Review of compliance City of Bradford Metropolitan District Council Norman Lodge Region: Location address: Type of service: Yorkshire & Humberside 1a Glenroyd Avenue Odsal Bradford West Yorkshire BD6 1EX Rehabilitation services Date of Publication: October 2011 Care home service without nursing Overview of the service: Norman Lodge is a single storey, purpose built, local authority residential and day care resource centre for older people. The home provides residential care for people who require respite, rehabilitation, assessment, and longterm care. The residential home Page 1 of 20
functions from four different units, with one unit for rehabilitation. Each unit has a lounge, dining and kitchen area. Specialist equipment to enable independent living is provided on the respite and rehabilitation units. Page 2 of 20
Summary of our findings for the essential standards of quality and safety Our current overall judgement Norman Lodge was meeting all the essential standards of quality and safety but, to maintain this, we have suggested that some improvements are made. The summary below describes why we carried out this review, what we found and any action required. Why we carried out this review We carried out this review as part of our routine schedule of planned reviews. How we carried out this review We reviewed all the information we hold about this provider, carried out a visit on 7 September 2011, observed how people were being cared for, talked to staff and talked to people who use services. What people told us We spoke with three people who use the service and they told us that they were very happy with the care they receive. They told us that staff were very helpful and always explained what they were doing. One person told us that she likes to draw and also likes to have a glass of whisky each morning, which the staff normally provide for her. Two of the people who use the service told us that staff regularly speak to them about their care plans and they are kept involved in developing their care plans. The people we spoke with told us that if they had any concerns or complaints, they would speak to the manager. They also told us that staff were friendly and that they had no issues or concerns relating to staff. People told us that they felt there were enough staff around and they had never had an instance where a member of staff was unavailable to assist them. What we found about the standards we reviewed and how well Norman Lodge was meeting them Outcome 01: People should be treated with respect, involved in discussions about their care and treatment and able to influence how the service is run Page 3 of 20
People's privacy, dignity and human rights are respected and their diversity needs are understood. Staff actively consult with and involve people who use the service in developing written care plans. People are involved and listened to by staff and requests made about their care are acted upon. Overall, we found that Norman Lodge was meeting this essential standard. Outcome 04: People should get safe and appropriate care that meets their needs and supports their rights People using the service have an assessment and plan of care that meets their needs and protects their rights. Care plans are reviewed and involve all relevant staff and people using the service. Overall, we found that Norman Lodge was meeting this essential standard. Outcome 07: People should be protected from abuse and staff should respect their human rights There are processes in place to minimise and prevent abuse from occurring. The majority of staff are informed and have been trained in the requirements for safeguarding vulnerable adults as part of their induction. The provider needs to ensure that staff receive regular updates on adult safeguarding training so that staff are up to date with current guidance and legislation. Overall, we found that Norman Lodge was meeting this essential standard but, to maintain this, we have suggested that some improvements are made. Outcome 13: There should be enough members of staff to keep people safe and meet their health and welfare needs There is an assessment of the peoples' needs and the staff skills, qualifications and experience that are needed. The staffing levels and skill mix are appropriate to the needs of the people who use the service. The systems in place allow cover for staff rotas and periods of leave or absence. Overall, we found that Norman Lodge was meeting this essential standard. Outcome 16: The service should have quality checking systems to manage risks and assure the health, welfare and safety of people who receive care The provider has systems in place to identify, analyse and review risks, incidents and errors. Information about quality and safety is gathered and monitored to identify risks and areas for improvement. Overall, we found that Norman Lodge was meeting this essential standard. Actions we have asked the service to take We have asked the provider to send us a report within 28 days of them receiving this Page 4 of 20
report, setting out the action they will take to improve. We will check to make sure that the improvements have been made. Where we have concerns we have a range of enforcement powers we can use to protect the safety and welfare of people who use this service. Any regulatory decision that CQC takes is open to challenge by a registered person through a variety of internal and external appeal processes. We will publish a further report on any action we have taken. Other information Please see previous reports for more information about previous reviews. Page 5 of 20
