Inspection on 19/10/05 for Norwood Grange EMI Residential Home

This inspection was carried out on 19th October 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

Norwood Grange EMI Residential... 04/07/06

Norwood Grange EMI Residential... 04/05/05

Norwood Grange EMI Residential... 19/10/04

Norwood Grange EMI Residential... 12/05/04

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

CARE HOMES FOR OLDER PEOPLE Norwood Grange EMI Residential Home Longley Lane Sheffield South Yorkshire S5 7JD Lead Inspector Carol Ann Makin Unannounced Inspection 19th October 2005 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 Norwood Grange EMI Residential Home DS0000032191.V254905.R01.S.doc Version 5.0 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. Norwood Grange EMI Residential Home DS0000032191.V254905.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Norwood Grange EMI Residential Home Address Longley Lane Sheffield South Yorkshire S5 7JD 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) 0114 2431039 0114 2431039 Mr Baljit Kalar Mr Resham Singh, Mrs Rajinder Kalar Post Vacant Care Home 25 Category(ies) of Dementia - over 65 years of age (25) registration, with number of places Norwood Grange EMI Residential Home DS0000032191.V254905.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Maintain Staffing Levels of 431.64 care hours per week. Mrs Rajinder Kalar and Mr Resham Singh do not enter the home until their CRB enhanced checks are received by, and are acceptable to, the CSCI. 4th August 2005 Date of last inspection Brief Description of the Service: Norwood Grange is a residential care home for older people. It is registered to provide personal care and accommodation for twenty-five residents over the age of 65 years with dementia. The home is situated in a residential area of Sheffield, near to local shops, a main bus route and the Northern General Hospital. The home is privately owned and is an older stone built property with accommodation for service users on two floors. Access to the second floor is via a lift or staircase. The home has a safe enclosed garden area, which has recently been landscaped and new garden furniture has been provided. There is a car parking area to the front of the property. Norwood Grange EMI Residential Home DS0000032191.V254905.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out over a five and half hour period. Since the last inspection Sheila Hides has been appointed as the manager. Selections of records were checked and a tour of the environment of the home was carried out. The inspector observed staff interaction with residents and discussions were held with the new manager and the homes area manager. What the service does well: What has improved since the last inspection? All vacant staff posts had been filled and the necessary checks had been carried out before new staff commenced their employment. New staff were attending induction training on the day of the inspection. Resident’s appearances had improved all looked well groomed and dressed. New carpets had been fitted in the dining room and one lounge. Norwood Grange EMI Residential Home DS0000032191.V254905.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Norwood Grange EMI Residential Home DS0000032191.V254905.R01.S.doc Version 5.0 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 Norwood Grange EMI Residential Home DS0000032191.V254905.R01.S.doc Version 5.0 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. The Service User Guide is given to all relatives and a copy was seen in resident’s bedrooms so that the full information about the home is available. Not all residents received a contract detailing the homes terms and conditions before entering the home so that resident’s families do not know what the fees and charges will be. A full needs assessment is carried out for residents before admission to the home to ensure that the home can meet the needs of the resident’s fully. EVIDENCE: The manager stated that the homes updated Service User Guide is given to all relatives and a copy was seen in all resident’s bedrooms that were checked. The two residents files checked did not contain a copy of their contract giving the terms and conditions of their occupancy at the home. A full needs assessment completed before admission was included in the resident’s files. Norwood Grange EMI Residential Home DS0000032191.V254905.