Inspection on 09/05/06 for Norton Lees Lodge

This inspection was carried out on 9th May 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 27/11/06

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 Unannounced Inspection 9th May 2006 09:00 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.V294377.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.V294377.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 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.V294377.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. 3rd February 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. The home has a pleasant enclosed garden. Car parking is available. A copy of the previous inspection report was not displayed and available in the home. The manager said that it had not been made freely available for residents or visitors to the home. Information about how to raise any issues of concern or make a complaint was on display in the entrance hall. The manager confirmed that the range of monthly fees from 9th May 2006 were £341 - £450 per week. Additional charges included newspapers, hairdressing and private chiropody. Norton Lees Lodge DS0000066121.V294377.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 key inspection carried out by Mike O’Neil and Sue Turner, regulation inspectors. This inspection took place between the hours of 9.00 am and 3:45 pm. Sarah Eason, manager, awaiting registration with the Commission for Social Care Inspection (CSCI), and Julie Wright Head of Operations, Orchard Care Homes, were present during the inspection. The manager submitted a pre inspection questionnaire and 11 residents returned care home surveys to the CSCI prior to the actual visit to the home. The residents’ views and some information from the questionnaire are 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, 4 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. What the service does well: What has improved since the last inspection? The standard of the care plans had improved and the staff had clearly made an effort to meet the requirements made at the last inspection. The inspectors observed that the standard of personal care the residents had received had improved since the last inspection. Staff had clearly made an effort to provide a more stimulating environment by providing some activities for the residents. Norton Lees Lodge DS0000066121.V294377.R01.S.doc Version 5.1 Page 6 Efforts had been made to orientate residents to the date, time and place. Clocks were visible, and wipe boards contained information such as the date, weather and menu. Also nameplates had been fitted to the residents’ doors. A new conservatory is currently being built which, when completed, will provide increased space and privacy for the residents. The kitchenettes were generally cleaner and food was being safely stored. Hazardous cleaning products were being safely stored in locked cupboards. The double fire doors around the home had been resealed so there was no gap visible in them meaning that the fire protection system of the home was safer. 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 company must be recognised as a positive step, in achieving a satisfactory service for the residents of Norton Lees Lodge. 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.V294377.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.V294377.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 1,2, 3 and 4. Standard 6 is not applicable to this home. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was not providing sufficient updated information to inform service users 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. Staff had received training that would help them meet the specialist needs of the residents in Norton Lees Lodge. EVIDENCE: A statement of purpose and service user guide was available for all residents or their relatives. The statement of purpose was not adequate, however as it did not contain the relevant experience of the provider, manager and staff working at the home. A copy of the previous inspection report was not displayed and available in the home. The manager said that it had not been made freely available for residents or visitors to the home. Norton Lees Lodge DS0000066121.V294377.R01.S.doc Version 5.1 Page 9 Contracts and terms and conditions of residence were seen in three resident files checked. Staff spoken to said that assessments were undertaken prior to admission to ensure the service could meet prospective residents needs. The home’s manager and social workers of the residents carried these out. Copies of care management assessments were available and held within resident files. Staff training files checked identified that staff had received training on dementia care and this was confirmed by the staff who were interviewed. Norton Lees Lodge DS0000066121.V294377.R01.S.doc Version 5.1 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): 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. Inadequacies in the residents care plan documentation meant that the resident’s health social and personal care needs may not be fully met. Some medication storage and procedures presented a risk to the residents’ health and welfare. Residents said that the staff promoted their privacy and dignity. 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 meet the requirements made at the last inspection. Three previous requirements made had been met. However the care plans checked were still not satisfactory, and the information in them, was inadequate to ensure that the resident’s changing health, social and personal care needs could be met. Norton Lees Lodge DS0000066121.V294377.R01.S.doc Version 5.1 Page 11 The residents’ wishes regarding dying and death were not recorded in the care plans checked. 