What we found for each essential standard of quality and safety we reviewed Page 6 of 20
The following pages detail our findings and our regulatory judgement for each essential standard and outcome that we reviewed, linked to specific regulated activities where appropriate. We will have reached one of the following judgements for each essential standard. Compliant means that people who use services are experiencing the outcomes relating to the essential standard. A minor concern means that people who use services are safe but are not always experiencing the outcomes relating to this essential standard. A moderate concern means that people who use services are safe but are not always experiencing the outcomes relating to this essential standard and there is an impact on their health and wellbeing because of this. A major concern means that people who use services are not experiencing the outcomes relating to this essential standard and are not protected from unsafe or inappropriate care, treatment and support. Where we identify compliance, no further action is taken. Where we have concerns, the most appropriate action is taken to ensure that the necessary improvements are made. Where there are a number of concerns, we may look at them together to decide the level of action to take. More information about each of the outcomes can be found in the Guidance about compliance: Essential standards of quality and safety Page 7 of 20
Outcome 01: Respecting and involving people who use services What the outcome says This is what people who use services should expect. People who use services: * Understand the care, treatment and support choices available to them. * Can express their views, so far as they are able to do so, and are involved in making decisions about their care, treatment and support. * Have their privacy, dignity and independence respected. * Have their views and experiences taken into account in the way the service is provided and delivered. What we found Our judgement The provider is compliant with Outcome 01: Respecting and involving people who use services Our findings What people who use the service experienced and told us We spoke with three people who use the service and they told us that they were very happy with the care they receive. They told us that staff were very helpful and always explained what they were doing. One person told us that she likes to draw and also likes to have a glass of whisky each morning, which the staff normally provide for her. Other evidence As part of their compliance assessment, the provider told us that all staff are trained in aspects of dignity in care and equality and diversity. Staff practices are observed and discussed within staff supervisions. The provider told us that they have information about advocacy services within the home and seek advocacy support as needed in line with the Mental Capacity Act 2005. The provider told us that people who use the service or their representatives are fully involved in the planning and development of care plans. They also told us that staff are trained to complete care plans and to highlight a person centred approach in all aspects of people's lives. Page 8 of 20
Each person who uses the service is provided with a statement of purpose and a service user guide, which provide information about the services they receive. During the visit, we spoke to the manager, who told us that when a person first starts to use the service, an initial assessment is carried out at the person's home to establish their needs. Following the initial review, the care plan documents are written, based on the person's needs and preferences. The provider sends out annual quality questionnaires to people who use the service. These were last sent out in August 2011. The manager told us that people's relatives are given a separate survey questionnaire, so that their views can be sought. The survey results are currently being collated and analysed by the manager, who will present the findings as a formal report. Staff meetings and meetings with people who use the service take place on a monthly basis. We looked at minutes from recent resident's meetings, which showed that people are involved in planning meals, organising activities and things that affect the general day to day running of the home. The manager also told us that she conducts daily walk rounds and people who use the service are also able speak to the manager at any time. During the visit, we observed the care being delivered in a way that maintains the privacy, dignity and independence of people who use service. In the dining and lounge areas, we observed people who use the service being cared for by staff. We looked at three care plans. The manager told us that care plans are written and updated with the involvement of people who the service and their representatives. This was reflected in the care plan documents we looked at. The care plans we looked at also included information about people's life history, likes and dislikes. Our judgement People's privacy, dignity and human rights are respected and their diversity needs are understood. Staff actively consult with and involve people who use the service in developing written care plans. People are involved and listened to by staff and requests made about their care are acted upon. Overall, we found that Norman Lodge was meeting this essential standard. Page 9 of 20
