Care Home: Norton Lees Hall

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What the care home does well Before moving into the home people were given information to help them make a decision about whether the home was right for them or not. Each person had a contract so they knew the terms and conditions of their stay. Assessments were carried before people moved into the home. This helped staff to make a judgement about whether they could meet people`s needs. Medicines were stored and handled safely. People were treated with respect and their right to privacy was upheld. People were encouraged and supported to maintain important personal and family relationships.People were encouraged to make choices and to have as much control over their live as possible. Complaints were taken seriously and acted upon. The procedures in place protected people from abuse. The environment was safe, clean, well maintained and comfortable. People told us. "Our rooms are very nice", "they are kept very clean it`s like home from home". There was enough trained staff to meet people`s needs. Staff were fully checked before they were employed. This made sure that people were protected from harm. People told us "the staff are always here to help we never have to wait too long before someone comes to assist us". The home has a new manager who started at the home five weeks before the inspection. People said they felt the home was run in the best interest of the people using the service. People are able to make comments about the service. There are examples of changes being made because of comments received. There are procedures in place to make sure peoples monies are looked after safely. The staff work in a way that upholds the health safety and welfare of themselves and of the people using the service. What has improved since the last inspection? NVQ training is ongoing for all staff. The home has a manager who is trained to the required standard. People`s financial records are checked regularly and signed as evidence of this. What the care home could do better: Care plans need to include more detail to cover all areas of a persons needs including risk assessments. Further improvement could be made with the activities programme and the opportunities for people to go out. Records of care given need to reflect in more detail what is detailed in the care plan. Improvement needs to be made to the preparation of meat to make sure it is tender enough for people to eat. Action needs to be taken to make sure the mealtime experience is more relaxed and dignified for people. Recommendations from the hygiene standards agency regarding the kitchen need to be complied with. CARE HOMES FOR OLDER PEOPLE Norton Lees Hall 156 Warminster Road Norton Lees Sheffield South Yorkshire S8 8PQ Lead Inspector Shirley Samuels Key Unannounced Inspection 9th April 2008 8:45 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 Norton Lees Hall DS0000065376.V361974.R01.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. Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Norton Lees Hall Address 156 Warminster Road Norton Lees Sheffield South Yorkshire S8 8PQ 0845 6027470 0114 2589731 nortonleeshall@orchardcarehomes.com www.orchardcarehomes.com Orchard Care Homes.Com Limited Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mrs Diane Lesley Whitehead Care Home 40 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (40) of places Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. A specific service user named in the application dated 13.06.06 can be admitted to the home and reside at the home provided that their care needs can be met. 17th April 2007 Date of last inspection Brief Description of the Service: Norton Lees Hall is situated in the Norton Lees area of Sheffield close to local shops, other amenities and a bus route. The building is purpose built and has two floors accommodating service users who require personal care. The home is registered for 40 places. The home has a sufficient number of baths, toilets and showers. All the bedrooms are single and have en-suite toilets. The home is accessible to people, ramps and a lift are available, and aids and adaptations are in place. The home has a pleasant enclosed garden. Car parking is available. The manager confirmed that from 17 April 2008 the weekly range of fees charged for accommodation and care varied from £327 - £535. Additional charges were made for services such as chiropody and hairdressing. The inspection report is available in the entrance to the home. Further information can be obtained by contacting the home. Norton Lees Hall DS0000065376.V361974.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 two star. This means people who use the service experience good quality outcomes. This was a key inspection carried out by Shirley Samuels on 9 April 2008 from 8:45 am - 5:45 pm In the report we make reference to “us” and “we”, when we do this we are referring to the inspector and the Commission for Social Care Inspection. The inspector sought the views of six people using the service, five staff, twelve relatives and the manager who assisted with the inspection. This visit was a key inspection and the inspector checked all the key standards. During this visit we looked at the environment, and made observations on the staff’s manner and attitude towards people. We checked samples of documents that related to peoples support, care and safety. These included three assessments and care plans, three medication records, and three staff recruitment files. The inspector looked at other information before visiting the home. This included the Annual quality assurance assessment (AQAA). The inspector would like to thank everyone for their welcome and help in this inspection. What the service does well: Before moving into the home people were given information to help them make a decision about whether the home was right for them or not. Each person had a contract so they knew the terms and conditions of their stay. Assessments were carried before people moved into the home. This helped staff to make a judgement about whether they could meet people’s needs. Medicines were stored and handled safely. People were treated with respect and their right to privacy was upheld. People were encouraged and supported to maintain important personal and family relationships. Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 6 People were encouraged to make choices and to have as much control over their live as possible. Complaints were taken seriously and acted upon. The procedures in place protected people from abuse. The environment was safe, clean, well maintained and comfortable. People told us. “Our rooms are very nice”, “they are kept very clean it’s like home from home”. There was enough trained staff to meet people’s needs. Staff were fully checked before they were employed. This made sure that people were protected from harm. People told us “the staff are always here to help we never have to wait too long before someone comes to assist us”. The home has a new manager who started at the home five weeks before the inspection. People said they felt the home was run in the best interest of the people using the service. People are able to make comments about the service. There are examples of changes being made because of comments received. There are procedures in place to make sure peoples monies are looked after safely. The staff work in a way that upholds the health safety and welfare of themselves and of the people using the service. What has improved since the last inspection? What they could do better: Care plans need to include more detail to cover all areas of a persons needs including risk assessments. Further improvement could be made with the activities programme and the opportunities for people to go out. Records of care given need to reflect in more detail what is detailed in the care plan. Improvement needs to be made to the preparation of meat to make sure it is tender enough for people to eat. Action needs to be taken to make sure the mealtime experience is more relaxed and dignified for people. Recommendations from the hygiene standards agency regarding the kitchen need to be complied with. Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 8 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 Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6. People who use the service experience good outcomes in this area. We made this judgement using a range of evidence including a visit to the service. People receive information about the home and their needs are assessed before they move into the home. The home does not provide intermediate care. EVIDENCE: In the AQAA the manager told us that assessments were carried out before admission, people were offered the opportunity to look around and that written information about the home was provided. In each of the bedrooms there was a pack of written information about the home. People told us they were given information and relatives confirmed this. This made sure that people had the information they needed to make a decision about whether the home was right for them or not. Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 10 On each file there was a contract, which detailed the fee being paid and what the fee included. This made sure that people knew the terms and conditions of their stay at the home. On each of the files we saw assessments of peoples needs this was completed by a social worker for people funded by the local authority. For people selffunding staff at the home carried out an assessment. Staff said, in the main the information detailed in the assessments reflected the person when they were admitted. Where there were gaps in the information they were usually able to obtain it quickly. This made sure that staff had the information they needed, to make a judgement about whether they could meet people’s needs. The home did not provide intermediate care. Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good outcomes in this area. We made this judgement using a range of evidence including a visit to the service. There were shortfalls in care planning and record keeping. The new manager was aware of this and had taken action to ensure these were improved. The medication system was well managed and people’s rights were upheld. EVIDENCE: In the AQAA the manager said, people had a care plan, they were registered and visited by health care professionals. There was a medication system that was overseen by the local pharmacy. She said people were treated with dignity and respect. Some people had a care plan which included an assessment of need in all the main areas. A care plan was developed in the areas were needs were identified. With details of action staff needed to take to meet peoples needs. Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 12 The details and quality of the information was not consistent in all the files. This meant that staff did not always have all the information they needed to meet people’s needs. Some relatives said they had been approached to contribute to the care plan and care plan review, others said they had not. This shows that relatives are not consistently invited to be involved in writing the care plan. The manager acknowledged that improvements were needed. Action was being taken to make sure that all care plans contained the information required. The records of care given were of a reasonable quality however some improvements could be made to make sure they reflected what was in the care plan. People’s files contained a lot of information that was out of date and no longer relevant. The set up of the files made it impractical for staff to make reference to the care plan when they were writing daily notes. There were some examples of care plans not identifying people’s needs in some areas. For example there was one person who used a motorised wheelchair. The care plan made no reference to this and there was no risk assessment in place. The records showed that people received visits from health care professionals, which included GP, dentist, chiropodist and opticians. Staff said they made observations of people and sought the appropriate help and treatment. People told us that if they were unwell the staff did not hesitate to contact the doctor. Relatives told us the staff kept them informed of any changes in the condition of the person using the service. This made sure that people’s health care needs were met. There was an incident form in a person’s file, which reported finding a ‘skin tear’. There was no reference to this in the person’s daily notes and nothing to say it had been followed up. The staff responsible for administering medication told us they had received training. Two