Inspection on 21/06/06 for Norway Lodge Nursing Home

This inspection was carried out on 21st June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 13/02/06

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 Julie King Key Unannounced Inspection 09:30 21 & 28th June 2006 st 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.V289033.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.V289033.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 chrisaread@btconnect.com 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.V289033.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 13th February 2006 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 service user’s 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. Accommodation 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 service user’s. Norway Lodge Nursing Home DS0000020924.V289033.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over two days during which time all staff personnel files, a selection of service user’s care files, various health & safety records and the fire book were examined. A complete tour of the premises, both internally and externally also took place. A number of service users and some staff were spoken to, and one member of the multidisciplinary healthcare team was also consulted. There were no relatives or service user’s representatives available for discussion during this inspection, but CSCI questionnaires will be sent to all representatives and relatives as part of this inspection. What the service does well: What has improved since the last inspection? What they could do better: There are many outstanding requirements from the previous inspection in February 2006. There appears to be minimal communication between key personnel within the home, including the registered provider. All aspects of recruitment and some areas of health and safety, and fire are non-compliances with previously issued requirements. As this home provides clear evidence of serious issues of concern regarding the lack of compliance, the CSCI will have little alternative but to consider using it’s statutory powers of enforcement action. Norway Lodge Nursing Home DS0000020924.V289033.R01.S.doc Version 5.1 Page 6 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.V289033.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 Norway Lodge Nursing Home DS0000020924.V289033.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): 1,2,3,4,5,6. The Home’s Statement of Purpose and Service Users Guide could not be evidenced, therefore the home cannot provide sufficient information for service users to make an informed choice regarding it’s services and facilities.. The pre-admission assessment was not evident on files examined, therefore cannot ensure that the skill mix of the workforce in the home can meet the service user’s identified care needs. EVIDENCE: The Statement of Purpose and Service User Guide were not available at Norway Lodge at the time of this unannounced inspection until the second day. This is a non compliance with regulation as both documents should be readily available for prospective and current service users at all times. Contracts were not available to see for privately paying service users, and it was not clear whether or not contracts for these service users are in place. A pre-admission assessment was shown to the inspector, but this document was on the home’s computer and not completed for any particular service user. Norway Lodge Nursing Home DS0000020924.V289033.R01.S.doc Version 5.1 Page 9 However during the second day of the inspection, completed pre-admission assessments were produced by the floor manager who had been able to access the manager’s office during the manager’s absence. All assessments seen were completed, albeit to varying degrees, and it was made a requirement for all assessments to be fully completed prior to new service users being admitted. The lack of basic information regarding the pre-admission assessment could not evidence that all needs of the service users are being met. Holistic care plans were in place, but it was not possible to ascertain how these plans were developed without the initial assessment process being completed. A lack of staff mandatory and specialist training was clearly evident- this does not assist how the home can evidence they can meet the needs of their service users. Norway Lodge Nursing Home DS0000020924.V289033.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): 7,8,9,10,11. Service user’s individual health, personal and social care needs are clearly recorded, and provides care staff the information they need to meet the service user’s care needs. Personal support in the home is offered in such a way as to promote and protect the service user’s privacy, dignity and independence. EVIDENCE: As part of this unannounced inspection, a number of service users were casetracked (i.e., followed from admission to the home in all aspects). Part of this process included examination of records, care plans and discussion of social involvement at the home. Most of the care plans and records seen were of an adequate standard, and appear to be improved from the previous inspection. All the records seen contained GP / multidisciplinary healthcare team involvement (MDT); bedrail assessments and consent; care plans based on the Roper, Logan & Tierney model of nursing care; dependency profiles; Waterlow (tissue viability) score; moving & handling, nutritional, psychological and continence assessments, and weight and general observations charts. Most care files also contained an up to date colour photograph. Norway Lodge Nursing Home DS0000020924.V289033.R01.S.doc Version 5.1 Page 11 Some of the nursing and care staff have undertaken training on tissue viability. The Primary Care Trust (PCT) tissue viability nurse (TVNS) visits the home at any time if the need arises, and was available to discuss this aspect of care during the inspection. Currently no service user in the home has a pressure sore, but one is receiving specialist care from the TVNS for an ongoing problem. All service users can access their NHS entitlements which includes dentists, opticians and chiropodist. Care staff escort service users when they have to attend clinic appointments in the local hospitals. There is a serious problem with service user’s unwanted medications. A clinical waste company is contracted to remove the drugs from the home, presently the service user’s drugs are being stored underneath the acting managers desk. The storage box contained hundreds of various pills and tablets, as did the three plastic carrier bags also being stored under the acting manager’s desk. This is very concerning, especially as this serious non-compliance was brought to the acting manager’s attention during the previous inspection in February 2006 and nothing has been done to rectify the problem. The practice of illegal medication storage must cease immediately or the Commission will consider using it’s statutory powers of enforcement to obtain compliance. On the day of the unannounced inspection, service user’s told the inspector that staff in the home were always courteous, respectful, and maintained their privacy and dignity when doing personal care. Norway Lodge Nursing Home DS0000020924.V289033.