Inspection on 04/07/06 for Norwood Grange EMI Residential Home

This inspection was carried out on 4th July 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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... 19/10/05

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 Janice Griffin Key Unannounced Inspection 4th July 2006 7:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Norwood Grange EMI Residential Home DS0000032191.V300154.R02.S.doc Version 5.2 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.V300154.R02.S.doc Version 5.2 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 none 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.V300154.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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. Maintain Staffing Levels of 431.64 care hours per week. Date of last inspection 19th October 2005 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 previous inspection report was made available to service users and their families on request. The weekly fees are: £358 this information was provided on 4th July 2006. The home charges extra for chiropody, toiletries, clothing, telephone and hairdressing. Norwood Grange EMI Residential Home DS0000032191.V300154.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place from 7:00 am to 3:00 pm. Only seven of the service users at this home could contribute to the inspection process so the inspector spent a lot of time observing the direct care offered to other service users. As part of the inspection process the inspector spoke to, seven service users, one relative, three staff, the acting manager and the area manager. The inspector would like to thank the service users, relative, the staff and the managers for their openness and for their commitment to the inspection process. The inspector was pleased to note that the service users and relative spoke positively of the ongoing support provided by the staff. Observations confirmed that service users were extremely comfortable and at ease in the company of the managers and staff who were approachable, supportive and appeared sensitive to their needs and feelings of the service users. The relative described the service as ‘superb’. A number of records were examined which included, the managers preinspection questionnaire, medication records, three service users care plans, three weeks menus and three weeks staff rotas. Records relating to staff recruitment, staff training and the homes quality assurance systems were also checked. Several areas of the building were also inspected. Since the last inspection no complaints have been made about this service. The home has a system for displaying information and bringing attention to community events and activities. Feedback on the inspection was given to the area manager and the acting manager. What the service does well: The environment is homely, friendly and welcoming. The relative said his mother was well cared for by the staff. He described the staff as being “very good” and very hard working. Service users were able to visit the home for trial periods. The manager said she considers carefully the needs assessment for each prospective service user before agreeing to their admission to the home. Service users were only admitted once it had been determined that the home could meet their needs. Clear information about contracts/terms and conditions, fees and extra charges is available in a format appropriate to each individual service user and their families. All service users attended a variety of social and leisure activities and these were based very much on the personal preferences of each individual. Feedback was being sought on a regular basis from service users families. Staff interacted well with each service user and it was obvious from discussions with the service users and relative that staff had developed positive Norwood Grange EMI Residential Home DS0000032191.V300154.R02.S.doc Version 5.2 Page 6 relationships with them. The cook was familiar with the food likes and dislikes of service users. The inspector observed the breakfast and lunch offered to service users the food provided was of good quality, well presented and a good choice of food was offered. Most of the staff team are qualified and experienced to work with the needs of service users with dementia. The acting manager has worked hard to ensure the medication systems are efficient. Documentation and discussion with three staff showed that they have had training in the specialist area of work that they work in. Records were in the main well ordered and up to date and the manager was keen to ensure that any issues found were addressed. What has improved since the last inspection? 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.V300154.R02.S.doc Version 5.2 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.V300154.R02.S.doc Version 5.2 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): 2, 3 and 6. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussion with seven service users, one relative, the acting manager and a visit to the home. No service users have moved into the home without having his or her needs assessed, this ensures that care needs can be met. Service users were able to have informal introductory visits to the home at the time of their admission. The service users confirmed that this helped them to get to know everyone at the home, which made them feel less anxious. Intermediate care is not provided at this home. EVIDENCE: Detailed full needs assessments had been completed by the referring social worker for all service users admitted to the home. Families had been involved in the assessment process as appropriate. Service users spoken to said at the time of their admission they were able to have informal introductory visits to the home and they had been provided with Norwood Grange EMI Residential Home DS0000032191.V300154.R02.S.doc Version 5.2 Page 9 a contract containing the relevant information. Records checked and discussion with one relative confirmed that service users families had been involved in decisions regarding the arrangements. An up to date contract/statement of terms and conditions had been provided to service users and signed copies were retained on individual files. These clearly detailed the fees, including any extra charges, and the services and facilities provided by the home. Norwood Grange EMI Residential Home DS0000032191.V300154.R02.S.doc Version 5.2 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 and 10. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussion with seven service users, one relative, three staff and a visit to the home. Service users were encouraged and supported by staff to make decisions. This protects the rights and well being of service users. Information in care plans was not adequate, as it did not allow the staff to have full knowledge of the service users gender choice of staff assisting with personal care needs. There was evidence in the care plans to show that the service users and their families are involved with the care planning production and the review. This allows the service users and their families to have a say in how the care needs will be met. The procedures in place to ensure the safe management of medication are not adequate. As some procedures do not protect the service users from harm. EVIDENCE: Staff were observed knocking on bedroom doors and waited to be invited in before entering. Three service users plans of care were checked. Each set out Norwood Grange EMI Residential Home DS0000032191.V300154.R02.S.doc Version 5.2 Page 11 individual service users needs and the action required and taken by staff to ensure those needs were met. Discussion with three staff identified that a range of health professionals visited the home to assist in maintaining health care needs. Service users weight was being checked on a regular basis. Ranges of aids to assist service users with mobility problems were provided; these included lifting hoists, assisted baths, walking frames and wheelchairs. Two care plans did not detail the gender of staff that they wished to support the service user with their personal care. The home has admitted one person from different cultural background and the care plan included details of the cultural preferences and expectations of the service user. Relatives have been involved with production of the care plans and the reviews. Service users who were able could retain control of their own medication, a lockable facility was provided to store such items. Records were kept of medication received, and disposed of. Medication was securely stored and well administered, however one medication recording chart had not been signed on one occasion to show whether medication had been given or not. A pharmacist had checked the home’s medication systems in March 2006, no issues of concern were noted at that visit. Norwood Grange EMI Residential Home DS0000032191.V300154.R02.S.doc Version 5.2 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 and 15. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussions with seven service users, one relative, three staff and a visit to the home. Service users had access to a range of leisure activities based on their individual choices and preferences. Service users and a relative confirmed that the routines of daily living were flexible and suited the service users individual preferences. Service users were supported with maintaining and developing contact with their family and friends, the relative spoken to said that he was always made welcome at the home. Which creates a home that people want to visit. A good choice of food was offered to service users at breakfast and lunchtime. No service users required a special diet. EVIDENCE: The aims and objectives of this home reinforced the importance of treating service users with respect. Seven service users and one relative confirmed that staff were extremely supportive and always encouraged the service users to become integrated into the local community, when they felt able to do this and with the appropriate staff support provided. Norwood Grange EMI Residential Home DS0000032191.V300154.R02.S.doc Version 5.2 Page 13 Staff confirmed that they were encouraged to support service users with discovering how to enjoy social situations and activities. The cook was familiar with the food likes and dislikes of service users. The inspector observed the breakfast and lunch offered to service users the food provided was of good quality, well presented and a good choice of food was offered. Special cutlery and crockery was provided for those service users who had difficulty using knives and forks. Norwood Grange EMI Residential Home DS0000032191.V300154.R02.S.doc Version 5.2 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 and 18. Quality in this outcome area is: good. This judgement has been made using available written evidence, discussions with seven service users, one relative, three staff and a visit to the home. The homes complaints procedure was clear, accessible and contained the necessary information. Service users were protected from abuse by the awareness of staff through training and the homes procedures. EVIDENCE: The complaints procedure was available for service users, visitors, relatives and staff. The area manager confirmed that this would be available in alternative formats and languages should this be requested. Service users and a relative spoken to said that they knew that they could complain if they were not happy about anything and that they felt able to discuss any issues or concerns that they may have with the managers and staff. They also said that the staff were always available and that they were encouraged to talk about anything that troubled them or caused them anxiety. Since the last inspection no complaints have been received at the home or to the Commission For Social Care Inspection. Staff had been made aware of the action to take in dealing with third party information. Norwood Grange EMI Residential Home DS0000032191.V300154.R02.S.doc Version 5.2 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 and 26. Quality in this outcome area is adequate. This judgement has been made after discussion with seven service users, one relative, three staff members and using available written evidence including a visit to the home. Building work to build a large extension is currently being undertaken. The environment within the home was clean providing a comfortable environment for service users. Some decoration and furniture were damaged making the home look shabby in parts. Some electrical string light cords were dirty and one refuse bin was not fitted with a lid, open packets of food were stored on the kitchen shelf. This is not hygienic. EVIDENCE: Some parts of the home had been redecorated but some areas still had damaged decoration, a bedroom cabinet was noted to be damaged, a bedroom door had come off it’s hinges. Norwood Grange EMI Residential Home DS0000032191.V300154.R02.S.doc Version 5.2 Page 16 The bedroom doors were fitted with suitable door locks and lockable facilities were provided in all bedrooms. Appropriate seating had been provided in the garden for those service users wishing to sit outdoors whenever the weather permitted. Each floor had a number of toilets and bathrooms. Assisted baths were provided for those service users with mobility problems. Toilets were easily accessible as they were close to lounge and dining areas. All the toilets had been adapted for service users with physical disabilities. Staff confirmed that they were provided with protective clothing if they needed it and that all the equipment was in good working order and that it had been serviced as required. One refuse bin, which contained used pads, was not fitted with a lid. Open packets of food were noted on the shelf in the kitchen. Norwood Grange EMI Residential Home DS0000032191.V300154.R02.