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. Residents care plans do not contain the information in sufficient detail to meet this standard. This could result in the staff not having the information required to meet the full needs of the residents they care for. Continuing health care is provided and health care professionals are consulted when the changing health needs of a resident deteriorates. The medication storage and administration is well managed ensuring that the health and well being of the residents is maintained. Resident’s dignity is maintained and they are treated with respect by the staff. EVIDENCE: Care plans need further development. Risk assessments are in place and had been reviewed however they were not dated. One care plan had conflicting information it was recorded that the resident’s level of dementia was deteriorating however on the review sheet it was recorded that there was no change Norwood Grange EMI Residential Home DS0000032191.V254905.R01.S.doc Version 5.0 Page 10 There was evidence that the resident and relative had been involved in the care planning. Health needs were recorded in the care plans and the input from health care professionals was recorded. The medication system was checked, secure storage is maintained and the storage cabinet was clean and tidy. Medication recording sheet were completed fully and the information for the administration of medications was clear. The inspector observed staff interaction with residents in the dining room and lounges. Residents were spoken to with respect and there was lively banter between residents and staff creating a happy atmosphere. Norwood Grange EMI Residential Home DS0000032191.V254905.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Social activities take place that are of interest to each resident this ensures that they are kept motivated and occupied through the stimulation this creates. Contacts with resident’s family are maintained for the well being of the residents. Residents are encouraged to bring their personal possessions into the home to help in maintaining their independent personal choices and comfort of having familiar things around them. Food health and hygiene standards were not maintained to ensure that the health and welfare of the residents was protected. EVIDENCE: Social activities were taking place during the inspection; the manager stated that an art session took place once a week and an art therapist was employed for this, which the residents enjoyed. The manager said contact is maintained with resident’s families where possible and there was evidence that they were involved in the plan of care. Families are encouraged to visit. Norwood Grange EMI Residential Home DS0000032191.V254905.R01.S.doc Version 5.0 Page 12 Resident’s rooms seen all contained their own personal possessions. Poor health and hygiene practices were seen in the kitchen. Open shelves were dusty, food was left out on the worktop uncovered, a tub of margarine was left open and the margarine was full of debris which looked like toast crumbs. The cook’s apron was dirty and food stored in the freezers and fridges was not dated or covered sufficiently. The cutlery container and cutlery was not clean and food debris and the lid off a tin can were on the floor. The faulty dishwasher had been replaced and there was sufficient food kept in stock. The manager stated that extra chairs had been provided so that staff could sit with the residents when they needed to give assistance with feeding. Norwood Grange EMI Residential Home DS0000032191.V254905.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18. The adult protection procedure had not been updated to include the Department of Health guidance “No Secrets”. The staff training and adult protection procedures need to be improved to ensure that more robust protection systems are in place for the residents. EVIDENCE: Not all staff had received training in adult protection. The manager said that a date had been planned for this training to take place. The adult protection procedure had not been updated to include the Department of Health guidance “No Secrets”. Norwood Grange EMI Residential Home DS0000032191.V254905.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,25,26. In the main the home is well decorated and maintained however in some areas of the home further maintenance/ refurbishment is needed for the residents so that they live in a pleasant and well maintained environment. Three bedrooms and a bathroom needed improving for the residents benefit however the communal rooms were comfortable and homely. A pleasant sitting area is provided outside for the residents to enjoy weather permitting. Aids and adaptations are provided to aid the residents with mobility problems. One rusty hoist seat requires replacing for the health and safety of the residents. Parts of the home had an unpleasant odour making it unpleasant for the residents and visitors. The home is kept warm for the resident’s comfort. Norwood Grange EMI Residential Home DS0000032191.V254905.R01.S.doc Version 5.0 Page 15 EVIDENCE: Improvements have been made to the homes environment. New carpets have been fitted in the dining room and a lounge. General repairs had been carried out and a record is kept of these and any that requires attention. The manager said that a continence programme had been introduced however two bedrooms checked had an offensive odour. One bathroom was not clean the frame around the toilet was dirty and also a bedpan stored in the bathroom. The lounges and dining room was pleasant and contained homely touches. The home is now a non-smoking home. There is a safe pleasant area outside with garden furniture for the residents to enjoy when the weather permits. Residents have access to all parts of the