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): 12,13,14,15. Service users are encouraged to exercise choice and to have flexibility how they spend their day in the home. However, there are minimal organised activities for service users. Organised activities could allow independence, choice and individuality for each service user. Service users receive a varied nutritious diet that is in accordance with their preferences. EVIDENCE: Service users spoken to informed the inspector that the staff “tried their best to do things”, but sometimes the “days are long”. Currently there is no activities organiser at Norway Lodge, and the care staff try to accommodate the service user’s needs regarding activities when time allows. The inspector was informed that once per week an external activities person attends the home for ‘chair exercises’, which appears popular with the service users. On the first day of this unannounced inspection, a number of care staff were indirectly observed sitting with some of the service users, talking to them and interacting in a positive manner. Service users spoken to confirmed that they had a good rapport with all staff. Norway Lodge Nursing Home DS0000020924.V289033.R01.S.doc Version 5.1 Page 13 Visitors are allowed in the home at any reasonable time of day, and service users may entertain their visitors, in the communal lounges, or in their own bedroom. There was no evidence to suggest the service users maintain contact with the local community as they may wish to. The kitchens and associated records were inspected, and it was evident that the cook was in process of changing all previous records to a new, Environmental Health approved recording system. However, prior to this new system being implemented, no fridge, freezer or cooked food temperatures were being monitored and recorded on a regular basis. Menus were on a fourweekly cycle, and alternatives were shown. Specialist dietary needs, such as diabetic diets, are also catered for. Pureed meals are served with the individual vegetables and meat served separately in accordance with good practice guidelines. All service users spoken to told the inspector that they enjoyed their meals, and had surprise Birthday cakes, etc. Norway Lodge Nursing Home DS0000020924.V289033.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): 16,17,18. The complaints procedure was inaccessible, potentially leaving service users at risk. EVIDENCE: On both days of this unannounced inspection there was no complaints procedure displayed in the home, and as the Statement of Purpose was also unavailable, there appeared to be no way to access information regarding how to make a complaint. Since the previous inspection there has not been any complaints to the CSCI about this service. There is no religious or political persuasion at this home, and service users are assisted in the voting process as needed. Examination of staff personnel files could not evidence adequate training for all staff regarding the protection of vulnerable adults, however upon discussion staff were able to inform the inspector about basic procedures. Norway Lodge Nursing Home DS0000020924.V289033.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): 19,20,21,22,23,24,25,26. The staff are 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 residents are able to take into the care home their own furniture providing they satisfy current fire regulations. Norway Lodge Nursing Home DS0000020924.V289033.R01.S.doc Version 5.1 Page 16 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 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 – this was requested at the previous inspection. The main environmental findings are as follows:Outside • General waste skip overflowing and very malodorous • Numerous cardboard boxes piled up against the boundary wall to a height of approximately five foot • Many items of discarded furniture next to handyman’s shed • Gardens to the front, side and rear overgrown and untidy • Exterior wood work rotten • Kitchen fly screen torn almost completely off external door Inside • Dining room – has been repainted, but some areas of water damage clearly evident on wall and ceiling • Hoist – no safety certificate • Lift – no safety certificate • No PAT (Portable Appliance Test) – for small electrical items • General waste, rather than clinical waste or non-touch bins in toilets – this presents as an infection control hazard • Many extractor fans not working • Bedrails – no competent person to assess • Heavy items being stored above head height on wardrobes • Most wardrobes are not secured to the wall • Room 5 – final fire exit obstructed with furniture • Room 5 bathroom – full of Christmas trees (one in the bath), and numerous bags and boxes of decorations belonging to the home • Room 6 – en suite toilet has no curtains or obscured glass, so the service user has no privacy or dignity protection whatsoever • Lack of boiler maintenance records • Room 3 – Oxygen stored in room, not secured and no warning signs posted as required Norway Lodge Nursing Home DS0000020924.V289033.R01.S.doc Version 5.1 Page 17 • • • • • Laundry – no COSHH (Control of Substances Hazardous to Health) information readily available Bathroom clinical and bare – highlighted in previous inspection report No hot water temperature checks in bathrooms Sluice – no lids on clinical waste bins Medications to be returned stored under manager’s desk. It would appear that the acting manager holds no budget for the home, and monies needed for residents comfort and the smooth running of the home on a day-to-day basis is held by the handyman/administrator in the company’s Liverpool office. This arrangement seems to restrict how the acting manager purchases essentials, both for the home and basic general administration. Norway Lodge Nursing Home DS0000020924.V289033.