Care Home: Norman Lodge

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What the care home does well People who live at the home told us , "Staff are always very helpful" "My requests are always carried out very quick" A health professional told us that care staff are able to assist when needed and that they provide good handover information about daily issues, for example, how well a person is mobilising. . People who live at the home have their needs thoroughly assessed before they come to stay. This ensures that the home can meet their needs. Visitors are encouraged and made welcome. This helps people maintain contact with family and friends. People who live at the home have regular meetings and have been able to make changes so that their needs are met. The home is very clean, homely and well maintained. The home has good access and there are wide corridors that meet the needs of people with mobility problems. Norman Lodge DS0000033549.V374875.R01.S.doc Version 5.2 Staff receive training that helps them understand and meet the needs of people they look after. What has improved since the last inspection? The service user guide has been updated and this ensure that people have a detailed guide to services provided at the home Medication practice has been reviewed and new procedures introduced to make sure that records are completely fully and people get their medication as prescribed. Menus are now displayed at each table. This helps inform people about the menu and available alternatives. Font needs changing in these 3 paragraphs Improvements have been made to decoration and furnishings which continue to promote a homely and relaxed atmosphere. What the care home could do better: .Staffing levels must be kept under review to make sure that people`s needs are not overlooked and to make sure that people`s needs are met in timely way. People who come for short stays or for permanent admission should have a contract setting out the terms and conditions of their stay. Activities for people who are not able to or do not wish to access the daycare should continue to improve so that people have access to activities to occupy their time. Care plans and risk assessments should continue to be updated to make sure that staff have access to current information allowing them to provide care in a consistent and safe way. Key inspection report CARE HOMES FOR OLDER PEOPLE Norman Lodge 1a Glenroyd Avenue, Cleckheaton Road Odsal Bradford BD6 1EX Lead Inspector Sughra Nazir Key Unannounced Inspection 7th April 2009 09:00 DS0000033549.V374875.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Norman Lodge DS0000033549.V374875.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Norman Lodge DS0000033549.V374875.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norman Lodge Address 1a Glenroyd Avenue, Cleckheaton Road Odsal Bradford BD6 1EX 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) 01274 691520 01274 675129 anne.jones@bradford.gov.uk City of Bradford Metropolitan District Council Department of Social Services Mrs Anne Jones Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35), Physical disability (2) of places Norman Lodge DS0000033549.V374875.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP, Physical disability - code PD, maximum number of places: 2. The maximum number of service users who can be accommodated is: 35 The places for PD are for service users aged 55 and over 2. 3. Date of last inspection 4th April 2007 Brief Description of the Service: Norman Lodge is a single storey, purpose built Local Authority residential and day care resource centre for older people. In addition to day care, the home provides residential care for people who require respite, rehabilitation, assessment, and long-term care. Nursing care is not provided. Day care is not regulated and therefore is not inspected. The residential part of the home functions from four different wings, with one wing dedicated to rehabilitation. Each wing has a lounge, dining and kitchen area, and specialist equipment to enable and encourage independent living is provided on the respite and rehabilitation wings. People using wheelchairs have access to the well-kept gardens and courtyards where there is outdoor seating. The home is located in the centre of a new housing estate, close to the city centre of Bradford. There is limited parking in site. Local amenities include an off license, hairdressing salon, public houses, betting shop and newsagents. Copies of previous inspection report are available at the home. The fees charged are £465.68 with additional charges for toiletries, hairdressing, daily papers and certain activities Norman Lodge DS0000033549.V374875.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This report is based on information gathered in a number of ways. • A review of the information held on the home’s file since its last inspection. •Four surveys sent back to us by people who live at the home, and one survey form received from a health professional. • An unannounced visit to the home, which lasted about six hours. This visit included a tour of the premises and talking to people who live at the home, staff and management. We also looked at menus and people’s care plans and watched staff looking after people. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: People who live at the home told us , Staff are always very helpful My requests are always carried out very quick A health professional told us that care staff are able to assist when needed and that they provide good handover information about daily issues, for example, how well a person is mobilising. . People who live at the home have their needs thoroughly assessed before they come to stay. This ensures that the home can meet their needs. Visitors are encouraged and made welcome. This helps people maintain contact with family and friends. People who live at the home have regular meetings and have been able to make changes so that their needs are met. The home is very clean, homely and well maintained. The home has good access and there are wide corridors that meet the needs of people with mobility problems. Norman Lodge DS0000033549.V374875.R01.S.doc Version 5.2 Page 6 Staff receive training that helps them understand and meet the needs of people they look after. What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Norman Lodge DS0000033549.V374875.R01.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 Norman Lodge DS0000033549.V374875.R01.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1,2. 3 and 6 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have some of the information they need to decide whether the service is right for them. By carrying out a thorough assessment the home makes sure that staff will be able to meet peoples needs. EVIDENCE: The service user guide has been updated and we saw a welcome pack that contains all the required information to guide and inform potential users of the service. At a previous inspection people who come to stay for a short while and on a permanent basis told us they did not have contracts telling them terms and conditions for their stay. We looked at two files and saw that one person had a contract signed by the placing authority and their relative. On another file we Norman Lodge DS0000033549.V374875.R01.S.doc Version 5.2 Page 9 saw that although the person was now staying on a permanent basis there was a contract only describing short-term respite stay. The manager said that this is common practice across all local authority services. We saw no evidence that people had received copies of contracts signed. We spoke to people in the respite wing and none of them could recall receiving a contract for their stay. Giving people clear information about their stay will help give them a clear understanding of the terms and conditions of their stay. The files we looked at showed detailed assessments of peoples needs are carried out before people move in. This helps the home make sure that they will be able to provide care to meet those needs. People or their relatives are always involved in the assessment process. One relative told us staff had been to assess their relative in hospital. They had been involved in the assessment staff carried out. We saw that the information in one pre-admission assessment was changed after consultation with the person. This provides good evidence of involving people in their care and is good practice. The home provides care on an intermediate or short-term basis for people making the transition from hospital to home. Files we saw show that there are assessments in place that help people build up their skills to care for themselves independently. Norman Lodge DS0000033549.V374875.R01.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care people receive is based on their individual needs. The principles of respect dignity and privacy are put into practice. Staff know how to look after people properly because they have detailed information that tells them about peoples abilities and needs. Making sure that all the information is up-to-date will help staff to deliver care in a consistent and safe way. EVIDENCE: A new care planning format was introduced approximately two years ago. Care plan files are very detailed and contain a lot of information. The filing of current details at the front of each section may help staff to make sure the care they provide is based on the most up-to-date information. We looked at two care files in depth. Each file had a core assessment and a detailed pre-admission completed by the home. Both files also had a wide Norman Lodge DS0000033549.V374875.R01.S.doc Version 5.2 Page 11 range of care plans and risk assessments to help staff identify and deliver specific care needs. Some documentation was not dated or unsigned. Although there were monthly reviews on each file many care plans had not been updated to reflect the changes that staff had noted elsewhere. We also saw that on one file an earlier care plan for personal care showed that the person needed verbal prompts for personal care and needed cream administering to lower legs. This information was missed off the reviewed care plan. This could mean peoples needs are overlooked. There was some information about peoples life histories and their likes and dislikes. This helps staff provide individualised care. We discussed plans to find out and agree changes to one persons care based on their cultural background. Discussions that have already taken place should be recorded. We saw that risk assessments were detailed. However we saw that some risk assessments were in need of updating to take account of a change in people needs for example deterioration in physical abilities or change in mental health. Risk assessments should be updated regularly and supported by care planning to make sure that people receive the care they need safely. All the files we saw had good