Inspection on 27/11/06 for Norton Lees Lodge

This inspection was carried out on 27th November 2006.

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 Lees Lodge 27/11/07

Norton Lees Lodge 09/05/06

Norton Lees Lodge 03/02/06

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

CARE HOMES FOR OLDER PEOPLE Norton Lees Lodge 156 Warminster Road Norton Lees Sheffield South Yorkshire S8 8PQ Lead Inspector Michael O`Neil Key Unannounced Inspection 27th November 2006 09:20 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 Lees Lodge DS0000066121.V315220.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. Norton Lees Lodge DS0000066121.V315220.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norton Lees Lodge Address 156 Warminster Road Norton Lees Sheffield South Yorkshire S8 8PQ 0845 6027471 0114 2586458 nortonleeslodge@orchardcarehomes.com 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) Post Vacant Care Home 40 Category(ies) of Dementia - over 65 years of age (40) registration, with number of places Norton Lees Lodge DS0000066121.V315220.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three service users over the age of 60 years may be accommodated at the home. 9th May 2006 Date of last inspection Brief Description of the Service: Norton Lees Lodge 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 dementia 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. A conservatory has been built in the past few months, which has created additional space for the residents. The home has a pleasant enclosed garden. Car parking is available. The manager confirmed that the range of monthly fees from 27th November 2006 were £345 - £480 per week. Additional charges included hairdressing and private chiropody. Norton Lees Lodge DS0000066121.V315220.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 and Shelagh Murphy, regulation inspectors. This inspection took place between the hours of 9.20 am and 3:25 pm. Karen De La Mare, manager, awaiting registration with the CSCI, and Philip Middleton, area manager, Orchard Care Homes, were present during the inspection. 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. 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 7 staff, 2 relatives and 10 residents. The inspectors wish 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 entrance hall. What the service does well: A notice board was sited in the entrance hall of the home. The board contained very useful information such as the date, photographs of the staff on duty, the food menu and the activities organised for the residents on that particular day. The inspector was very impressed with the sound knowledge staff had of the residents’ diagnosis and their health and social needs. Staff said they had undertaken training relating to the needs of the residents. Residents consistently added comments such as” staff are lovely ”and the “staff are nice”. Relatives made comments such as “the staff are caring”. Some residents were not able to say whether they felt that they were being well cared for; these residents were well dressed in clean, age appropriate clothing and attention had been paid to hair and nail care. 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. A friendly, lively and welcoming feel was evident in Norton Lees Lodge. Norton Lees Lodge DS0000066121.V315220.R01.S.doc Version 5.2 Page 6 Residents said that they had a choice of food and that the quality of food served was good. Lunch was served in a pleasant relaxed manner and residents were sat at tables, which had been nicely set. In the main the home was clean and tidy. Lounge and dining areas were domestically furnished to a high standard. Bedrooms checked were comfortable and homely. Residents said their beds were comfortable. Bed linen checked was clean and in a good condition. Staff said they were encouraged to attend training on various care topics and that there were good training opportunities available to them. Residents and relatives said that they met regularly with the manager and spoke positively about her approachability and helpfulness. What has improved since the last inspection? The statement of purpose had been updated since the last inspection and contained the relevant experience of the provider, manager and staff working at the home. The standard of the care plans had improved since the last inspection and the staff had clearly made an effort to meet the requirements made at the last inspection. Three previous requirements made had been met. It should be noted that the standard of the care plan documentation has improved throughout the year. Records checked showed that staff were receiving more detailed medication training. Staff some residents and relatives said that the home seemed a much “happier place over the last few months”. This was evident on the day of inspection. Staff were making an effort to provide a more stimulating environment for the residents. The home were developing links within the local community including local church groups and other clubs. Since the last inspection a refurbishment of the home has occurred and a new conservatory has been built. Some carpets have also been replaced. This has improved the space available to the residents and the general environment of the home. Residents and staff said the temperature control in the home had improved since the last inspection. Staff said staffing levels had improved over the past few months and were adequate. Residents said there was always a member of staff available when they needed them. Norton Lees Lodge DS0000066121.V315220.R01.S.doc Version 5.2 Page 7 The style of management in the home has improved significantly since the last inspection with senior management supporting the home manager on a regular basis. There had been some improvements in health and safety issues since the last inspection. The kitchenettes were cleaner and food was being safely stored. 