home, handrails are provided and the bathrooms contain hoists and toilet seat risers. One hoist seat was rusty the manager said that a new seat had been ordered. In the main the bedrooms were well decorated and contained sufficient furniture and furnishings. One bedroom checked had damaged wallpaper and a radiator was in need of cleaning. Screens are provided in shared bedrooms. The home was warm, some windows had been replaced and the windows had restrainers fitted. All radiators are fitted with guards; in one room the guard needed removing in order to clean debris from the radiator. Norwood Grange EMI Residential Home DS0000032191.V254905.R01.S.doc Version 5.0 Page 16 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 number of staff hours provided per week did meet the homes condition of registration to ensure that the resident’s needs are met. The recruitment information obtained for new staff had improved and evidence seen in staff files checked suggested that robust recruitment procedures are in place for the protection of the residents. Staff training has been arranged, which will enable them to meet the different needs of the residents at the home, but the lack of a staff development programme could mean that training needs may not be fully met. Not all staff have received mandatory training that would assist them to fulfil their roles adequately. Although the majority of the staff group are new to the home it appeared that they worked well together for the benefit of the residents. New staff receive induction training to enable them to have a sound knowledge of what is expected of them and how to care for the residents well being. EVIDENCE: Four weeks rotas were checked and staffing levels were being maintained. Due to the large turnover of staff the home falls way below the 50 expected to have an NVQ level 2 qualifications. Three staff have achieved this and the manager said that arrangements were being made for more staff to commence this training. Norwood Grange EMI Residential Home DS0000032191.V254905.R01.S.doc Version 5.0 Page 17 It is acknowledged that action is being taken to provide training for staff however more is needed to ensure that the staff have received all mandatory training that includes Adult Protection, Infection Control and Dementia Care. A staff development programme had not been produced. The new manager said that she was collating the information from staff and would be producing a programme with the information gathered. The majority of the staff working at the home had started their employment recently and it was noted that the resident’s appearances had improved. They looked well groomed and seemed far more animated that on previous inspections and the inspector congratulates the staff on this. On the day of the inspection some new staff were attending an induction training session with external training consultants. The files checked contained details of the induction that had taken place within the home. There had been improvements in the two staff files checked. The contained all relevant information that is required to know that robust recruitment practices is now in place. Norwood Grange EMI Residential Home DS0000032191.V254905.R01.S.doc Version 5.0 Page 18 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): 31,33,35,38. The overall management of the home has improved; a new manager has recently been recruited to the home. Her comments about the improvements planned indicated that she was committed to providing quality care for the residents benefit. In the last three months recruitment had taken place and all staff posts had been filled. The manager is to be congratulated; the major change of staffing could have been detrimental for the residents as it is they appeared settled with the new staff and happy. The homes quality assurance system needs implementing fully and feedback obtained from residents, relatives and visiting professionals. This will enable the process of formulating plans easier to maintain and improve the quality of care provided. Records of resident’s finances that are controlled by the home were not all available for inspection and the residents account sheets had not been audited. Norwood Grange EMI Residential Home DS0000032191.V254905.R01.S.doc Version 5.0 Page 19 The safety fire systems are maintained and no hazards substances were seen in the home ensuring residents safety. The gas systems and appliances had not had their annual checks carried out to ensure the systems are working effectively and safely. EVIDENCE: Since the last inspection a new manager has been appointed. She was clear on the improvements that was needed in the home and said she was committed to making the changes necessary for the well being of the residents. At this time she has not applied for registration with the CSCI. She said that she was in the process of completing her NVQ level 4 qualifications that would meet the registration standards. The manager said that she had started the process of giving out questionnaires but had not completed the process for the homes quality assurance