evidence that healthcare professionals are involved in peoples care. A health professional told us that care staff are able to assist when needed and that they provide good handover information about daily issues, for example how well a person is mobilising. A relative said that staff are very good at keeping them informed and work with the family to make sure hospital appointments etc are attended. All medication records seen were accurately maintained. There are new procedures in place for carrying out weekly audits of records, checking in medication and specifying the dosage of medication given. The application of creams is not recorded on medication charts and the process of recording on daily observation records may not provide an accurate picture of how often creams are applied. We discussed a revision to this practice to ensure that peoples needs are not overlooked. People who wish to administer their own medication are encouraged to do so and they are appropriately risk assessed, which means that people can retain their independence managing their own medications safely. Any changes in peoples ability to administer their medication should be recorded. We saw that people get personal care in private and staff respect dignity when helping people move or talking to people about their care needs Norman Lodge DS0000033549.V374875.R01.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have flexible routines and have access to some activities and food that meets their needs. They are supported to keep in contact with family and friends. EVIDENCE: Staff told us about the activity plans now in place for each unit and the role of the activity coordinator. We saw that the plan was displayed on one unit. A relative told us that they felt that there should be more stimulation and more opportunities to go out. Another relative told us that they had been able to enjoy sitting in the garden and that their relative had been on trips to Skipton and to a Christmas lunch. Staff told us that they always ask people at about 11 am whether they would like to take part in activities at the day centre. We were told that there is usually space to accommodate most people in the day centre. Current staffing levels make it difficult for staff to arrange activities on the units. When asked about activities when the day centre is closed people said Norman Lodge DS0000033549.V374875.R01.S.doc Version 5.2 Page 13 There is not much going on at the weekends. You can watch a film or read a book. We all have tvs in our rooms which the service pays for. One person told us that there are always activities arranged by the home to take part in, they said I like to join in as I like company”. Staff told us about a movie night once a week and regular Saturday evening events including entertainment, themed nights where food from different cultures is served. People told us they enjoyed an alcoholic drink on Saturday nights and that it was a good night. Through fundraising staff have purchased two large tvs and a Nintendo Wii games console. The console is used mainly in the day centre and staff told us though it took some getting used to, people did have fun with it. The planned additional staffing will help the service make sure that people’s social needs are more fully met. The home enjoys good relationships with its neighbours and staff told us about neighbours helping with events. We saw that a priest was visiting someone and staff told us about monthly church services at the home. Routines are flexible and staff and people who live at the home told us that mealtimes varied to suit peoples needs and preferences. People can choose whether they sit in the dining area or their rooms to eat. Having smaller units means people enjoy their meals in a more relaxed informal atmosphere. Tables are nicely set and include a range of sauces and condiments. Portion sizes are varied. People told us that they enjoyed the shepherd pie and vegetables. They told us about changes that could be made to the menu based on their preferences or their medical condition for example diabetes. We saw that the service had been awarded 5 stars for its hygiene by an environmental health inspection. This is excellent practice and shows that the home has effective procedures and practice for food hygiene. Staff told us that the meals provision has been outsourced to a catering company. Staff told us that they will be in discussion to make sure that peoples preferences are accommodated and that there is always food available as alternatives. Norman Lodge DS0000033549.V374875.R01.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be confident that their views will be listened to and acted upon. Staff are trained to keep people safe from abuse EVIDENCE: We have received no complaints about this service since the last inspection. Information we saw at the home tells us that complaints made directly to them are responded to in a timely way. We looked at the complaints record in the home. The acknowledgement letter and response letters we saw were well written and clearly identified any remedial action. Information notices telling people how to complain are displayed around the home. There are also posters displayed to tell people what to do if they suspect abuse. We saw mental capacity assessments on two files, one for someone with language difficulties may need following up with the use of an interpreter to make sure the assessment is accurate. All staff have had some training on keeping people safe from abuse. Staff were very confident in talking about what they would do if they suspected abuse. The service seeks advice appropriately from the local adult protection unit. Norman Lodge DS0000033549.V374875.R01.