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected 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 risk. EVIDENCE: As part of this unannounced inspection, and following the requirements issued at the previous inspection, staff personnel files were examined. All staff employed had their files checked for evidence of correct recruitment, training and development. Not one file contained a POVA, CRB or all the other supporting documentation as required. A regulation manager from CSCI was contacted immediately at the Liverpool CSCI office with a view to contacting the homes registered person about the serious breach of regulations. This was not possible as staff informed the inspectors that the registered person did not reside in this country and had no telephone number for her. The lack of administration and management of the home as regard to staff security checks is putting residents at risk and must be rectified immediately. Norway Lodge Nursing Home DS0000020924.V289033.R01.S.doc Version 5.1 Page 19 This continued non-compliance will result in the CSCI considering using it’s statutory powers of enforcement to obtain compliance. Norway Lodge Nursing Home DS0000020924.V289033.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,37,38. 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. Continued failure to comply with legal requirements reflects on the responsible persons ability to fully discharge their responsibilities, and will lead to the CSCI considering its use of its powers of enforcement EVIDENCE: The homes acting manager is a first level nurse with many years experience working in care homes, recently as a senior manager grade. The home’s handyman/administrator interviewed her and appointed her. The acting manager has applied to the commission for registration, which is currently being processed. Norway Lodge Nursing Home DS0000020924.V289033.R01.S.doc Version 5.1 Page 21 The acting manager of the home has only met the owner/registered person of the home on one occasion, in April 2006. If the registered person met with the acting manager on a regular basis, then the acting manager could receive training, supervisions and appraisals, all of which she has not received. All communications on the conduct of the home is via the handyman/administrator who holds the budget for the home. It could not be ascertained whether or not this person accurately communicated with the owner/registered person of the home on a regular basis. 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 the past few months, therefore the monthly written report on the home which is required by Regulation 26 of The Care Homes Regulations 2001, 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 and is a noncompliance with the previous inspection requirements. The inspector was very concerned to be informed that the registered person or their representative is looking after some service user’s financial accounts, and have to issue cheques on their behalf. It was unclear as to whether the person acting on behalf of the service user had applied for power of attorney, etc. It was also concerning to evidence two service users who’s money was being held by the provider had not received any cash/credit for a considerable period of time, and were overdrawn on their personal allowance record. One of the service users is having to borrow cigarettes from other service users and staff as they have no accessible funds to purchase their own. The acting manager was able to evidence requests to the registered person via the handyman/administrator for accessible money for these service users. A personal cheque apparently issued by the handyman/administrator was in the acting manager’s office – this allegedly was to cash for one of the service users who are having their finances “looked after” by the registered person or their representative. Quality assurance audits and provider visits were not evident, but staff meetings are held on a regular basis with minutes recorded. Service user meetings are still not being held despite this being requested at the last inspection. Staff supervision records are in place for some staff, not all, and are minimal in their content. Appraisals have also commenced, but were evident for some, not all staff. Norway Lodge Nursing Home DS0000020924.V289033.R01.S.doc Version 5.1 Page 22 There are a number of serious concerns regarding health and safety, most of which are non-compliances with previously issued requirements. Breaches of legislation include the lack of safety certificates for the following:• Hoists • Passenger lifts • Fire risk assessment • Staff fire training • No staff POVA’s or CRB’s All of the above breaches were identified in the previous inspection and requirements with timescales were given for compliance. None of the above have been met. This now constitutes a non-compliance, leaving the CSCI with no alternative but to consider enforcement action against the registered person. Norway Lodge Nursing Home DS0000020924.V289033.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 1 2 2 2 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 2 2 2 2 3 2 2 3 STAFFING Standard No Score 27 2 28 2 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 2 1 1 1 1 1 1 Norway Lodge Nursing Home DS0000020924.V289033.