Inspection on 03/02/06 for Norton Lees Lodge

This inspection was carried out on 3rd February 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Norton Lees Lodge 27/11/07

Norton Lees Lodge 27/11/06

Norton Lees Lodge 09/05/06

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 Unannounced Inspection 3rd February 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Norton Lees Lodge DS0000066121.V282188.R01.S.doc Version 5.1 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.V282188.R01.S.doc Version 5.1 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 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) Orchard Care Homes.Com Ltd Post Vacant Care Home 40 Category(ies) of Dementia - over 65 years of age (40) registration, with number of places Norton Lees Lodge DS0000066121.V282188.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three service users over the age of 60 years may be accommodated at the home. This was the first inspection of this service. 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. The home has a pleasant enclosed garden. Car parking is available. Norton Lees Lodge DS0000066121.V282188.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by Mike O’Neil and Sue Turner, regulation inspectors. Karen De La Mare ,deputy manager was present during the inspection. Opportunity was taken to make a partial tour of the premises, inspect a sample of records and policies and talk to 4 staff, 2 relatives, a visiting health care professional and 14 residents. The inspectors wish to thank the staff, relatives and residents for their time, friendliness and co-operation throughout the inspection process. What the service does well: What has improved since the last inspection? What they could do better: The homes statement of purpose and service user guide should be available to all residents and their representatives. Staff require further skills and experience in order to deliver the care necessary. Norton Lees Lodge DS0000066121.V282188.R01.S.doc Version 5.1 Page 6 Resident care plans must contain sufficient detail and relatives need to be involved in the drawing up and evaluation of the care plans, to ensure a consistant high standard of care is provided. Care plans and risk assessments must be reviewed monthly. Personal care of each resident must be maintained. Arrangements to ensure that residents are provided with stimulation and orientation to date,time and place should be in place. Food served must suitable for the residents assessed needs and preferences. There must be a complaints procedure. Nameplates must be fitted to all bedroom doors. All areas of the home must be kept clean and free from offensive odours. There must be sufficient numbers of competent and experienced staff on duty at all times. Service users must benefit from the ethos, leadership and management approach of the home. The fire authority must be consulted regarding the effectiveness of the fire doors and action taken as appropriate. 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.V282188.R01.S.doc Version 5.1 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 Lees Lodge DS0000066121.V282188.R01.S.doc Version 5.1 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): Standards 1 and 4. Residents and their relatives do not have the information they need to make an informed choice about where they live. Staff had not received the training needed to provide them with the skills to meet the specialist needs of the residents. EVIDENCE: A statement of purpose and service user guide was not available for all residents or their relatives. A statement of purpose was available in the reception of the home, however this was not accessible to the residents and the document was out of date. Staff said they had not received any recent training on dementia care and said that they needed this training to help them meet the specialist and indeed some basic needs of the residents in Norton Lees Lodge. Norton Lees Lodge DS0000066121.V282188.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8 and 10. The residents’ health and personal care needs were not adequately documented in the care plans. The relatives and residents were not adequately consulted when the care plans were drawn up or evaluated. Not all of the residents personal care needs were being met. EVIDENCE: The two care plans checked were not satisfactory, and the information in them, was inadequate to ensure that the resident’s health needs could be met. • The care plans were did not provide enough detail of the actual care needs of the residents. • The care plans had not been reviewed by the staff for 3 months. • There was no evidence to suggest that the resident or their relatives were involved in the drawing up of the care plans. • Staff had not reviewed risk assessments in one care plan for over two months despite the resident suffering a recent serious fall. Norton Lees Lodge DS0000066121.V282188.R01.S.doc Version 5.1 Page 10 Some of the residents, particularly the ladies were well dressed in clean clothes and had received a satisfactory standard of personal care. The inspectors did see however that two male residents had received an unacceptable level of care. They were unshaven, had food stains on their clothes and were not wearing any socks. The relatives and visiting health professional said that they felt that the standard of care delivered by staff was good. Staff were observed to be assisting residents in a friendly manner, doors were closed where staff were helping with personal care. Norton Lees Lodge DS0000066121.V282188.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12 and 15. Residents’ social and recreational interests were not being met. Meals served at the home were of a good quality and offered choice. However snacks served were not all suitable for the residents assessed needs. EVIDENCE: The inspectors felt that there was a lack of stimulation and orientation for the residents at Norton Lees Lodge. There were no clocks visible, no newspapers or menu boards that would orientate the residents to time and place. No activities coordinator is employed at the home and residents made such comments as “I’m like a prisoner here, we don’t go out and there is nothing to do.” “We never go out” “I’m bored “ “I’m hemmed in” Staff said they did arrange some activities for residents but these were on an adhoc basis, were not advertised anywhere in the home and were only possible when staffing levels permitted. Residents said that they enjoyed their meals, that they had a choice of food and that the food served was of a good quality. However the inspectors observed that snacks served were not all suitable for the residents assessed needs. A resident was seen trying to eat a cream cracker that had been given Norton Lees Lodge DS0000066121.V282188.R01.S.doc Version 5.1 Page 12 to him as a snack. The resident however could not bite into the cracker, as he did not have any teeth. Norton Lees Lodge DS0000066121.V282188.