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. Relatives interviewed said they would like to be involved in planning their residents care but said that the staff had not approached them to ask for any information. The nutritional needs of the residents were not adequately monitored. The care plans identified that the residents must be weighed monthly, however the residents had not been weighed in the last 4 months. The care plans did identify that a range of health professionals visited the home to assist in maintaining the residents health care needs. Updated risk assessments were recorded in the care plans. The plans checked set out individual needs and the action required by staff to ensure those needs were met. Residents were well dressed in clean clothes and had received a good standard of personal care. The inspectors observed that the standard of personal care the residents had received had improved since the last inspection. All the residents interviewed and via questionnaires submitted to the CSCI said they were “satisfied” with the care they received at Norton Lees Lodge. Residents also made positive comments such as “I’m quite happy here”,” staff always help you”,” the staff are lovely and I’m very happy here” and ”I’m happy here and feel safe”. All the relatives interviewed said they were “satisfied” with the care provided by the staff of Norton Lees Lodge. Relatives also made comments such as “the staff are fantastic” and some relatives felt there had been a recent improvement in the standard of care delivered at the home. Medicine Administration Records (MAR) checked were adequate. The standard of the MAR sheet recording had improved since the last inspection. Medicines were securely stored around the home in locked cupboards. However medicines that were waiting to be returned to pharmacy were not locked in a cupboard but were left in a box on the locked treatment room floor. The manager said she had contacted the pharmacy but was still waiting for the medicines to be collected. Certificates were available to indicate that staff had undertaken training in the principles of safely dispensing medication. However there were no signed records of how detailed the medication training was. Staff were unsure as to where there records were. A residents eye drops that required refrigeration were being stored in the drug trolley at room temperature. Staff were observed respecting residents privacy by knocking on their doors before entering. The interactions between staff and residents appeared respectful and caring. Residents said the staff were ‘kind’,’ caring’ and ‘helpful’. Norton Lees Lodge DS0000066121.V294377.R01.S.doc Version 5.1 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): Standards 12,13,14 and 15. Quality in this outcome area is adequate. 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. 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’ family and friends. 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. Throughout the day friends and family were seen visiting the home and there seemed to be a very friendly and welcoming feel in Norton Lees Lodge. Visitors knew the majority of the residents and visa versa, which meant that residents were communicating with visitors even if they were not related. Activities were occurring during the inspection and staff had clearly made an effort to provide a more stimulating environment for the residents. Norton Lees Lodge DS0000066121.V294377.R01.S.doc Version 5.1 Page 13 Efforts had been made to orientate residents to the date, time and place. Clocks were visible, and wipe boards contained information such as the date, weather and menu. Some residents said that the activities arranged were still held on an adhoc basis and they wanted more time on a 1 to 1 basis to talk to staff and to get out of the home on trips or even a visit to the shop. A more individualised activity programme is needed which should encompass the likes and dislikes of the residents, this information could be discussed with relatives, if they were more involved in the residents care plans. This would enable residents’ opportunity to exercise their choice in relation to social and leisure activities. Lunch was served in a pleasant relaxed manner. The tables were pleasantly set and drinks were provided with lunch. Residents said that they enjoyed their lunch and residents’ specific requests for lunch were being catered for. Residents said that they had a choice of food and that the food served was of a good quality. Residents added comments such as “the food is marvellous” and” the food is quite nice”. The inspector observed fresh fruit, which had been cut up, being served to residents during the morning. Norton Lees Lodge DS0000066121.V294377.R01.S.doc Version 5.1 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): 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 homes complaints policy was on display in the entrance area of the home. It contained relevant information and informed the reader who to contact external to the home, should the complainant wish to do so. Relatives and residents said that if they had any concerns that they would feel comfortable in talking to the staff or the manager. Relatives said that they had recently raised concerns with the management of Orchard Care Homes and said that they had been listened too and some action taken to rectify the concerns raised. A record of complaints was seen at the home. Staff had received information on adult abuse and some staff had received formal training. Records of this training were seen in staff files checked. Norton Lees Lodge DS0000066121.V294377.R01.S.doc Version 5.1 Page 15 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 19,22,24,25 and 26. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The environment within the home was not maintained to an adequate enough standard to provide a comfortable home for service users. 