Inspection on 03/08/05 for Norway Lodge Nursing Home

This inspection was carried out on 3rd August 2005.

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 13/02/06

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 10 Reservoir Road Prenton, Birkenhead Wirral CH42 8LJ Lead Inspector Leila Mavropoulou Unannounced 03 August 2005 - 10:00 am 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 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 F52 F02 S20924 Norway Lodge V243912 030805 Stage 4.doc Version 1.40 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 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 (CRH) Care Home 29 Category(ies) of (OP) Old age registration, with number of places Norway Lodge F52 F02 S20924 Norway Lodge V243912 030805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 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 female who is in need of nursing care so increasing the number of beds to 29 until the 31 August 2004. Date of last inspection 17th December 2004 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 a passenger lift. 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 toile ensuite. To the rear of the property there is a secluded garden, which is used frequently by the residents. Norway Lodge F52 F02 S20924 Norway Lodge V243912 030805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection. To inform the findings of the inspection the inspector spoke to residents, staff and management of the home, inspected residents and staff files and other records and walked around the building to assess the environment. What the service does well: What has improved since the last inspection? What they could do better: All residents must have an up to date care plans and risk assessments to ensure that all staff are aware of what support and assistance the resident needs. This is necessary to promote the health and safety of the residents and continuity of care of the residents. The care plans must be reviewed regularly to ensure that shows the changing needs of the residents. The record keeping of the resident’s information could be improved to ensure staff are able to monitor the care and health needs of the residents such as various health charts e.g. weight charts, Blood Pressure. The manager must ensure that systems in place for the monitoring of residents safety are adhered to such as: checking of bed rails. Norway Lodge F52 F02 S20924 Norway Lodge V243912 030805 Stage 4.doc Version 1.40 Page 6 Formal staff supervision should be implemented to identify training needs of the staff and ensure that they are confident in carrying out their responsibilities. 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 F52 F02 S20924 Norway Lodge V243912 030805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Norway Lodge F52 F02 S20924 Norway Lodge V243912 030805 Stage 4.doc Version 1.40 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 standard(s) 1,2,3,6 Staff assesses prospective resident prior to admission to ensure that the home can provide the necessary care to the resident. EVIDENCE: The home has developed a Statement of Purpose, which describes the services and facilities provided at Norway Lodge. This should be reviewed to reflect the changes in the home since it was written. As evidenced in the home’s Statement of Purpose and inspection of resident’s files that were recently admitted to the home the staff at the care home carries out their own assessment to ensure that the home would be able to meet the assessed needs of the residents. Where possible prospective residents are invited to the home for a meal. Contracts were seen in the resident’s file inspected. However, where there has been an increase in weekly fees the resident must informed and a record kept on their file. The home does not provide intermediate care. Norway Lodge F52 F02 S20924 Norway Lodge V243912 030805 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 The recording of the care provided to residents must be improved to show how their assessed health needs are being met. EVIDENCE: Currently, the new manager is implementing a new system of recording of the resident’s information, care plans and risk assessments. The newly completed care plans and risk assessments seen are detailed and easy to follow. However, the care plans seen were not developed with the resident or their representative. The inspector observed other health professionals visiting the home during the inspection and the residents files inspected showed that their health needs were reviewed by the dietician, chiropodist, the Tissue Viability Nurse and GP. Where necessary residents are provided with pressure relieving equipment to minimise pressure ulcers from developing for a variety of reasons. These include pressure cushions, specialist beds etc. Inspection of the resident’s medication records show that the home maintains an accurate record of all medication received into the care home, administered and returned to the pharmacist. Observation of staff carrying out their duties showed that the residents are treated with respect and dignity. This was evidenced by the way staff spoke to the residents, knocking on residents door before entering, the manner in which staff assisted residents etc. This was evidence further by screens in shared bedrooms. Norway Lodge F52 F02 S20924 Norway Lodge V243912 030805 Stage 4.doc Version 1.40 Page 10 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 standard(s) 12,13,14,15 The residents exercise control over their daily routine, however the well being of the residents could be improved by reviewing existing activities programme. EVIDENCE: A tour of the building show that the residents are able to choose their daily routines such as time of getting up, where to have their meal, where to watch television as many residents have a television in their bedroom. The home has appointed an activities person to work 20 hours per week recently. Discussion with residents and staff confirmed that entertainment is brought into the home such as: singer who played and accordion recently, which the residents enjoy. The home has an unrestricted visiting policy and resident’s can choose where to see their visitors. One visitor spoken to said that they were satisfied with the care provided at Norway Lodge. Observation of resident’s bedrooms showed that some residents had brought into the home some of their own furnishings to make their bedroom more homely, eg. television, small fridge, radio/cassette, pictures and ornaments etc. Residents are able to choose where to have their meals in the home. Observation at mealtime showed that some residents had their meal in the lounge, some in their bedroom and others in the dining room. Many of the residents at Norway Lodge requires assistance at mealtimes and the staffing level are adequate to provide the necessary level of assistance at mealtimes. Norway Lodge F52 F02 S20924 Norway Lodge V243912 030805 Stage 4.doc Version 1.40 Page 11 Norway Lodge caters for residents requiring a special diet as observed during lunchtime such as: soft diet, diabetic diet etc. Norway Lodge F52 F02 S20924 Norway Lodge V243912 030805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 16,18 The residents and their families are able to raise concerns about the service provided at Norway Lodge to improve individual residents care. 