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 Lees Lodge DS0000066121.V315220.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 Norton Lees Lodge DS0000066121.V315220.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1 and 3. Standard 6 is not applicable to this home. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provided sufficient updated information to inform residents about their rights and choices. Residents’ assessments prior to admission took place. These enabled staff to be aware of residents needs to ensure that they could be met. EVIDENCE: A statement of purpose and service user guide was available for all residents or their relatives. The statement of purpose had been updated since the last inspection and contained the relevant experience of the provider, manager and staff working at the home. A copy of the previous inspection report was displayed and available in the home. Norton Lees Lodge DS0000066121.V315220.R01.S.doc Version 5.2 Page 10 A notice board was sited in the entrance hall of the home. The board contained very useful information such as the date, photographs of the staff on duty, the food menu and the activities organised for the residents on that particular day. Three care plans were checked and these contained assessments of the service users’ needs. The assessments were formulated into a plan of care for each person. Norton Lees Lodge DS0000066121.V315220.R01.S.doc Version 5.2 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 the following standard(s): Standards 7, 8, 9,10 and 11. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although there had been a significant improvement in the residents care plan documentation the residents’ health, social and personal care needs were still not documented in sufficient detail to ensure that the resident’s needs could be fully met. Residents themselves said that the care they were receiving was good. Two relatives interviewed confirmed that they felt the needs of their relative were being met. One medication procedure provided a risk to the residents’ health and welfare. Service users privacy and dignity was maintained. EVIDENCE: Three resident care plans were checked. The standard of the care plans had improved since the last inspection and the staff had clearly made an effort to Norton Lees Lodge DS0000066121.V315220.R01.S.doc Version 5.2 Page 12 meet the requirements made at the last inspection. Three previous requirements made had been met. It should be noted that the standard of the care plan documentation has improved throughout the year. The care plans did not meet the required standard, however because the care plans did not contain detailed information as to how the residents’ health, social or personal needs could be fully met. There was evidence to suggest that the resident or their relatives were involved in the drawing up or the reviewing of the care plans. A relative said they were kept informed of their residents care and that the staff often asked them for information. The nutritional needs of the residents were now being monitored. The care plans identified that residents were being weighed regularly. The care plans identified that a range of health professionals visited the home to assist in maintaining the residents health care needs. Staff were updating resident risk assessments and the care plans on a monthly basis. The inspector was very impressed with the sound knowledge staff had of the residents’ diagnosis and their health and social needs. Staff said they had undertaken training relating to the needs of the residents. The residents’ wishes regarding dying and death were now being recorded in the care plans checked. Some residents were not able to say whether they felt that they were being well cared for; these residents were well dressed in clean, age appropriate clothing and attention had been paid to hair and nail care. Residents said that the care they were receiving was good. Residents consistently added comments such as” staff are lovely ”and the “staff are nice”. Relatives made comments such as “the staff are caring”. Medicines were securely stored around the home in locked cupboards. (Previous requirements met) The inspector observed a staff member dispense medication to residents in a safe and hygienic way. Staff said they had received medication training. Records checked showed that staff had received medication training. (Previous requirement met) Medicine Administration Records (MAR) checked were completed with staffs’ signatures. Residents’ health and safety was not fully maintained however because not all Medicine Administration Records (MAR) were adequate. One resident’s allergy to a specific medication was not recorded on the MAR sheet. Norton Lees Lodge DS0000066121.V315220.R01.S.doc Version 5.2 Page 13 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 inspectors saw staff consistently treating residents in respectful and friendly way. Norton Lees Lodge DS0000066121.V315220.R01.S.doc Version 5.2 Page 14 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): Standards 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were able to make choices about daily living and some choices about social activities. Increased social activities had been made available to residents. To improve choices and maintain interests, activities need to be more individualised to the residents assessed needs and preferences. The home had an open visiting policy, which assisted in maintaining good relationships with residents’ representatives. Meals served at the home were of a good quality and offered choice. 