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. Orientation around the home has been made easier for residents because since the last inspection bedroom doors have been fitted with nameplates. A strong unpleasant odour was noticeable in two bedrooms and the odour had spread to the corridor. This odour is totally unacceptable particularly in view of the fact that the home had not consulted with health professionals/specialists, in order to try and reduce the problems associated with the residents’ Norton Lees Lodge DS0000066121.V294377.R01.S.doc Version 5.1 Page 16 incontinence problem. This was highlighted as a requirement when the inspectors made an additional visit to the home the home in March 2006. Residents said that the smell was “appalling” and relatives said that the smell was “atrocious”. The air temperature in the first floor lounge was uncomfortably warm. A relative said at times the heat was “unbearable” and residents said they were “very uncomfortable” in the heat. The company therefore must look into why the heat is so high and take action to rectify the problem. Staff said that only one master key was available for their use, which could mean that in the event of an emergency immediate access to rooms may not be possible. Residents also said that they did not have a key to their room to enable them to maintain some privacy. The manager said that she was aware of the situation and had ordered the keys from a local locksmith. The keys should be available to all residents, who request a key, in the next few days. On a positive note the building of a new conservatory has commenced. When completed the conservatory will provide increased space and privacy for the residents. Norton Lees Lodge DS0000066121.V294377.R01.S.doc Version 5.1 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. Insufficient staff were provided to meet the needs of the residents. The recruitment information obtained for new staff was sufficient to adequately protect the welfare of residents who lived at the home. Staff received adequate training on their induction to have the required skills to meet the residents’ needs. A proportion of staff undertook NVQ training. EVIDENCE: The staff rota identified agreed minimum care staffing levels were rostered to work on each shift. However after interviewing different disciplines of staff and interviewing some relatives the inspector was informed that care staff were actually undertaking non-direct care duties. Staff have to carry out laundry duties as a laundry assistant is only employed for 3 days a week and also clean the lounge areas at night. 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. The manager did confirm that care staff were undertaking these duties. Some residents and relatives said that the staff were really busy and spent time undertaking cleaning and other non-care duties. Norton Lees Lodge DS0000066121.V294377.R01.S.doc Version 5.1 Page 18 The required 50 of care staff had not achieved their level 2/3 NVQ qualification, although the manager said a number of staff had enrolled or were undertaking their NVQ training. Three staff recruitment files were checked. The staff files contained references from the staff’s last employer, information to verify identity and Criminal Record Bureau (CRB) and Protection Of Vulnerable Adults (POVA) checks. The manager confirmed that all staff working at the home had completed an enhanced CRB/POVA check. There was a training and development plan for the staff. Staff said they were encouraged to attend training on various care topics but in recent months this training was on an adhoc basis. Three staff files checked identified that the staff had received in depth induction training when they commenced work at Norton Lees Lodge. Norton Lees Lodge DS0000066121.V294377.R01.S.doc Version 5.1 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): Standards 31,32,33,35,36,37 and 38. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The style of management in the home has improved since the last inspection. Staff were not being adequately supervised, so they may not have the required skills to meet the residents needs. Residents’ confidentiality was safeguarded, as their records were securely stored in the home. Some of the homes policies and financial procedures did not fully promote the health, safety and welfare of residents and staff. EVIDENCE: The manager is relatively new to post and she is being supported at the home 4 days a week by the Head of Operations, Orchard Care Homes. The company have clearly recognised the need to address the issues of concern at Norton Norton Lees Lodge DS0000066121.V294377.R01.S.doc Version 5.1 Page 20 Lees Lodge. The time and effort by the management of the company must be recognised as a positive step, in achieving a satisfactory service for the residents of Norton Lees Lodge. At the time of the inspection the CSCI area office had not received the application to register the manager. The manager has been in post for two months and is aware for the need to register. The manager and Head of Operations 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. The residents, relatives and staff were very positive about the manager’s approachability. Residents said that they met regularly with the manager and spoke positively about her approachability and helpfulness. The home had a quality assurance system, however the audit tool only been completed in part on an adhoc basis over the last 4 months. The company policy states that a section of the audit tool must be completed monthly. On a positive note the manager had recently sent out questionnaires to the relatives and residents to ask for their views of the home, one of the questionnaires contained some negative comments and the area manager had followed upon these concerns and contacted the relative in an attempt to address the issues. 