medication rounds were observed and staff seemed competent and confident. People were appropriately supervised while taking medication. Medication was stored, administered, recorded and disposed of appropriately. There were written procedures in place to support staff. This made sure that people were protected by the procedures for dealing with medicines. People told us that sometimes the laundry took a long time to be returned. Some told us clothing had been lost. This was confirmed by some of the Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 13 relatives who added sometimes they found clothing, that belong to someone else in their relative’s wardrobe and drawers. People told us that the staff spoke to them in a proper manner. Observations were made of staff approaching people in a gentle and patient way. Staff were observed offering people choices for example, did they want a bath and when. Relatives said in the main they found the staff friendly, approachable and helpful. This made sure people were treated with respect and their rights were upheld. Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience adequate outcomes in this area. We made this judgement using a range of evidence including a visit to the service. People are encouraged to make choices and exercise control over their lives. People experience shortfalls in the provision of activities and the quality of the food. EVIDENCE: In the AQAA the manager told us the menus were balanced, nutritious and choice was available. People are actively encouraged to voice their preference about activities. There are Links with the local community and regular meetings are held with the people who use the service. People told us that activities did take place and they were able to go out on trips. Staff said craft sessions and beauty days were arranged and that entertainers were sometimes booked. There was a schedule of activities. This was not displayed and not all the events took place. Staff said they experienced some difficulties motivating some of the people. One relative commented that a trip to the coast last year Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 15 was not suitable as it required too much walking and a wheelchair was not available. There had been some improvement in the provision of activities in the last 12 months however further progress is needed. To make sure that people have the opportunity to be involved in activities of their own choice according to their own individual needs and interest. People told us they were able to keep in contact with friends and family. Relatives said they were able to visit at any reasonable time. People said they were able to choose how to spend their day. They were able to go to their room when they wished and decide when to get up and go to bed. Staff said they encouraged people to make choices by giving them information, and letting people know their options. Staff said people were given choice about, food, clothing activities etc. This showed that people were encouraged to make choices and to have as much choice over their live as possible. Some people told us they were satisfied with the food. A number of people told us that the main problem with the food was that the meat was always tough. Several relatives told us people using the service had made comment about the meat, to them when they had visited. On the day of the visit we tasted the food that was prepared for people. There was a choice of lamb or salmon layer. The meat was very thick and it was difficult to cut. Observation at lunch showed that many of the people needed help to cut the meat and found it difficult to chew. There was a phone sighted in the dining room, which was connected to the main number for all callers to the home. During lunch the phone rang several times and was extremely loud. The trolley for food waste, dirty plates and cutlery was sighted in clear view of people eating. At breakfast tea was served to people from one large teapot. This did not promote the dignity and independence of the people using the service. Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good outcomes in this area. We made this judgement using a range of evidence including a visit to the service. Complaints are taken seriously and people are protected from harm. EVIDENCE: In the AQQA the manager told us there had been 6 complaints in the last 12 months. All had been investigated within the 28 days and five had been upheld. In the last 12 months the home has had two anonymous complaints about the standard of care. These complaints raised concerns about staff attitude and lack of attention to people’s needs. One of these concerns has been passed to adult safeguarding and is ongoing. The second complaint was passed to the manager to investigate. The manager has responded to the Commission for social care inspection with her findings. The concerns could not be substantiated however some recommendations were made. Records of complaints were seen. They detailed the content of the complaint, the outcome of the investigation and the action taken. Relatives told us that in the main complaints were dealt with quickly. They added that this had Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 17 improved since the new manager had started. This shows that complaints are listened to and taken seriously. Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience good outcomes in this area. We made this judgement using a range of evidence including a visit to the service. The environment meets the needs of the people using the service. EVIDENCE: In the AQAA the manager told us the home was decorated and furnished to a high standard. People told us they were happy with their bedrooms. They said, “The rooms are comfortable, nice and clean”. The communal areas were inviting, roomy, bright and airy. All the bedrooms were single with en-suite toilets. Relatives told us that, in the main the home was clean and hygienic. Comments were made about an offensive odour in one part of the home at a Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 19 particular time of the evening. Staff agreed with this and was looking at ways to resolve the problem. Gloves and aprons were provided and staff said they had received training on infection control. Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good outcomes in this area. We made this judgement using a range of evidence including a visit to the service. There are enough trained and competent staff to meet the needs of the people using the service. EVIDENCE: In the AQAA the manager told us, Staffing levels were maintained and there was a training plan in place for staff. Staff told us in the main they felt there was enough staff on duty. There was a minimum of five care staff two on each floor and one person who, “floated” working on both floors. The staff said it could be difficult when there were 3 or 4 people ill, who needed extra care and supervision. People told us “there is always staff around”, “I never have to wait long before someone comes”, “The staff are very nice they will sit and talk to us if they have time “,” The staff are very good they are friendly”. Relatives said the staff were approachable and friendly. They commented that the staff team was consistent and the home did not use too many agency staff. This made sure that people were cared for by staff they were familiar with. Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 21 Staff said they worked well as a team. They said, people using the service had a high regard for them and showed they appreciated the support they received. The manager told us there was 18 care staff employed at the home and 13 had obtained their National vocational Qualification (NVQ) level 2 in care. This made sure that people were in safe hands. We checked three staff files they included evidence of all the recruitment checks including criminal records, references and employment history. This made sure that people were protected by the homes recruitment procedures. Staff told us they attended regular training. Recent training had included, mental health, dementia care, manual handling, health and safety fire instruction, food hygiene, first aid and infection control. This made sure that staff had the training they needed to do their job. Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience good outcomes in this area. We made this judgement using a range of evidence including a visit to the service. The home is well managed, the procedures, ensure the health safety and welfare of people using the service and the staff. EVIDENCE: There has been a new manager appointed, who had been in post five weeks at the time of this inspection. She has 13 years experience and is qualified to manage a care home. This means people live in a home that is run by a person who is suitable for the job. Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 23 People told us they knew who the manager was and were able to point her out when she came into the room. Relatives spoke positively about the manager and said she was approachable. A representative of the organisation visits the home monthly. They carry out checks on how the service is being run. As part of these checks people using the service, staff and relatives are able to comment. A report is written with action points for improvement. This made sure that the home was run in the best interest of the people using the service. People told us they were satisfied with the arrangements for the management of their finances. Three people’s financial records were checked. Records were kept of all transactions and receipts were kept. The records showed that the manager checked the procedures and any cash stored at the home. This made sure that peoples financial interest were safeguarded. Staff were seen using appropriate moving and handling techniques and confirmed they had received moving and handling training. The records showed that staff had received health and safety training including fire safety. The records showed that the Hygiene standards agency had recently visited the home. The kitchen was given a “three star good” rating. Some recommendations were made; the manager said that all the recommendation were being addressed. Staff told us they were aware of their responsibilities for themselves and the people in their care. They said, where hazards were identified they were reported and sorted out quickly. This made sure the safety and welfare of the people using the service and the staff was promoted and protected. Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 24 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 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 2 Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 Requirement The care plan must set out in detail the action, which staff need to take to meet all aspects of the personal and social care needs of the people using the service. (Previous requirement) Care plans must include risk assessments. The residents daily notes must reflect the information actually recorded in the residents care plan. (Previous requirement) Documentation must be available to show that residents and/or their relatives have been involved in the drawing up and evaluation of the residents care plan. (Previous requirement) Details of all accidents and incidents must be recorded in people’s daily notes giving details of the action taken and the outcome. Procedures must be in place to make sure peoples clothing is returned to then quickly and that DS0000065376.V361974.R01.S.doc Timescale for action 20/05/08 2 3 OP7 OP7 15 15 20/05/08 20/05/08 4 OP7 15 20/05/08 5 OP8 17 20/05/08 6 OP10 16 20/05/08 Norton Lees Hall Version 5.2 Page 26 7 8 9 10 OP15 OP15 OP26 OP38 16 12 16 16 clothing is not lost. Action must be taken to make sure that meat served to people is tender enough for them to eat. Care must be taken to make sure that mealtimes are relaxed, pleasant and dignified. The home must be free from offensive odour. All the recommendations made by the hygiene standards agency must be complied with. 20/05/08 20/05/08 20/05/08 20/05/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard OP7 OP7 OP7 OP12 Good Practice Recommendations People’s files should be checked to make sure they only contain relevant and current information. Peoples files should be organised in a way that make them practical for staff to use. Staff should receive training in care planning and report writing. The development of the activities programme should take place. Activities scheduled should actually take place. Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Norton Lees Hall DS0000065376.V361974.R01.S.doc Version 5.2 Page 28 - 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!