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home is warm well-lit and has a friendly, homely, atmosphere. The layout and design of the home allows for small groups of people to live together in a non-institutional environment. Each unit separates into smaller groups of bedrooms with separate lounge, dining, and kitchen areas. There is no lounge on the respite unit and the dining room is small. People told us they tend to sit in the main lounge or use the day centre. The four units in the home are themed on Salts, Lister, Forster and Priestley and there are a large number of pictures displayed that depict bygone Norman Lodge DS0000033549.V374875.R01.S.doc Version 5.2 Page 16 Bradford. One relative said that the pictures were conversation points and reflected the memories of people living at the home. Corridors and lounge areas are spacious and suit the needs of people who use wheelchairs. Bedrooms are comfortable and have a range of items to make them personal to the person using them. One relative told us that they had brought in pictures to help personalise their relatives room. They also said that the room was decorated soon after their relative moved in. External access is good for people with mobility problems and there are attractive gardens for people to sit out and enjoy. A visiting health professional and a relative commented about the parking restrictions outside the home. There is some parking in the homes car park but there are restrictions in place in the surrounding residential area. The manager told us that the service had looked at increasing the car parking area but this has not been pursued. All shared areas and bedrooms we looked at were clean and smelt fresh. People told us, The home is always clean Norman Lodge has first class cleaners and all areas are very clean every day. Norman Lodge DS0000033549.V374875.R01.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive their care from well-trained staff recruited using a robust recruitment procedure. Staffing levels must be reviewed to make sure that peoples needs are met in a timely way. EVIDENCE: People told us, Staff are always very helpful They have to work hard as they are shortstaffed My requests are always carried out very quick They have been shortstaffed for a while They see to you when they can but we know it can be a while if they are seeing to someone else Staff always tell you if they are busy and cant come to help you, sometimes we look after each other because you know there are people worse off than you. A relative said, a ratio of one staff member for nine people is not enough. They need more stimulation Norman Lodge DS0000033549.V374875.R01.S.doc Version 5.2 Page 18 We saw that there was one member of care staff employed to work on each unit with an additional member of staff floating across all four units. Staff told us that they received some assistance at mealtimes from domestic staff on duty who have also had food hygiene training. On one unit the only care worker on duty was a trainee care assistant. Staff said that domestic staff and day-care staff if available provided additional support. They also told us that staff recruitment had taken place and that additional staff employed would mean there were two staff on duty on each unit during the day. The manager told us following the inspection that this situation had arisen due to sickness and leave etc and confirmed recruitment was underway, however interim measures may be needed to ensure care needs are not compromised and inexperienced staff are not left with sole responsibility for a unit. Management staff told us that the night time staffing levels are two carers on duty at the home with access to a third carer who would be working at a nearby local authority-owned dementia care home. Staffing levels should have regard for the dependency levels of people in the home. Staff told us about one person who was found to be wandering and a relative told us that their relative had been found walking on another unit. We saw that there was one person who needed the assistance of two staff with their personal care and their care plan documented this could be as often as 5 or 6 times a night. A second person has deteriorating health and often needs two people to assist. Having only two staff on duty to meet everyones needs could mean that some people do not receive their care in a timely way. People reported helping each other when they know care staff are delayed, this practice puts them and others at unnecessary risk. The service must review the staffing levels on both days and nights to make sure that people receive their care in a timely way and are not at risk. The service should have regard for the number of people who may need assistance during the night It is not appropriate for the service to rely on staff being brought in from a nearby local authority-owned dementia care home to supplement the staffing at Norman Lodge. The needs of people in the other home could mean that their third member of staff is not available to provide cover to Norman Lodge and there is a risk of peoples care needs not being met. Alternative arrangements must be put in place and confirmation of such action submitted to the