Archived: Norton Lees Hall

Updated 23 November 2016

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

This inspection took place on 17 October 2016 and was unannounced.

The inspection was carried out by two adult social care inspectors and an expert by experience.

An expert-by-experience is a person who has personal experience of using or caring for someone who uses this type of care service. The expert by experience had knowledge of the care of older people and people living with dementia.

Before the inspection, the provider completed a Provider Information Return (PIR). This is a form that asks the provider to give some key information about the service, what the service does well and improvements they plan to make.

We reviewed the information we held about the home which included statutory notifications of notifiable events. A notification is the action that a registered provider is legally bound to take to tell us about any changes to their regulated services or incidents that have taken place in them. We sought feedback from the local authority which commissions services from the home.

During the inspection we spoke with six people who lived at the home, four relatives who were visiting, a district nurse, six members of staff, the manager, the care manager and a senior carer. We observed interactions between staff and people in the home throughout the day, including during activities and at lunch time.

We reviewed the care records of four people, three staff recruitment and training files, medication records and records which related to the processes in the home and the monitoring of the quality and safety of the care being delivered.

Updated 23 November 2016

This was an unannounced inspection took place on 17 October 2016. The home was last inspected in January 2014 and was found to be fully compliant at that time.

Norton Lees Hall is a 40 bedded care home which offers accommodation over two floors for older people and people living with dementia. The home is run by Orchard Care Homes Ltd. It is located in the Norton Lees area of Sheffield close to local amenities and local transport links.

There was no registered manager in place at the time of the inspection; however there was a manager in place who was planning to register to manage the service. A registered manager is a person who has registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Staff had undertaken safeguarding training and were able to demonstrate their knowledge and understanding of how to protect people from harm.

There were risk assessments in place which related to all aspects of people’s needs; however some of these did not identify specific risks and show the measures needed to minimise the risks.

There was sufficient staff to meet people’s needs, other than at lunchtime on the first floor, where there were people who had to wait a significant time for assistance. People had access to a choice of food and drink throughout the day.

The management of medicines was safe and records were well-maintained.

The home was not clean in some areas and there were malodours present in some places.

Staff received all mandatory training and this was regularly refreshed. Staff received supervisions and appraisals.

Mental capacity assessments were not completed correctly and were contradictory to other information about people, which included the applications made for Deprivation of Liberty Safeguards.

Staff were kind, caring and patient and have positive relationships with the people they supported.

People’s dignity was not always protected as people were not asked if they wished to be assisted to the toilet, and people were not always given their own clothes to wear.

Care plans were detailed and person centred, and regularly reviewed, however there was no evidence people were involved in the creation and review of their care plans.

There was a programme of varied activities which we observed people to enjoy, however some people were at risk of social isolation as they remained in their rooms.

Staff felt supported by the management team; however feedback from relatives was that there had been a lack of consistent management in the home for a long period.

Monitoring processes whilst extensive were not consistently carried out and were not effective in identifying issues and ensuring action was taken to achieve the necessary improvement.

Records were not always of an acceptable standard as they lacked detail and did not achieve their purpose because of this.

The provider was not meeting the requirements of five regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. You can see what action we told the provider to take at the back of the full version of the report.