Outcome 04: Care and welfare of people who use services What the outcome says This is what people who use services should expect. People who use services: * Experience effective, safe and appropriate care, treatment and support that meets their needs and protects their rights. What we found Our judgement The provider is compliant with Outcome 04: Care and welfare of people who use services Our findings What people who use the service experienced and told us Two people we spoke with told us that staff regularly speak to them about their care plans and they are kept involved in developing their care plans. Other evidence The home provides care for up to 35 people and is split into four residential units. There are two long term residential units, a rehabilitation unit and a respite care unit. The home also has a day centre. Each unit is similar in layout and includes people's rooms, a kitchen, dining room, lounge and a bathroom. Within two of the units, each room had en suite toilet facilities. Within the other two units, the rooms had sinks only; however, there were five toilets within each of these units for people to use. At the time of the visit, there were approximately 31 people living at the home. During the visit, we looked at three care plan files. These included details about the people who use the service, such as general practitioner (GP) and next of kin details. The care plans included information for people's personal care, continence, mobility, sight, hearing, nutritional, mental capacity and religious needs. They also contained risk assessments for medication, pressure areas, manual handling and nutritional needs. The records we looked at were generally complete and up to date. The manager told us that care plans and risk assessments are reviewed on a monthly basis to check that they are up to date. A full review of peoples' care needs is carried out every six months. This review involves the people who use the service. The provider also carries out an annual review which involves other professionals such as social workers. Page 10 of 20
The care plans and risk assessments we looked at were being reviewed on a regular basis and showed involvement from people who use the service or their representatives. There was evidence that other health care professionals are involved in people's care, for example GPs, the practice nurse, dietitians and chiropodists. We observed care being delivered in a way that generally supported people's care needs, welfare and safety. The people we saw appeared to be relaxed and well cared for. Some people were watching television in the lounge areas whilst others were involved in playing bingo. Our judgement People using the service have an assessment and plan of care that meets their needs and protects their rights. Care plans are reviewed and involve all relevant staff and people using the service. Overall, we found that Norman Lodge was meeting this essential standard. Page 11 of 20
Outcome 07: Safeguarding people who use services from abuse What the outcome says This is what people who use services should expect. People who use services: * Are protected from abuse, or the risk of abuse, and their human rights are respected and upheld. What we found Our judgement There are minor concerns with Outcome 07: Safeguarding people who use services from abuse Our findings What people who use the service experienced and told us The people we spoke with told us they had no concerns about the care they receive. They told us that if they had any concerns or complaints, they would speak to the manager. Other evidence The provider has a safeguarding adults policy which is based on the Department of Health's 'No Secrets' guidance. The manager told us that staff are given training in adult safeguarding and how to detect signs of abuse as part of their induction training. Issues relating to safeguarding are also routinely discussed with staff during staff supervisions and at staff meetings. During the visit, we spoke with two care assistants and the deputy manager. They told us that they had received safeguarding training as part of their induction and were aware of how to detect signs of abuse. They also told us that they would report any safeguarding concerns to the senior carers or the manager. The staff we spoke to told us that they were aware of the whistleblowing policy and had been given information on how to report concerns to other agencies, such as the local authority safeguarding unit. A copy of the complaints policy and a compliants leaflet was displayed on a notice board near the entrance to the home. This included information and contact details if a Page 12 of 20
person had any concerns or issues. The notice board also included contact information for the local authority safeguarding unit and the Care Quality Commission (CQC). The manager monitors staff training through a training matrix. The training matrix showed that all staff had received safeguarding training as part of their induction, however, it was unclear if staff had received any formal updates or training in adult safeguarding since their induction. Some staff had received their induction training in 2004 and 2005. The manager told us that staff have been given ad hoc training and updates since their induction but there is no formal refresher or update training in place for all staff. The manager and deputy manager had already identified that there is a need for formal refresher training in adult safeguarding and this issue had been discussed with senior management. The manager told us that staff are well informed in adult safeguarding processes through monthly staff meetings and formal staff supervisions. Staff are required to complete common induction standards (CIS) training as part of their formal supervision. These include training in adult protection. The manager alternates staff supervisions on a monthly basis so that staff undergo formal supervision one month and then CIS training the next month. Our judgement There are processes in place to minimise and prevent abuse from occurring. The majority of staff are informed and have been trained in the requirements for safeguarding vulnerable adults as part of their induction. The provider needs to ensure that staff receive regular updates on adult safeguarding training so that staff are up to date with current guidance and legislation. Overall, we found that Norman Lodge was meeting this essential standard but, to maintain this, we have suggested that some improvements are made. Page 13 of 20