system. One residents finance records was checked, a record is kept when any purchases are made on behalf of a resident. There was no evidence that the financial records of the residents had been audited. The manager said that a bank account was used that is used solely for the resident’s whose money is handled by the home however there was no information at the home of this account. Secure facilities are provided for the safe keeping of resident’s monies and valuables at the home. When the building was checked, no fire exits were blocked and doors closed into their rebates. No hazardous substances were seen insecurely stored. The previous requirement that all staff must receive updated statutory training had not been actioned. A water supply had been provided to the top floor where the manager’s office and staff accommodation was situated. The gas maintenance records indicated that they were due for servicing the previous month, the manager said that she would take action to have the annual service carried out. Norwood Grange EMI Residential Home DS0000032191.V254905.R01.S.doc Version 5.0 Page 20 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 3 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 2 2 3 2 3 X X 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 X 1 1 Norwood Grange EMI Residential Home DS0000032191.V254905.R01.S.doc Version 5.0 Page 21 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 2, 37. Regulation 5, 17. Requirement Timescale for action 01/02/06 2 7, 37, 38. 13 3 7, 37 12,15,21, 43,Sch 3 4 15, 38. 12, 16, 23, 43. 12, 16, 23, 43. 5 15, 38. Residents must receive a contract which details the terms and conditions of occupancy and fees. Discussions must take place with the placing authority of how their financial assessment process can be carried out quicker to facilitate this requirement. The previous timescale for action to be taken of 1/09/05 was not met. Residents risk assessments must 01/02/06 be reviewed and updated regularly or where needs have changed; all reviews must be signed and dated. Residents care plans must be 01/02/06 fully completed to meet the required standards these plans must show evidence of monthly review and updating. The previous timescale of 1 Feb 05 was not met. Opened food stored in freezers 01/01/06 and refrigerators must be dated. The previous timescale of 1 Feb 05 was not met. Satisfactory health and hygiene 01/12/05 standards must be maintained in DS0000032191.V254905.R01.S.doc Version 5.0 Page 22 Norwood Grange EMI Residential Home 6 18, 37. 10, 12, 13, 43. 7 18. 10, 13, 18, 43. 10, 12, 23, 43. 8 19, 26. 9 10 11 12 19, 21. 24. 26. 30. 21, 43. 23, 43. 23, 43. 10, 18, 43. 13 30. 10, 18, 43. 14 33. 10, 24, 43. 15 35. 10, 20, 23, 43. the kitchen at all times. The adult protection procedure must include the Department of Health Guidance ‘No Secrets’. The previous timescale of 1 Feb 05 was not met All staff must receive training in adult protection. The previous timescale of 1 Mar 05 was not met. The areas of the home, with offensive odours, must be thoroughly cleaned and kept clean. Carpets must be replaced if the smell cannot be eradicated. The identified rusting hoist seat in a bathroom must be renovated or replaced. The identified bedroom with damaged decorations must be redecorated. The identified radiator must be cleaned. The home must produce a staff development programme, which meets the National Training Organisation specification. The previous timescale of 1 Jan 05 was not met Staff must receive specialist training in all aspects of dementia care relevant to their role to meet the aims and objectives of the home and service provided. The previous timescale for action taken of 1 Sept 05 The quality assurance system and annual development plan must be implemented fully. The previous timescale of 1 Jan 05 was not met. Service users must have their own individual bank accounts. An independent accountant must audit Service users monies yearly. The previous timescale of DS0000032191.V254905.R01.S.doc 01/01/06 01/02/06 01/01/06 01/01/06 01/02/06 01/01/06 01/01/06 01/02/06 01/02/06 01/02/06 Norwood Grange EMI Residential Home Version 5.0 Page 23 16 17 35. 38. 10, 20, 23, 43. 10, 13, 18, 43. 18 38. 12, 23, 43. 1 Jan 05 was not met Information relating to residents finances that the home controls must be available for inspection. All staff must receive updated statutory training including infection control. The previous timescale given for action of 1 Sept 05 was not met. The gas systems must be serviced at the frequency recommended. 01/01/06 01/02/06 01/11/05 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 Refer to Standard 7 Good Practice Recommendations Information on service users accidents should be collated to identify any patterns or trends that require action taking. Norwood Grange EMI Residential Home DS0000032191.V254905.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Norwood Grange EMI Residential Home DS0000032191.V254905.R01.S.doc Version 5.0 Page 25 - 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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