. The hot water temperature in one bathroom checked measured a safe temperature below 45 degrees centigrade. This will assist in maintaining resident safety. DS0000065376.V331546.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff were employed in sufficient numbers to meet the residents needs. Recruitment procedures promoted the protection of residents. Staff have completed training that ensures these staff have the competences to meet the residents needs. Staff undertook induction training to ensure they had the skills needed to carry out their duties. EVIDENCE: The manager stated that agreed staffing levels were being maintained and the staff rota identified agreed staffing levels had been met. Staff said staffing levels were adequate and levels had improved in the previous few months. Staff said they did not now have to undertake non-care duties and this had freed up their time so that they could spend more time with the residents. Relatives said that staff were very visible around the home when they visited. DS0000065376.V331546.R01.S.doc Version 5.2 Page 19 The required 50 of care staff had not achieved their level 2/3 NVQ qualifications, although the manager said a number of staff had enrolled or were undertaking their NVQ training. The recruitment records of 2 recently employed staff members were checked. The staff had provided employment histories and the home had obtained two written references for each of them. These were satisfactory. Protection Of Vulnerable Adults (POVA) checks had been made. Enhanced Criminal Record Bureau (CRB) checks had been obtained for the staff members. There was a training and development plan for the staff. Staff said they were encouraged to attend training on various care topics and that there were good training opportunities available to them. Staff interviewed said that when they started work they received induction training in the first two months of their employment. Two staff files checked identified that the member of staff had received induction training when they commenced work. DS0000065376.V331546.R01.S.doc Version 5.2 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,32,33,35,36 and 38. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. There was a positive style of management in the home. This would have a positive affect on the quality of the service the residents receive. Some of the homes financial procedures did not fully promote the welfare of the residents. The homes other policies and procedures promoted the health, safety and welfare of residents and staff. DS0000065376.V331546.R01.S.doc Version 5.2 Page 21 EVIDENCE: The care manager is experienced in the care of older people and has registered to undertake her NVQ level 4 award. The manager was very positive about the inspection process and was committed to improve the service of Norton Lees Hall and meet the National Minimum Standards and Care Home Regulations. In the last year significant progress had been made to improve the service. Residents, staff and relatives said that they met regularly with the manager of the home and spoke positively about her approachability and helpfulness. Staff said they had felt much more “supported” by the senior management of Orchard Care Homes over the last few months. The home had an active quality assurance system. There was evidence of internal auditing of the homes environment, services and records. Staff meetings were held and minutes of these meetings were seen. The responsible individual visited the home on a regular basis, a report was written following the visits. A copy of the responsible individuals monthly report has always been sent to the local office of the CSCI. The home handles money on behalf of some residents. Account sheets were kept and receipts were seen for all transactions. However, residents’ financial interests were not fully safeguarded because a second individual was not signing the document to witness transactions such as deposits or withdrawals from an account. Staff said they were receiving supervision and support from the homes management. The inspector saw records to confirm that staff supervision had taken place. Accident/incident records were being maintained and the manager was monitoring these records. Staff said they had received recent fire safety and other health and safety training .A sample of records showed that staff were receiving this statutory training. Fire records stated that weekly testing of the fire alarm system had occurred. A sample of records showed servicing of the homes utility systems had occurred. DS0000065376.V331546.R01.S.doc Version 5.2 Page 22 Practice fire drills had been conducted in the home and the records identified the length of the drill, the time the drill was held and any corrective action taken after the drill had been completed. At the time of inspection fire exits were clear and window restraints were in situ at first floor windows checked to prevent falls. Hazardous products were safely stored in the home. This will promote the safety and welfare of the residents. DS0000065376.V331546.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 X 2 3 X 3 DS0000065376.V331546.R01.S.doc Version 5.2 Page 24 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 Requirement The social interests of all residents must be recorded so that their specific diverse and varying needs can be met. The residents daily notes must reflect the information actually recorded in the residents care plan. (Previous requirement) The care plan must set out in detail the action, which staff need to take to meet all aspects of the personal and social care needs of the resident. Documentation must be available to show that residents and/or their relatives have been involved in the drawing up and evaluation of the residents care plan. (Previous requirement) 50 of care staff must be trained to NVQ level 2 or equivalent. (Previous requirement) The manager must be trained to NVQ level 4 or equivalent in management. (Previous requirement) DS0000065376.V331546.R01.S.doc Timescale for action 01/07/07 2. OP7 15 01/07/07 3. OP7 15 01/07/07 4. OP7 15 01/07/07 5. OP28 18 31/12/07 6. OP31 9,18 31/12/07 Version 5.2 Page 25 7. OP35 13,16,17 Residents’ financial interests must be safeguarded by staff counter signing financial statements when witnessing transactions. 01/06/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000065376.V331546.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000065376.V331546.R01.S.doc Version 5.2 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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