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is: good. This judgement has been made after discussion with seven service users, one relative, three staff and using available evidence including a visit to the home. Care staff had a range of skills and experience, which effectively supported the service users. This will ultimately benefit the health and welfare of the service users. The homes recruitment procedures were not adequate, as they do not protect the service users from harm. The home had a training and development plan and some staff had completed a range of training relevant to their role. This allows the staff to ensure they meet the individual assessed needs of service users. Some staff still need training on caring for service users with dementia. 20 of staff have completed their NVQ level 2 training. EVIDENCE: The service users and relative said that there was always enough staff on duty. They said that the staff worked very hard and described them as “smashing”. Staff were approachable and sensitive to the needs of service users and were able to communicate effectively with each person. Three staff files were checked; the files demonstrated that a thorough recruitment processes had not been followed as required by the Care Homes Regulations. Gaps were noted in two staff’s employment history. Norwood Grange EMI Residential Home DS0000032191.V300154.R02.S.doc Version 5.2 Page 18 Staff spoken to had an understanding of the home’s fire procedures; they had received training on moving and handling, fire, food safety and infection control. Staff files checked and discussions with three staff and the manager confirmed that all staff had completed detailed induction training. 20 of the staff team were qualified to NVQ level 2. Some had received training on caring for people with dementia. Staff were being formally supervised at the frequency required to fully ensure individual staff development and the monitoring of care practices Norwood Grange EMI Residential Home DS0000032191.V300154.R02.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in these outcome areas is: adequate. This judgement has been made after discussion with the acting manager, seven service users, one relative and three staff and using available written evidence including a visit to the home. The service users, relative and three staff spoken to said the managers were approachable and very professional. The relative described the owner of the home and the managers as being ‘smashing’. The manager is not yet registered with Commission For Social Care Inspection, an application to register her as been received. The manager has not yet completed NVQ level 4 training. This could enhance her management abilities. Relatives surveys are completed twelve monthly and a newsletter is produced monthly, which ensures that the home is run in the best interest of service users. The responsible individual visits the home on a monthly basis but a written report is not produced following the visit. This poor management practice. Records were in the main up to date and well ordered to ensure the best interests of service users. The homes policies and procedures met the required standards. Norwood Grange EMI Residential Home DS0000032191.V300154.R02.S.doc Version 5.2 Page 20 A safe environment was provided in all parts of the home. This protects the health and welfare of the service users. EVIDENCE: The manager had a job description that clearly defined her roles and responsibilities and staff were aware of her role. Staff said she is committed to ensuring that the home provides a high standards of care, she completes regular internal audits on all aspects of the service provided by the home. She is to start her NVQ level 4 training later this year. Staff spoken to had an understanding of the home’s fire procedures; they had received training on moving and handling, fire, food safety and infection control. There was a quality assurance system, which sought the views of relatives. A monthly newsletter is sent to all relatives. The responsible individual visit the home on a regular basis but a report is not written following the visits. No fire exits were blocked and hazardous substances were securely stored. The manager handles money on behalf of some service users, account sheets were kept, receipts were available for all transactions. The managers audit the accounts monthly. Norwood Grange EMI Residential Home DS0000032191.V300154.R02.S.doc Version 5.2 Page 21 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 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 1 STAFFING Standard No Score 27 3 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 3 Norwood Grange EMI Residential Home DS0000032191.V300154.R02.S.doc Version 5.2 Page 22 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 OP8 Regulation 12 Requirement The care plans must detail the service users preference of the gender of staff assisting with personal care tasks. Medication charts must always be signed to show whether medication has been given or not. The areas with damaged decorations must be redecorated. This is outstanding from 01/09/05. The damaged furniture must be repaired or replaced. The dirty string light cords must be cleaned or replaced. Food stored in the kitchen must been in sealed containers. A minimum of 50 of the care staff must be trained to NVQ level 2. A thorough recruitment system must be adhered to as required by the Standards and Regulations. All staff must receive specialist training in all aspects of dementia care relevant to their role to meet the aims and DS0000032191.V300154.R02.S.doc Timescale for action 09/09/06 2. OP9 13 04/07/06 3. OP19 23 01/10/06 4. 5. 6. 7. 8. OP19 OP26 OP26 OP28 OP29 23 16 16 18 19 01/10/06 01/08/06 04/07/06 01/04/07 04/07/06 9. OP30 18 01/09/06 Norwood Grange EMI Residential Home Version 5.2 Page 23 10. 11. OP31 OP33 9 26 objectives of the home and service provided. This is outstanding from 01/09/05. The manager must have training at NVQ Level 4 in management. The responsible individual must complete a written report following his monthly visits to the home. 01/10/07 01/08/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Norwood Grange EMI Residential Home DS0000032191.V300154.R02.S.doc Version 5.2 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.V300154.R02.S.doc Version 5.2 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. 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