Inspection on 13/02/06 for Norway Lodge Nursing Home

This inspection was carried out on 13th 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Norway Lodge Nursing Home 15/06/07

Norway Lodge Nursing Home 27/10/06

Norway Lodge Nursing Home 21/06/06

Norway Lodge Nursing Home 03/08/05

Norway Lodge Nursing Home 17/12/04

Norway Lodge Nursing Home 14/06/04

Similar services:

Thornton Lodge

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

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

CARE HOMES FOR OLDER PEOPLE Norway Lodge Nursing Home 10 Reservoir Road Prenton Birkenhead Wirral CH42 8LJ Lead Inspector John McCabe Unannounced Inspection 13th February 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Norway Lodge Nursing Home DS0000020924.V282305.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. Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Norway Lodge Nursing Home Address 10 Reservoir Road Prenton Birkenhead Wirral CH42 8LJ 0151 608 8164 0151 608 8164 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Elizabeth Mary Coquelin Care Home 29 Category(ies) of Old age, not falling within any other category registration, with number (29) of places Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 28 beds nursing / 10 beds personal care in an overall total of 28 1 named adult under 65 years of age within the overall total of 28 1 named service user over 50 years old, within the overall number of 29 places 3rd August 2005 Date of last inspection Brief Description of the Service: Norway Lodge is a large detached property in the Prenton area of the Wirral. It has large car parking area to the front of the property with garden benches where the residents can sit. The home provides both nursing and personal support to older people. The accommodation is provided on three floors which are easily accessible by passenger lifts. On the ground floor there is a large lounge and dining room and some bedrooms. Acccommodation is provided in both single and shared bedrooms and many of the bedrooms have a toilets ensuite. To the rear of the property there is a secluded garden, which is used frequently by the residents. Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection began at 0930 hours and took place over six hours; the acting manager of the home was present throughout the inspection. Files and documents of both residents and staff were reviewed; residents, relatives, and staff were spoken with on the conduct of the home. A full tour of the building took place, which included, gardens, bedrooms, laundry and kitchen. What the service does well: What has improved since the last inspection? The residents care plans and risk assessments have improved since the last inspection enabling care staff to have the required information to care for the residents. Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 Page 6 What they could do better: Communication. The registered person does not visit the home, the acting manager who has been in post for nine (9) months has yet to meet with her, all communication regards the conduct of the home is conveyed via the administrator/handyman who has an office in Liverpool city centre. The home must produce a Statement of Purpose and a Service users Guide to ensure all prospective residents and stakeholder share up to date information on the home. Typex must not be used to deface the Commission for Social Care Inspection (CSCI) homes registration certificate. The home Pre Admission Nursing Assessment must be revised to include details of the resident’s state of cognitive impairment to ensure the care needs of the resident are identified. The home must have organised activities for the residents, and their participation in the activities must be documented. The complaints procedures for the home should be publicly displayed and also written in to the Service Users guide. Environmentally, bathrooms, garden need attention to ensure safety of the residents and staff. No staff can be employed in the home without an Enhanced Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA) certificate, or a POVA First Certificate. Currently seven to ten staff are working in the home without the regulatory checks. This was a legal requirement in the last inspection report. All staff in the home must have documented supervision six times per year. The home must have up to date documentation on the fire safety systems, and staff must be involved in fire drills. The home appliances, boilers, gas electrics hoist and lifts must have an up to date certificate of worthiness. The homes Employers Liability Insurance Certificate is out of date. All of the above statements will be explained in the text of report together with standard and regulation. Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 Page 7 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. Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 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 Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 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): 1,2,3,4,5. The Home’s Statement of Purpose, and Service Users Guide could not be evidenced, these documents help to promote and guide that the home stays within the category of resident agreed with the commission, and prospective residents have some knowledge of the home before they decide to move in on a permanent basis. The residents’ pre-admission nursing/personal care assessment documentation is inadequate and does not ensure that the skill mix of the workforce in the home can meet the resident’s identified care needs. EVIDENCE: All residents in the home are provided with a statement of terms and conditions, plus a contract when they move in to the home on a permanent basis. Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 Page 10 The homes Statement of Purpose and Service Users Guide could not be evidenced. The acting manager told the inspector that the documents maybe in the company’s Liverpool Office. It will be a legal requirement in this inspection report for the registered person to forward copies of these documents to the CSCI Liverpool/Wirral office. Residents are able to visit the home or have an overnight stay before they move in on a permanent basis. The home’s senior nurses undertake a nursing pre admission assessment on residents before they are admitted to the home, to help ensure care needs are Identified. Other health care professionals known to the resident are also involved in the assessment. However, some of the residents who have been admitted to the home recently have confusional states and cognitive impairment. The pre admission document must be revised to includes aspects of mental health and cognitive impairment, and include memory loss, disorders of perception (hallucinations), challenging behaviours, wandering and communication pathways. This additional information may help to identify the assessed and changing care needs of the residents. Care staff in the home undertake mandatory training, which is ongoing, this includes manual handling, fire awareness, food hygiene. However it was difficult to evidence that care staff has undertaken specialist training. Special care training includes dementia, stroke, diabetes, and challenging behaviours. This training is to help to ensure that the assessed and changing care needs of the residents are met. Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 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): 7,8,9,10. Resident’s individual health, personal and social care needs are clearly recorded, and provides care staff the information they need to meet the residents care needs. Personal support in the home is offered in such a way as to promote and protect the resident’s privacy, dignity and independence. EVIDENCE: The care plans have improved since the last inspection with more details of the residents care needs All residents in the home have an individual care plan, which is formulated on admission to the home, reviewed by the senior nurses on a monthly basis. Daily health records are documented for each resident, this includes any critical incidences plus any visits from GPs, specialist nurses etc. Some of the care staff have undertaken training on tissue viability. The Primary Care Trust (PCT) tissue viability nurse will visit the home at any time if needs arise. No resident in the home has a pressure sore. Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 Page 12 All residents in the home can access their NHS entitlements; which includes, dentists, opticians, and chiropodist. Care staff will accompany residents for hospital or clinic appointments. GPs visit residents when needs arise. Care staff escort’ residents when they have to attend clinic appointments in the local hospitals. No resident in the home self medicates, all medications for residents are administered by the nurses in the home. The protocols for the receipt, storage, and documentation of medications in the home are in accordance with the National Minimum Standards (NMS). A photograph of the resident is on their individual Medicine Administration Record Sheet (MARS). The manager told the inspector that the administrator took the photographs and then removed the camera back to the Liverpool office of the company. This is not good practice, the camera should remain in the care home and only accessed by the care manager to help ensure the privacy and dignity of the resident and conform with the Data Protection Act 1998. There is a problem with resident’s unwanted medications. A clinical waste company is contracted to remove the drugs from the home, presently the residents drugs are being “popped” out of blister packs and stored underneath the acting managers desk. The storage box contained hundreds of various pills, and tablets. Staff had popped each individual tablet, at possible risk to their health as they may have inhaled or ingested particles from the drugs. The practice of popping from blister packs must stop, and two trained staff must count and sign drugs that are to be removed from the home by the clinical waste company. A signature and date of the representative from the waste company must be recorded before the drugs leave the care home. On the day of the unannounced inspection, residents told the inspector that staff in the home were always courteous, respectful, and maintained their privacy and dignity when doing personal care. Relatives confirmed these statements to the inspector Some residents have asked for same gender carers to undertake personal care with them; staff always fulfil this request. Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,1,3,14,15. Residents are encouraged to exercise choice and to have flexibility how they spend their day in the home. However, there are no organised activities for residents. Organised activities could allow independence, choice and individuality for each resident. Residents receive a varied nutritious diet that is in accordance with their preferences. EVIDENCE: On admission to the home the resident with help from a family member, should be encouraged to complete a “Getting to know you” questionnaire, which is a “Work life History” of the resident, and includes schooling, work, hobbies, food likes and dislikes etc. This information is then used to facilitate organised activities for the resident. When residents participate in organised activities, it should be recorded in the resident’s personal file. Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 Page 14 Visitors are allowed in the home at any reasonable time of day, and residents may entertain their visitors, in the communal lounges, or in their own bedroom. There was no evidence to suggest the residents maintain contact with the local community as they may wish to. The residents informed the inspector that they enjoyed the variety of food in the home, and were looking forward to Savoury Mince or Sausage Pie for their lunch; different alternatives of food were available for the residents Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18 The home has a satisfactory complaints system, with evidence that residents feel their views are being listened to and acted upon. EVIDENCE: The home has an up to date complaints procedure which staff encourage the resident and family to use if they have concerns about the service provided. The manager keeps a record of all complaints and the action taken. The home has not received any complaints since the last inspection. In addition the home has various policies and procedures which staff are made aware of. Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,2,,23,24,25,26. The registered person is making efforts to improve the quality of the physical environment of the care home to provide a more “homely” atmosphere. EVIDENCE: A tour of the building showed that the home was clean and tidy both inside and outside. The care home has two domestic staff that have been employed for many years in the home, both these ladies take pride in their work; this is reflected by the cleanliness and tidiness of the home. Painting of the corridors and staircase in a light colour has brightened the areas and make them feel less enclosed. Norway Lodge has both single and shared bedrooms. In the latter a privacy screen is provided to promote residents privacy and dignity. The furnishings in some of the bedrooms are worn and broken and should be replaced. The Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 Page 17 residents are able to take into the care home their own furniture providing they satisfy current fire regulations The two communal rooms are situated on the ground floor. Both rooms are bright and can be used for a variety of activities. The dining room has been re decorated and a new carpet fitted. The home has a number of aids to promote the residents independence and health such as: passenger lift, grab rails, ramps, call system, various pressure relieving equipment to prevent pressure ulcers from developing, assisted baths etc. The residents have easy access to all parts of the home, via ramps, stair lifts and passenger lifts. The homes communal bathrooms are drab and appear clinical, the registered person of the home should consider painting the bathrooms to give them a more “homely” appearance. During the tour of the building it was observed that the store cupboard, which contained numerous chemical products, was open, even though the door was lockable. Some of the residents have varying degrees of cognitive impairment and would not be able to realise how dangerous these chemicals are if ingested. The acting manager was able to lock the door during the inspection. The garden area contains a great deal of “Lopped Trees” which have been cut from the homes gardens. This mound of decaying wood could possibly attract vermin and should be removed. Some of the minor repairs in the care remain outstanding. The administrator is also the homes handyman. On the day of the inspection a hot water boiler was being repaired by outside contactors. Some staff had attended training on Infection Control to improve their knowledge and working practices, so to make a safer environment for the residents. During the inspection of the resident’s linens, hand and bath towels were torn and tattered, in some case threadbare. The inspector was told that staff had bought towels from the local market to try and ensure the comfort of the residents. This not acceptable and it is the responsibility of the acting manager and the registered person to purchase linens for the residents. It would appear that the acting manager holds no budget for the home, and monies needed for residents comfort is held by the administrator in the Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 Page 18 Liverpool office, this arrangement may affect how the acting manager purchases essentials for the home. Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 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): 27,28,29 30. The standard of vetting and recruitment practices is wholly inadequate with significant failings in ensuring all the required checks are undertaken. This places the residents at an unnecessary and unacceptable level of potential risk. EVIDENCE: During case tracking of the staff personal files, it was revealed that at least 710 members of staff have no up to date, valid CRB/POVA enhanced certificates or, a POVA First certificate, this includes the acting manager of the home who has been in post for nine (9) months. Staff told the inspectors that they were employed on the basis of a portable CRB/POVA, including the homes manager. Portable CRB/POVA is not allowed in the adult care sector. Other staff said they had filled in the CRB form, and the administrator still had the forms. No member of the staff had received an enhanced CRB/POVA certificate at their home address. A regulation manager from CSCI was contacted immediately at the Liverpool CSCI office in Liverpool, with a view to contacting the homes registered person, about the serious breach of regulations, this became impossible as staff informed the inspectors that the registered person did not reside in this country and had no telephone number for her. Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 Page 20 The lack of administration and management of the home as regard to staff security checks has put residents at potential risk. The Personal Identification Number (PINS) of the homes registered nurses could not be evidenced. PINS of registered nurse must obtained and recorded on Nursing Midwifery Council (NMC) stationary, and up dated at least six monthly. The home has three (3) full time vacancies for care staff; the acting manager told the inspector that she was advertising for the staff. Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 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): 31,32,33,34,35,3,6,37,38 Staff morale in the care home appears good, resulting in an enthusiastic workforce that works positively with residents to improve their whole quality of life. However, the registered person must exercise appropriate control over the checking and vetting of all staff especially in respect of the recruitment, and the requirement for CRB/POVA checks. Continued failure to comply with legal requirements reflects on the responsible persons ability to fully discharge their responsibilities and may lead to the CSCI considering its use of its powers of enforcement Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 Page 22 EVIDENCE: The homes manager is a First level Nurse with nine (9) years experiences working in care homes, lately as a senior manager grade. The homes administrator interviewed her and appointed her. The acting manager has applied to the commission for registration. The acting manager of the home has never met the owner/registered person of the home; this could be a useful meeting of the responsible persons to discuss the conduct of the home. All communications on the conduct of the home is via the administrator who holds the budget for the home. It could not be ascertained whether or not the administrator communicated with the owner/registered person of the home. It is expected that the acting manager will successfully complete her NVQ Level 4 in Home Care Management in the summer of 2006. The registered person has not visited the home for at least nine months therefore the monthly written report on the home which is required by Regulation 26 of The Care Standards Act 2000 has not been complied with. This failure to produce a monthly written report on the conduct home will be included in the legal requirements in this inspection report. It could be evidenced that staff meetings do take place in the home, but there is no evidence that residents have meetings to talk about the conduct of the home. Currently, care staff in the home do not have documented supervision six times per year, this would help to ensure that all care staff have the opportunity to discuss with the manager, and other senior nurses, any issues, which can effect or improve the care for the residents. Documented supervision of all staff gives the staff and managers opportunities to discuss their own /or identified training needs. It could not be evidenced that newly employed staff in the home have any formal/documented induction course which is necessary to help staff in understanding the policies of the home, and to be aware of POVA, Whistle Blowing, the importance of privacy and dignity and confidentiality of the residents. The home does have qualified First Aid staff on day and night duty, which can be essential for both residents’ staff if there are accidents. Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 Page 23 The certificates of insurance and worthiness for the homes gas supply, mains electrics, lift, small electrical items, fire equipments could not be evidenced. Also it was impossible to evidence whether or not the day and night staff have been involved and participated in regular fire drills. A fire equipment certificate was displayed in the managers office, it was dated the 1/1/88. The inspector has requested that the local fire safety officer visits the premises for an up to date fire risk / safety assessment of the home. No service contract could be evidenced for the homes hoists, no staff member could remember when they were last serviced and inspected for safety The homes Employers Liability Insurance Certificate is out date (December 05), and needs renewing. Both residents and staff are put at potential risk if the above are not legally complied with. Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 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 2 3 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 2 3 3 3 3 3 STAFFING Standard No Score 27 2 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 1 3 1 Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 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 OP37 Regulation 10 Requirement The registered person must ensure that Typex is not used to deface the homes CSCI Certificate of Registration, and a new certificate is applied for from the CSCI. The registered person must ensure that the home has an up to date Statement of Purpose. The document must be forwarded to the Liverpool/Wirral CSCI office. Previous Timescale of the 15/09/05 Not Met. The registered person must ensure that the Service users Guide is up dated and a copy forwarded to the Liverpool/Wirral CSCI office. Previous Timescale of the 15/09/05 Not Met. The registered person must ensure that the home Pre Admission Nursing Assessment is reviewed to include more information about resident’s mental health and cognitive impairment. The registered person must DS0000020924.V282305.R01.S.doc Timescale for action 31/03/06 2 OP1 4 31/03/06 3 OP1 5 31/03/06 4 OP3 14 31/03/06 5 OP4 19 31/03/06 Page 26 Norway Lodge Nursing Home Version 5.1 6 OP9 13 7 OP10 12 8 OP12 12 9 OP19 23 10 OP19 23 11 OP19 13 12 OP21 12 13 OP27 18 ensure that care staff undertakes specialist care training to help ensure the assessed and changing care needs of the residents are met. The registered person must ensure that residents discarded medicines are recorded and disposed of in a safe and effective way. The registered person must ensure that the homes camera used for taking facial photographs of the residents remains in the home and is used for no other purpose than clinical type pictures (e.g. pressure sores). This will help to ensure the privacy, and confidentiality of the resident. The registered person must ensure that residents who choose to do so are engaged in organised activities of their choice. How they participate in activities is recorded in their personal file. The registered person must ensure that broken bedroom furniture in resident’s rooms is repaired or replaced. The registered person must ensure that the garden area is cleared of cut down trees so avoiding and dangers to staff and residents. The registered person must ensure that the homes chemical store cupboard is locked at all times, so preventing access by residents. The registered person must ensure that resident’s hand and bath towels are replaced if they are torn and tattered. The registered person must ensure that the home has the staff and skill mix to ensure the DS0000020924.V282305.R01.S.doc 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 31/03/06 Norway Lodge Nursing Home Version 5.1 Page 27 14 OP29 19 15 OP29 19 care needs of the residents is met. The registered person must ensure that the Personal Identification Numbers (PINS) are recorded and confirmed on Nursing an, Midwifery Council (NMC) stationery at least every six months. The registered person must ensure that no staff is employed in the home without an Enhanced CRB/POVA certificate or a POVA First Certificate. Previous Timescale of the 15/10/05 Not met. The registered person must ensure that all newly employed staff receives induction training within six weeks of employment in the care home. The registered person must ensure that the homes acting manager communicates a clear sense of direction and leadership which staff and residents understand and are able to relate to the aims and purpose of the home. The registered person must ensure that regular meetings for residents are held in the care home so their views on the conduct of the home can be recorded. The registered person must ensure that a monthly written report on the conduct of the care home if forwarded to the Liverpool/Wirral office CSCI The registered person must ensure that all care staff has documented supervision six times per year. Previous Timescale of the 15/10/05 Not Met. 31/03/06 28/02/06 16 OP30 19 31/03/06 17 OP32 9 31/03/06 18 OP33 24 31/03/06 19 OP33 26 31/03/06 20 OP36 19 31/03/06 Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 Page 28 21 OP38 17 22 OP38 12 23 OP38 12 24 OP38 23 The registered person must ensure that all staff in the home have regular fire drills, names of participants should be recorded The registered person must ensure that the homes certificates of insurance and worthiness for, gas, electric supply, lifts hoists, fire-fighting equipment is up to date and valid. These certificates must be forwarded to the Liverpool/Wirral office CSCI The registered person must ensure that a Service Contract for Hoist in the home is commenced, and that the hoists have annual inspections for their worthiness and safety The registered person must ensure that the homes Employer Liability Insurance Certificate is in date and valid. 31/03/06 31/03/06 31/03/06 31/03/06 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 Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 Page 29 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Norway Lodge Nursing Home DS0000020924.V282305.R01.S.doc Version 5.1 Page 30 - 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!