Commission. Recruitment was reviewed. The organisation has a robust recruitment policy, and those documents seen confirmed that this is followed. The two staff files we looked at showed that thorough checks are being carried out on staff before they start work at the home; this is to make sure they are suitable to work with older people. Norman Lodge DS0000033549.V374875.R01.S.doc Version 5.2 Page 19 Staff training is excellent with access to a wide range of courses including; • Skills for care induction • Food hygiene • Moving and handling • Adult protection • Palliative care The home has retained its Investors in People award. This provides evidence of a strong commitment to staff training and development. We saw a training matrix displayed which highlights any training needs. Norman Lodge DS0000033549.V374875.R01.S.doc Version 5.2 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service is managed and up-to-date policies and procedures help to ensure the health and safety of staff and people living at the home. EVIDENCE: We received a self assessment from the service. This helps us to identify the progress the service is making. More information is needed to make sure we have accurate information that relates specifically to this home. Norman Lodge DS0000033549.V374875.R01.S.doc Version 5.2 Page 21 Since the last inspection, the manager has registered with the Commission and this gives people added reassurance that she has the knowledge and skills to manage the service. There is also a deputy and assistant manager in place. We saw evidence that there are clear roles and responsibilities identified and this helps with the efficient management of the service. We saw various examples of developments in place to improve the service. The management should ensure that the good outcomes experienced by people are not adversely affected by low staffing levels. The home has regular meetings with people who live at the home and uses a range of methods to check and assure people about the quality of care. A relative told us that there are regular relatives meetings and there are minutes available to confirm that monthly meeting stake place with people who use the service. People using the respite service told us that there was a meeting every Sunday teatime that discussed the same topics each time such as menus but also told people about the services in the home. They were concerned that these meetings may not continue. We saw feedback questionnaires from people. Comments from the respite unit included, I enjoyed my fortnights stay and look forward to coming again Everything was fine including staff There is an actions box for staff to identify and record any actions taken as a result of feedback. This is good practice. We discussed the home s plans for sharing the outcome of feedback with people, their families and people with an interest in the home. There are robust systems in place for handling people’s money. Two signatures are required and records are now audited weekly to highlight any discrepancies. Monthly visits the provider is required to carry out continue to be carried out by a quality visitor. These visits are required so that the provider can demonstrate that they are assuring themselves about the standard of care provided. We saw that there are now up-to-date reports on file at the home overall the standard of recording has improved but can be variable. We were told that new quality visitors are buddied up with experienced colleagues to help improve practice. In a self assessment the managers told us that all the required policies and procedures are in place. No review dates are identified and we were told that each policy and procedure was currently being reviewed to make sure it was up-to-date. The environmental checks on wiring, gas safety etc are coordinated centrally. Managers told us these were up-to-date. Norman Lodge DS0000033549.V374875.R01.S.doc Version 5.2 Page 22 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 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 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 Standard No Score 16 4 17 X 18 3 3 X X X X X x 4 STAFFING Standard No Score 27 2 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Norman Lodge DS0000033549.V374875.R01.S.doc Version 5.2 Page 23 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 OP27 Regulation 18 (1) (a) Requirement An action plan must be put in place to address low staffing levels at the home both during the day and at night. This will ensure that there are sufficient staff on duty to meet the all the needs of people using the service at all times. Timescale for action 07/06/09 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 Refer to Standard OP2 OP7 Good Practice Recommendations All people staying at the home must be provided with a written contract, which tells them the terms and conditions of residency, so that they are fully informed. Care plans should be updated so that care staff can be sure that they are providing consistent care on the basis of peoples current needs. Norman Lodge DS0000033549.V374875.R01.S.doc Version 5.2 Page 24 3 OP8 Risk assessments should be updated regularly to make sure that care is provided in a safe way Norman Lodge DS0000033549.V374875.R01.S.doc Version 5.2 Page 25 Care Quality Commission Yorkshire and Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Norman Lodge DS0000033549.V374875.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!