Outcome 13: Staffing What the outcome says This is what people who use services should expect. People who use services: * Are safe and their health and welfare needs are met by sufficient numbers of appropriate staff. What we found Our judgement The provider is compliant with Outcome 13: Staffing Our findings What people who use the service experienced and told us The people we spoke with told us that they were generally happy with the care being provided. They also told us that staff were friendly and that they had no issues or concerns relating to staff. People told us that they felt there were enough staff around and they had never had an instance where a member of staff was unavailable to assist them. Other evidence The home is managed by the registered manager, who reports to a service manager. There is also a deputy manager and an assistant manager in place. There are four senior care assistants in place, who report to the manager and are responsible for the day to day supervision of care staff. During visit, the manager told us that the home provides care for up to 35 people. We looked at the staff rotas for the day and night shifts. The arrangements in place were for at least one senior care assistant present on all shifts along with one care assistant on the night shift, seven care assistants during the morning and five care assistants during the evening shift. There is an administrator, who also provides administrative support to a manager from another home managed by the provider. The provider has an activities coordinator in place, who also carries out hairdressing activities. There are six domestic assistants, with one based in each unit and an additional domestic assistant in the kitchen. The Page 14 of 20
domestic assistant also supports care staff during meal times. The home also has two cooks, who are employed through an external catering service. The manager told us that staffing ratios are reviewed regularly and if required increased to ensure adequate ratios to meet the needs of the people who use the service. The home uses three casual (bank) staff, who have received the same level of training as permanent staff. The casual staff are used to provide additional cover for holidays or sickness. The manager told us that they do not use agency staff. The manager confirmed that the home is adequately resourced to meet the needs of the people who use the service. Our judgement There is an assessment of the peoples' needs and the staff skills, qualifications and experience that are needed. The staffing levels and skill mix are appropriate to the needs of the people who use the service. The systems in place allow cover for staff rotas and periods of leave or absence. Overall, we found that Norman Lodge was meeting this essential standard. Page 15 of 20
Outcome 16: Assessing and monitoring the quality of service provision What the outcome says This is what people who use services should expect. People who use services: * Benefit from safe quality care, treatment and support, due to effective decision making and the management of risks to their health, welfare and safety. What we found Our judgement The provider is compliant with Outcome 16: Assessing and monitoring the quality of service provision Our findings What people who use the service experienced and told us People who use the service did not make any specific comments about this outcome. Other evidence The provider has processes in place to gather information about the safety and quality of the services provided. There are systems in place for monitoring documentation errors in care records. These records are reviewed on a monthly basis by senior care staff. The manager and deputy manager also carries out an audit of all care plan files approximately every three months. There are systems in place so that actions can be taken to address errors that have been identified. Domestic staff carry out cleaning duties in accordance with a cleaning schedule. They also complete a daily cleaning checklist form to document their activities. The work carried out by the domestic staff is reviewed on a daily basis by the senior care assistants. The manager reviews the domestic cleaning checklists on a monthly basis, including checks for cleaning activities in each of the units and the kitchen area. The manager carries out a monthly audit of the premises using a hazard identification checklist. This audit covers areas such as cleanliness, water testing, equipment maintenance, fire registers and assessments for the control of substances hazardous to health (COSHH). The manager is required to carry out an annual check of management administration, which covers information display boards, key worker system, the annual development Page 16 of 20