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, if able. Relatives spoken to said they were able to visit at any time and were made to feel welcome. A friendly, lively and welcoming feel was evident in Norton Lees Lodge. Staff some residents and relatives said that the home seemed a much “happier place over the last few months”. This was evident on the day of inspection. Norton Lees Lodge DS0000066121.V315220.R01.S.doc Version 5.2 Page 15 Some activities were occurring during the inspection and other activities including entertainers visiting the home were planned. Staff were making an effort to provide a more stimulating environment for the residents. Despite these efforts and improvements a more individualised and person centred activity programme is needed which should encompass the likes and dislikes of the residents. This would enable residents’ opportunity to exercise their choice in relation to social and leisure activities. The home were developing links within the local community including local church groups and other clubs. Residents said that they had a choice of food and that the quality of food served was good. Lunch was served in a pleasant relaxed manner and residents were sat at tables, which had been nicely set. Residents said that they enjoyed their lunch. Norton Lees Lodge DS0000066121.V315220.R01.S.doc Version 5.2 Page 16 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): Standards 16 and 18. Quality in this outcome area is good. This judgement has been made using available 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: The home had a complaints procedure, which included all the required information on how residents or their relatives could make complaints. It contained information on how to contact the CSCI if necessary. Residents and their relatives said that they would have no hesitation in raising concerns with the manager or any of the staff. 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 adult protection. Staff were aware of their duty to report any concerns immediately. There is an adult protection issue ongoing at the home that was appropriately reported using the local vulnerable adult protection policy. Norton Lees Lodge DS0000066121.V315220.R01.S.doc Version 5.2 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 the following standard(s): Standards 19, 21, 24, 25 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Investment in the homes environment has continued. The environment within the home was generally well maintained and in the main clean, providing a comfortable, safe environment for residents. EVIDENCE: In the main the home was clean and tidy. Lounge and dining areas were domestically furnished to a high standard. Bedrooms checked were comfortable and homely. Residents said their beds were comfortable. Bed linen checked was clean and in a good condition. Since the last inspection a refurbishment of the home has occurred and a new conservatory has been built. Some carpets have also been replaced. This has improved the space available to the residents and the general environment of the home. Norton Lees Lodge DS0000066121.V315220.R01.S.doc Version 5.2 Page 18 Some minor maintenance issues such as replacing light bulbs and reaffixing door handles required attention. Some residents said that they had a key to their room to enable them to maintain some privacy. (Previous requirement met) Not all staff had a master key, which could mean that in the event of an emergency immediate access to rooms may not be possible. The air temperature in the first floor lounge was comfortable, 23 degrees centigrade. Residents and staff said the temperature control in the home had improved since the last inspection. A strong unpleasant odour was noticeable in one bedroom and the odour had spread to the corridor. This has been highlighted as a requirement when the inspectors made visits to the home the home in March and May 2006.However since the last inspection there was evidence seen that the staff at the home had been regularly consulting with health professionals/specialists, in order to try and reduce the problems associated with the residents’ incontinence problem. The carpet in the affected room has also been replaced. Whilst this odour is unacceptable the evidence seen does suggest that the home are making every effort possible to try and eradicate the smell. Toilets and bathrooms were clean and tidy. However the bathrooms did look and feel very bare, institutionalised and clinical. The bathrooms could be made more homely and less clinical by adding some more domestic touches. 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. Norton Lees Lodge DS0000066121.V315220.R01.S.doc Version 5.2 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 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): Standards 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 had improved over the past few months and were adequate. Residents said there was always a member of staff available when they needed them. Relatives said that staff were very visible around the home when they visited and that agency staff were used only on a very infrequent basis. 