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 in their induction to protect the residents from abuse. Norway Lodge F52 F02 S20924 Norway Lodge V243912 030805 Stage 4.doc Version 1.40 Page 13 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 standard(s) 19,20,22,24,26 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. There has been improvement in the tidiness in the residents’ bedroom since the last inspection as many of the items of unwanted and used furniture has been removed. Also, the 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 many of the bedrooms are worn and should be replaced. The residents are able to take into the care home their own furniture providing they satisfy current fire regulation. 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 was recently decorated and a new carpet fitted. The home has a number aids to promote the residents independence and health such as: passenger lift, grab rails, ramps, call system, various pressure Norway Lodge F52 F02 S20924 Norway Lodge V243912 030805 Stage 4.doc Version 1.40 Page 14 relieving equipment to prevent pressure ulcers from developing, assisted baths etc. The residents have easy access to all parts of the home. Observation and discussion with staff show that they are aware of the home’s policies on infection control and recently some staff had attended training on Infection Control to improve their knowledge and working practices. Norway Lodge F52 F02 S20924 Norway Lodge V243912 030805 Stage 4.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30, The staffing in the care home has improved in recent months. However, the staff records must be improved to protect the residents. EVIDENCE: Observation during the inspection showed that the staffing levels were adequate to provide the necessary support and assistance to the residents. This was evidenced at lunchtime when a number of residents required assistance at the same time. Inspection of the staffing rota and discussion with the manager highlighted that the quality of care provided to the resident could be improve within the existing staffing resources by rearranging the exiting staffing hours to reflect the level of residents activity. The home employs sufficient domestic staff to maintain the cleanliness of the building, as the building was clean and tidy throughout. The staffing records are still incomplete as identified in the last inspection. The files inspected showed that not all staff had: two written references, Criminal Records Bureau checks, job descriptions and terms and conditions of employment as required by the regulations. Norway Lodge F52 F02 S20924 Norway Lodge V243912 030805 Stage 4.doc Version 1.40 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36,37,38 Improvements have been made in the day-to-day management of the home resulting in improve staff morale and quality of care provided to the residents. EVIDENCE: The manager has been in post for approximately four months with the expectation that an application will be made to the Commission to register the manager. Discussion with staff and general overview of the running of the care home indicate that improvements have been made in a number of areas in the day-to-day running of the home such as: reduction in the use of agency workers, increase staff meetings, staff feeling happier in the work place and feeling they are able to raise any concerns with the manager. To date the home has not developed a quality assurance system to monitor and evaluate the quality of care provided at the care home. A current Public Liability Insurance certificate was displayed to protect all persons that use the service at Norway Lodge. The home has a secure place Norway Lodge F52 F02 S20924 Norway Lodge V243912 030805 Stage 4.doc Version 1.40 Page 17 for the storage of the residents, valuables and monies and accurate records are kept with receipts for all resident’s expenditure. Discussion with the manager and staff confirm that formal supervision has not been implemented. Observation of the demands on the manager’s time and the location of the office suggest that day-to-day supervision of staff is also limited. The manager is working on improving the records keeping in the care home and resident have access to their records, which are kept in a secure place. The home’s records such as: fire log book, hot water temperature, accident book, maintenance of equipment used in the care home, risk assessment of the building show that the home promote the health and safety of the residents. However, the risk assessment of the building and residents’ bedroom must be improved and carried out more frequently. The registered person must ensure that staff training in food hygiene, moving and handling, fire awareness and first aid are kept up to date. Norway Lodge F52 F02 S20924 Norway Lodge V243912 030805 Stage 4.doc Version 1.40 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 x 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 3 x 3 x 3 x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 2 3 1 3 3 1 2 2 Norway Lodge F52 F02 S20924 Norway Lodge V243912 030805 Stage 4.doc Version 1.40 Page 19 yes Are there any outstanding requirements from the last inspection? 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 1 Regulation 4 Requirement The registered person shall ensure that the home has a Statement of Purpose which includes all of the items listed in Schedule of the 1 of Care Homes Regulation 2001. The registered person shall ensure that a service user plan is developed with the service user or their representative and keep it under review. The registered peson must ensure that all necessary information is obtained as required by this regulation, prior to staff commencing employment at the care home. The registered person must ensure that staff receive the necessary training to undetake their roles and responsibilities. The registered person shall develop a quality assurance system to monitor the quality of care provided at the care home. The registered person must ensure that staff at the care home are appropriately supervised. The registered person must ensure that all records are kept Timescale for action 15th September 2005 2. 7 15 15th September 2005 15th October 2005 3. 29 19 4. 30 13 &18 15th September 2005 30th September 2005 15th October 2005 15th September Page 20 5. 33 24 6. 36 18 7. 37 17 Norway Lodge F52 F02 S20924 Norway Lodge V243912 030805 Stage 4.doc Version 1.40 8. 38 13 9. 38 13 10. 38 17 up to date and comply with the Care Homes Regulation 2001. The registered person must ensure that detailed risk assessments are carried at regular intervals for all areas of the home. The registered person must ensure that all staff training is current on moving and handling, first aid, food hygiene,infection control and fire awareness. The registered person must ensure that the recording of accident in the care home is recording in the current format as required by the Health and Safety Executive. 2005 15th September 2005 15th September 2005 25th September 2005 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 2 24 Good Practice Recommendations The registered person should inform all service users of changes in their weekly fee and keep a record on their file. The registered person should develop a planned maintenance and renewal programme to replace the bedroom furniture in the care home. Norway Lodge F52 F02 S20924 Norway Lodge V243912 030805 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection 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 F52 F02 S20924 Norway Lodge V243912 030805 Stage 4.doc Version 1.40 Page 22 - 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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