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 Requirement 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 Timescales of the 15/09/05 & 31/03/06 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 Timescales of the 15/09/05 & 31/03/06 Not Met . The registered person must ensure adequate Pre Admission Assessments are available in each service user’s care files to provide information for the formulation of care plans. Previous timescale of 31/03/06 not met. The registered person must ensure that all staff undertakes DS0000020924.V289033.R01.S.doc Timescale for action 01/08/06 2. OP1 5 01/08/06 3. OP3 14 01/08/06 4. OP4 19 01/08/06 Norway Lodge Nursing Home Version 5.1 Page 25 specialist care training to help ensure the assessed and changing care needs of the service user’s are met. Previous timescale of 31/03/06 not met. 5. OP9 13 The registered person must ensure that service user’s discarded medicines are recorded and disposed of in a safe and effective way. Previous timescale of 31/03/06 not met. The registered person must ensure that service user’s who choose to do so are engaged in organised activities of their choice, and how they participate in activities is recorded in their personal file. Previous timescale of 31/03/06 not met. The registered person must ensure that the garden area is cleared of cut down trees so avoiding and dangers to staff and service user’s. Previous timescale of 31/03/06 not met. 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 15/10/05 & 31/03/06 not met. The registered person must ensure that all newly employed staff receives induction training within six weeks of employment in the care home. DS0000020924.V289033.R01.S.doc 21/06/06 6. OP12 12 01/08/06 7. OP19 23 01/08/06 8. OP29 19 01/08/06 9. OP30 19 01/08/06 Norway Lodge Nursing Home Version 5.1 Page 26 Previous timescale of 31/03/06 not met. 10. OP32 9 The registered person must 01/08/06 ensure that the homes acting manager communicates a clear sense of direction and leadership which staff and service user’s understand and are able to relate to the aims and purpose of the home. Previous timescale of 31/03/06 not met. The registered person must ensure that regular meetings for service user’s are held in the care home so their views on the conduct of the home can be recorded. Previous timescale of 31/03/06 not met. 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. Previous timescale of 31/03/06 not met. The registered person must ensure that all care staff has documented supervision six times per year. Previous timescale of 15/10/05 & 31/03/06 not met. The registered person must ensure that all staff in the home have regular fire drills, names of participants should be recorded. Previous timescale of 31/03/06 not met. 01/08/06 11. OP33 24 12. OP33 26 01/08/06 13. OP36 19 01/08/06 14. OP38 17 01/08/06 Norway Lodge Nursing Home DS0000020924.V289033.R01.S.doc Version 5.1 Page 27 15. OP38 12 The registered person must ensure that the homes safety certificates for the lifts, hoists and fire risk assessment are up to date and valid. These certificates must be forwarded to the Liverpool/Wirral office CSCI. Previous timescale of 31/03/06 not met. 01/08/06 16. OP38 12 The registered person must 01/08/06 ensure that a service contract for hoist in the home is commenced, and that the hoists have annual inspections for their worthiness and safety. Previous timescale of 31/03/06 not met. The registered person must keep at the care home a record of the care home’s charges to service users, including any extra amounts payable for additional services not covered by these charges, and the amounts paid by or in respect of each service user. The registered person must ensure that all staff receive adequate and appropriate training in the prevention of adult abuse. The registered person must ensure that the premises to be used as the care home are kept in a good state of repair internally and externally at all times – refer to findings in main body of report. The registered person must ensure that a suitably trained and competent person checks the fitting and appropriateness of all bedrails, and records of this are kept. The registered person must ensure that the heating systems DS0000020924.V289033.R01.S.doc 17. OP2 17 (2) 01/08/06 18. OP18 13 (6) 01/09/06 19. OP19 23 01/09/06 20. OP22 18 01/08/06 21. OP25 17 23 01/09/06 Page 28 Norway Lodge Nursing Home Version 5.1 22. OP28 18 23. 24. OP31 OP31 7 8 25. OP34 25 26. OP33 24 27. OP25 20 of the care home are maintained/ and safety checked by a suitably competent person, and records of this are kept. The registered person must ensure that all staff receive suitable and adequate training, specific to the role they perform, and specific to the needs of the service users – and that records of all training are kept. A person shall not carry on a care home unless he is fit to do so. The registered provider shall, having regard to the size of the care home, the statement of purpose, and the number and needs of the service users, carry on or manage the care home with sufficient care competence and skill. The registered provider shall carry on the care home in such manner as is likely to ensure that the care home will be financially viable for the purpose of achieving the aims and objectives set out in the statement of purpose. The registered person shall establish and maintain a system for reviewing at appropriate intervals, and improving the quality of care provided at the care home, including the quality of nursing. The registered person shall not pay money belonging to any service user into a bank account unless the account is in the name of the service user, or any of the service users, to which the money belongs; and shall ensure so far as practicable that persons working at the care home do not act as the agent of a service user. DS0000020924.V289033.R01.S.doc 01/09/06 01/09/06 01/09/06 01/09/06 01/09/06 01/08/06 Norway Lodge Nursing Home Version 5.1 Page 29 28. OP37 17 The registered person must ensure that all records and documents as specified in Schedules 1,2,3 & 4, are kept up to date and accurate, and available for inspection in the care home at all times. 01/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard OP15 OP16 OP27 Good Practice Recommendations It is strongly recommended that all fridge, freezer and cooked meat temperature records are recorded on a daily basis. It is recommended that an up to date complaints procedure is clearly displayed in the main reception or hallway areas. It is recommended that an additional care assistant is on duty during the night shift. Norway Lodge Nursing Home DS0000020924.V289033.R01.S.doc Version 5.1 Page 30 Commission for Social Care Inspection Liverpool Local 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.V289033.R01.S.doc Version 5.1 Page 31 - 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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