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 confirmed the home has insurance cover is in place. An up to date insurance certificate was displayed in the foyer of the home. The manager handles money on behalf of 3 residents. Only small amounts of cash are held. Account sheets were kept, however these were not up to date and there were no receipts seen for any transactions that may have been made. The manager assured the inspectors that the accounts would be updated and confirmation would be sent to the CSCI by the 15th May 2006 that this requirement had been met. The staff said that meetings had taken place with the management of the home. The manager said, however, that no minutes of these meetings were available as they were informal meetings. Staff said they were not receiving supervision on a regular basis. The manager confirmed that not all of the care staff had received management supervision. 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; • • The home did not have a fire risk assessment in place. 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. Norton Lees Lodge DS0000066121.V294377.R01.S.doc Version 5.1 Page 21 • • • Requirements made by an Environmental Health Officer on a visit to the home on 3rd March 2006 had not all been met. The manager did say that progress had been made to meet the requirements. The fridge in one kitchenette was not clean as the door seal was splattered with food debris. Staff had left a kettle boiling in a kitchenette where unsupervised residents were sat and walking around. There had been some improvements in health and safety issues since the last inspections. The kitchenettes were generally cleaner and food was being safely stored. Hazardous cleaning products were being stored safely in locked cupboards. The double fire doors around the home had been resealed so there was no gap visible in them meaning that the fire protection system of the home was safer. 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. 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.V294377.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 2 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 3 X X 3 X 2 2 1 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 3 2 1 3 1 Norton Lees Lodge DS0000066121.V294377.R01.S.doc Version 5.1 Page 23 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 OP1 Regulation 4 Requirement The statement of purpose must contain all the information required under Regulation 4 Schedule 1 of the Care Home Regulations 2001. The service user guide, which must be provided to all residents, must include a copy of the most recent inspection report. 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 timescale of 01/04/06 not met) Timescale for action 01/08/06 2. OP1 5 01/08/06 3. OP7 15 01/08/06 4. OP7 15 5. OP9 13 Details recorded in the care plan, 01/08/06 of the action to be taken by staff, to meet the residents needs must be implemented.(Weigh monthly) Detailed records must be 01/07/06 available to show that staff have received up-to-date accredited DS0000066121.V294377.R01.S.doc Version 5.1 Page 24 Norton Lees Lodge 6. 7. 8. 9. OP9 OP9 OP11 OP12 13 13 15 16 training in the receipt, storage, recording, handling, administration and disposal of medicines and the effects of medicines on service users. Medication must be securely stored. Medication needing refrigeration must be securely stored at the correct temperature. Residents’ wishes regarding dying and death must be sought and recorded in their care plan. Residents have the opportunity to exercise their choice in relation to social and leisure activities. Residents must be provided with keys to their rooms unless their risk assessments suggests otherwise. Doors to residents’ private accommodation must be accessible to staff in the case of emergencies. The heating (lounges) must be controlled so that residents live in comfortable surroundings. (Previous timescale of 01/06/05 not met) All areas of the home must be kept clean and free from offensive odours. (Previous timescale of 01/04/06 not met) There must be sufficient numbers of competent and experienced staff on duty at all times. (Previous timescale of 01/04/06 not met) 50 of care staff must be trained to NVQ level 2 or equivalent. The manager must forward an application to the CSCI to enable DS0000066121.V294377.R01.S.doc 01/06/06 01/06/06 01/09/06 01/09/06 10. OP24 16 01/07/06 11. OP24 12,13 01/06/06 12. OP25 23 01/07/06 13. OP26 23 01/06/06 14. OP27 18 01/07/06 15. 16. OP28 OP31 18 8,9 31/12/06 01/07/06 Norton Lees Lodge Version 5.1 Page 25 17. 18. OP31 OP33 9,18 24 19. OP35 16,17 20. OP36 18 21. OP38 16 22. OP38 16 23. OP38 23 24. 25. OP38 OP38 23 13 the registration of manager process to commence. The manager must be trained to NVQ level 4 or equivalent in management. Systems must be implemented and maintained to review and improve the quality of care and services at the home. Increased procedures must be put in place to ensure that residents’ financial interests are safeguarded. Formal staff supervision must occur at least six times a year. This supervision must be documented. Staff meetings must be held and minutes of these meetings must be recorded. Satisfactory standards of food hygiene must be maintained. (Previous timescale of 01/04/06 not met) Requirements made by the Environmental Health Officer during the inspection on 3rd March 2006 must be 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. A fire risk assessment must be in place at the home. Unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. (Kettle) 31/12/06 01/07/06 15/05/06 01/07/06 01/06/06 01/07/06 01/08/06 01/06/06 01/06/06 Norton Lees Lodge DS0000066121.V294377.R01.S.doc Version 5.1 Page 26 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.V294377.R01.S.doc Version 5.1 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.V294377.R01.S.doc Version 5.1 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. 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