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. Norton Lees Lodge DS0000066121.V315220.R01.S.doc Version 5.2 Page 20 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. A staff file checked identified that a member of staff had received induction training when they commenced work at Norton Lees Lodge. Norton Lees Lodge DS0000066121.V315220.R01.S.doc Version 5.2 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 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): Standards 31, 32, 33, 35, 36 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The style of management in the home has improved significantly since the last inspection with senior management supporting the home manager on a regular basis. Staff were generally being well supervised, so they have the required skills to meet the residents needs. Some of the homes policies and financial procedures did not fully promote the health, safety and welfare of residents and staff. EVIDENCE: The company have clearly recognised the need to address the issues of concern at Norton Lees Lodge. The time and effort by the management of the Norton Lees Lodge DS0000066121.V315220.R01.S.doc Version 5.2 Page 22 company must be recognised as a positive step, in achieving a satisfactory service for the residents of Norton Lees Lodge. The manager is aware for the need to register with the CSCI and has submitted her application to register as the manager. The manager said she had completed her level 4 NVQ management qualification but has not yet provided the CSCI with a copy of this certificate. The manager and area manager were very positive about the inspection process and were both committed to improve the service of Norton Lees Lodge and meet the National Minimum Standards and Care Home Regulations. Residents and relatives said that they met regularly with the manager and spoke positively about her approachability and helpfulness. 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. However there had only been two staff meetings held this year and staff said they wanted to meet the management more frequently so they could air there views and discuss any concerns they had. 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. Resident meetings took place at the home; relatives said they had met the management of the home. The manager handles money on behalf some residents. Only small amounts of cash are held. Account sheets were kept. These were up to date and there were receipts for any transactions that may have been made. Staff said they were receiving supervision on a regular basis. The inspector saw records to confirm that staff supervision had taken place. Records were securely stored around the home, which protected the residents’ best interests and confidentiality. The health and welfare of residents could not be fully protected, as • Practice fire drills had been conducted in the home, however the records did not identify the length of the drill, staff that participated in the drill and the drills were not conducted at different times of the day. • There was no evidence available to show that requirements made by the Environmental Health Officer during the inspection on 3rd March 2006 have been met. The manager did say that she believed all the works required had been completed. There had been some improvements in health and safety issues since the last inspection. The kitchenettes were cleaner and food was being safely stored. Kettles in the kitchenettes had been replaced with hot water flasks. Norton Lees Lodge DS0000066121.V315220.R01.S.doc Version 5.2 Page 23 Staff spoken to had an understanding of the home’s fire procedures; they had received training on moving and handling, fire and food safety. Three staff records checked confirmed that this training had occurred. 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 service users. Norton Lees Lodge DS0000066121.V315220.R01.S.doc Version 5.2 Page 24 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 2 X X 2 3 2 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 X 2 X 3 3 X 2 Norton Lees Lodge DS0000066121.V315220.R01.S.doc Version 5.2 Page 25 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 Resident care plans must contain sufficient detail to ensure that the resident receives a consistent high standard of care. Resident’s allergies must be recorded on their Medication Administration Record. Residents have the opportunity to exercise their choice in relation to social and leisure activities. Minor maintenance issues that require attention must be addressed. (Light bulbs, door handles) Toilets and bathrooms should be redecorated and touches added to make them more domestic in style and so less clinical. Doors to residents’ private accommodation must be accessible to staff in the case of emergencies. All areas of the home must be kept clean and free from offensive odours. 50 of care staff must be trained to NVQ level 2 or DS0000066121.V315220.R01.S.doc Timescale for action 01/03/07 2. 3. OP9 OP12 13 16 01/01/07 01/04/07 4. OP19 23 01/02/07 5. OP21 23 01/05/07 6. OP24 12,13 01/02/07 7. 8. OP26 OP28 23 18 01/01/07 31/12/06 Norton Lees Lodge Version 5.2 Page 26 equivalent. 9. OP31 9,18 The manager must be trained to NVQ level 4 or equivalent in management. 31/12/06 10. OP33 18 Staff meetings must be held on a 01/03/07 more frequent basis and minutes of these meetings must be recorded. Evidence must be produced to show that requirements made by the Environmental Health Officer during the inspection on 3rd March 2006 have been met. Fire Drills must be conducted at different times of the day/night so as to ensure that all staff working at the home are aware of the procedures to follow in the event of fire. Fire Drills records must indicate the duration of the drill and staff that participated in the drill. 01/01/07 11. OP38 16 12. OP38 23 01/01/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Norton Lees Lodge DS0000066121.V315220.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Lees Lodge DS0000066121.V315220.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!