plan and policies and procedures. The manager also carries out regular audits of staff files, staff training, complaints, safeguarding concerns and feedback from meetings for staff or people who use the service. Records and audit results are reviewed and analysed for trends by the manager. The manager has monthly meetings with the service manager to discuss ongoing issues and to report progress on complaints, safeguarding concerns and outstanding actions raised from audits. The home is also audited on an ad hoc basis by the service manager and a corporate auditor, who look at overall compliance against the providers corporate policies. Our judgement The provider has systems in place to identify, analyse and review risks, incidents and errors. Information about quality and safety is gathered and monitored to identify risks and areas for improvement. Overall, we found that Norman Lodge was meeting this essential standard. Page 17 of 20
Action we have asked the provider to take Improvement actions The table below shows where improvements should be made so that the service provider maintains compliance with the essential standards of quality and safety. Regulated activity Regulation Outcome Accommodation for persons who require nursing or personal care Regulation 11 HSCA 2008 (Regulated Activities) Regulations 2010 Outcome 07: Safeguarding people who use services from abuse Why we have concerns: There are processes in place to minimise and prevent abuse from occurring. The majority of staff are informed and have been trained in the requirements for safeguarding vulnerable adults as part of their induction. The provider needs to ensure that staff receive regular updates on adult safeguarding training so that staff are up to date with current guidance and legislation. Overall, we found that Norman Lodge was meeting this essential standard but, to maintain this, we have suggested that some improvements are made. The provider must send CQC a report about how they are going to maintain compliance with these essential standards. This report is requested under regulation 10(3) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. The provider's report should be sent within 28 days of this report being received. CQC should be informed in writing when these improvement actions are complete. Page 18 of 20
What is a review of compliance? By law, providers of certain adult social care and health care services have a legal responsibility to make sure they are meeting essential standards of quality and safety. These are the standards everyone should be able to expect when they receive care. The Care Quality Commission (CQC) has written guidance about what people who use services should experience when providers are meeting essential standards, called Guidance about compliance: Essential standards of quality and safety. CQC licenses services if they meet essential standards and will constantly monitor whether they continue to do so. We formally review services when we receive information that is of concern and as a result decide we need to check whether a service is still meeting one or more of the essential standards. We also formally review them at least every two years to check whether a service is meeting all of the essential standards in each of their locations. Our reviews include checking all available information and intelligence we hold about a provider. We may seek further information by contacting people who use services, public representative groups and organisations such as other regulators. We may also ask for further information from the provider and carry out a visit with direct observations of care. When making our judgements about whether services are meeting essential standards, we decide whether we need to take further regulatory action. This might include discussions with the provider about how they could improve. We only use this approach where issues can be resolved quickly, easily and where there is no immediate risk of serious harm to people. Where we have concerns that providers are not meeting essential standards, or where we judge that they are not going to keep meeting them, we may also set improvement actions or compliance actions, or take enforcement action: Improvement actions: These are actions a provider should take so that they maintain continuous compliance with essential standards. Where a provider is complying with essential standards, but we are concerned that they will not be able to maintain this, we ask them to send us a report describing the improvements they will make to enable them to do so. Compliance actions: These are actions a provider must take so that they achieve compliance with the essential standards. Where a provider is not meeting the essential standards but people are not at immediate risk of serious harm, we ask them to send us a report that says what they will do to make sure they comply. We monitor the implementation of action plans in these reports and, if necessary, take further action to make sure that essential standards are met. Enforcement action: These are actions we take using the criminal and/or civil procedures in the Health and Social Care Act 2008 and relevant regulations. These enforcement powers are set out in the law and mean that we can take swift, targeted action where services are failing people. Page 19 of 20
Information for the reader Document purpose Author Audience Further copies from Copyright Review of compliance report Care Quality Commission The general public 03000 616161 / www.cqc.org.uk Copyright (2010) 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. Care Quality Commission Website www.cqc.org.uk Telephone 03000 616161 Email address Postal address enquiries@cqc.org.uk Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Page 20 of 20