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18. The homes complaints procedure was not accessible. All complaints were not being recorded. Staff did have an understanding of the procedures to be followed should they suspect any abuse at the home. EVIDENCE: A complaints procedure was not displayed anywhere in the home. The deputy manager also said that not all concerns or complaints made by residents or their relatives were documented. Staff said they had received information on adult abuse and the protection of vulnerable adults. Norton Lees Lodge DS0000066121.V282188.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,21,22,24,25 and 26. The environment within the home was well maintained and in the main clean. A comfortable and safe environment was provided for the residents. Orientation around the home was made more difficult for residents because only a few of the bedroom doors were fitted with nameplates. 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. On the first floor corridor unpleasant odours were noticeable. See standard 27 for related issue. Orientation around the home was made more difficult for residents because only a few of the bedroom doors were fitted with nameplates. The home was warm in all areas. Window restrictors were fitted to all windows checked. Norton Lees Lodge DS0000066121.V282188.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27 and 30. Staff were not employed in sufficient numbers to meet the needs of residents in accordance with agreed staffing levels. Staff were not undertaking adequate training, which enabled them to meet the needs of the residents in the home. EVIDENCE: Staffing arrangements and numbers meant that at times residents’ needs may not be met. There was a shortfall of one care assistant during the daytime shift and one care assistant during the “twilight” shift, which meant that agreed staffing levels were not met. Only 1 domestic member of staff was employed during the day. In view of the cleanliness of the building the adequacy of this must be questioned. Staff said that current staffing numbers were not adequate to meet the needs of residents. Staff spoken to said that they had all received induction training, however the training had not included information about personal care or caring for people with dementia. Following induction, staff had not received any further training or information. Norton Lees Lodge DS0000066121.V282188.R01.S.doc Version 5.1 Page 16 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 32 and 38. Service users did not benefit from the ethos, leadership and management approach of the home. In the main the homes environment protected the health and safety of residents. EVIDENCE: This was the homes first inspection following their registration three months ago. It is therefore of great concern that CSCI inspectors have issued a substantial number of requirements, many of which relate to inadequate basic care practices. The manager appointed had left employment and the managers position had not been filled. Staff said they felt unsupported, without direction and there were no clear organisational structures. Norton Lees Lodge DS0000066121.V282188.R01.S.doc Version 5.1 Page 17 The inspectors felt there was a lack of leadership at the home and systems had not been put in place, which had resulted in there being a deterioration in the standard of the care and service provided at Norton Lees Lodge. The hot water temperature in a bathroom measured a safe temperature of 42 degrees centigrade. One staff member said they had received recent fire safety training. At the time of inspection no fire exits were blocked 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. The double fire doors seen by the inspectors had a half centimetre gap in between them, which may affect the ability of the doors to retain fires. Norton Lees Lodge DS0000066121.V282188.R01.S.doc Version 5.1 Page 18 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 2 X X 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 X 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 X 18 3 3 X 3 2 X 3 3 2 STAFFING Standard No Score 27 2 28 X 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X 1 X X X X X 2 Norton Lees Lodge DS0000066121.V282188.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement The homes statement of purpose and service user guide must be provided to all residents and any of their representatives. Staff must have the skills and experience to deliver the care required. 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. Resident care plans must contain sufficient detail to ensure that the residents receive a consistant high standard of care. Resident care plans must be reviewed at least every month. Residents risk assessments must be regularly reviewed. Care staff must maintain the personal care of each resident. Arrangements must be implemented to ensure that residents are provided with stimulation and are orientated to date,time and place. Food served must suitable for DS0000066121.V282188.R01.S.doc Timescale for action 01/04/06 2. 3. OP4 OP7 12,13,19 15 01/06/06 01/04/06 4. OP7 15 01/04/06 5. 6. 7. 8. OP7 OP7 OP8 OP12 15 15 12,13 16 01/04/06 01/04/06 01/04/06 01/04/06 9. OP15 16,17 01/04/06 Page 20 Norton Lees Lodge Version 5.1 10. OP16 22 11. 12. 13. OP22 OP26 OP27 23 23 18 14. 15. OP30 OP32 18 24 26 16. OP38 23 the residents assessed needs and preferences. A complaints procedure must be available as detailed in regulation 22 of the Care Home Regulations 2001. Nameplates must be fitted to all bedroom doors. All areas of the home must be kept clean and free from offensive odours. There must be sufficient numbers of competent and experienced staff on duty at all times. Staff must be provided with training appropriate to the work they are to perform. Service users must benefit from the ethos, leadership and management approach of the home. The fire authority must be consulted regarding the effectiveness of the fire doors and action taken as appropriate. 01/04/06 01/04/06 01/04/06 01/04/06 01/08/06 01/04/06 01/04/06 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.V282188.R01.S.doc Version 5.1 Page 21 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. 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