Inspection on 25/08/04 for Bywater Lodge

Care Home For Older PeopleBywater Lodge1 Leeds Road Allerton Bywater Wakefield West Yorkshire WF10 2DYUnannounced Inspection25th August 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Bywater Lodge Address 1 Leeds Road, Allerton Bywater, Wakefield, West Yorkshire, WF10 2DY Email address Name of registered provider(s)/company (if applicable) Tri-Care Limited Name of registered manager (if applicable) Janet Richards Type of registration Care Home No. of places registered (if applicable) 20 Tel No: 01977 66 79 79 Fax No: 01977 667879Category(ies) of registration, with (number of places) Dementia - over 65 years of age (20) Registration number B080000572 Date first registered 10th July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 21st May 2003 YES NO 15.03.04 If Yes refer to Part CBywater LodgePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 325th August 2004 10:00 am Kathleen FirthID Code156796Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMrs. Janet Richards - managerBywater LodgePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementBywater LodgePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Bywater Lodge. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Bywater LodgePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. Bywater Lodge is situated between Castleford and Garforth. It is a purpose built home providing care for 20 older people with mild to moderate dementia. The home does not provide nursing care but does have access to the local District nursing team where there is a need identified. All accommodation is in single rooms with ensuite facilities on two floors. The upper floor is accessed via a passenger lift or staircase. There is a television and telephone point in all bedrooms. All the bedrooms are decorated and furnished to a high standard. Meals are provided from a central kitchen with residents making their own choice at mealtimes. The home has a modern in-house laundry service, fully equipped hairdressing salon and hydrotherapy baths.Bywater LodgePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) This was an unannounced inspection and the manager Janet Richards was available throughout. The inspection focused on the requirements and recommendations identified during the previous inspection along with the standards not addressed at that time. The manager has addressed the recommendations and requirements issued at the last inspection, which are under her control, and has informed her managers of the others. As yet the home owners have not produced a service user guide in the format suggested at the last inspection. A recommendation regarding the open stairwell was made at the last inspection but has not been acted upon. There have been no accidents due to the staircase and pressure pads are in place to alert staff to the fact that service users are at the top/bottom of the staircase. The manager still has not been given any more time to carry out managerial duties but she is enrolled on a Degree course -- Management in Dementia Care due to start in September. No further work has been carried out in the garden area as there is building work being done at this time. Choice of Home (Standards 1-6) 2 of the 3 Standards assessed were met, 1 Standard was almost met and 1 standard did not apply A Statement of Purpose is available to all service users although it is not specific to this particular home and is the one issued by the head office. Evidence was seen of contracts on individual service users files which contained the terms and conditions of the home. Prospective service users visit the home prior to their admission wherever possible and are initially admitted for six weeks. A review is held following the six weeks and a decision made about the placement becoming permanent. A copy of this review is held on each individual file. There are no emergency admissions to the home. Health and Personal Care (Standards 7-11) 2 of the 2 Standards assessed were met All bedrooms have en suite toilet and washbasin with specialised bathing facilities being available in the home. Service users tend to use their own rooms if they want privacy when speaking to visitors. Following a bereavement, relatives are allowed reasonable time before they are expected to remove belongings from a room. The wishes of a service user regarding arrangements following their death are recorded on file. Religious ministers are welcomed into the home if that is the wish of the service user. Daily Life and Social Activities (Standards 12 ­15) The one Standard assessed was met The lunchtime meal was well presented and nutritious. Service users were observed to make their own choice of meal and receive the amount of support they required to eat and enjoy this. Bywater Lodge Page 6 Complaints and Protection (Standards 16 ­ 18) The one Standard assessed was met The use of the postal voting system is made available and service users are encouraged to make use of this. Environment (Standards 19-- 26) 4 of the 4 Standards assessed were met All bedrooms are for single use having en suite facilities, which are of a size to enable easy access and use including space for wheelchairs and walking aids. Assisted bathing facilities are available within the home in several locations. The home was well decorated and furnished throughout with adequate lighting and ventilation. Service users bring their own belongings with them if they so choose. Bedrooms are kept locked during the day and where appropriate service users have their own key, otherwise staff take responsibility for giving access. Hallways and stairs were clear and nothing was observed which could present danger to the service users. Water supplies were at the correct temperature. Staffing (Standards 27--30) The one standard assessed was met There is a robust recruitment policy in place with appropriate references and CRB checks carried out prior to staff starting work at the home. Management and Administration (Standards 31--38) 2 of the 2 Standards assessed were met The manager is involved in the day to day care of the service users and demonstrated her knowledge of their individual needs. Staff members spoken to during the inspection felt that she offered them good support and was always available/willing to discuss issues of concern with them either individually or as a group. Service users receive an annual questionnaire about quality assurance but it was felt that relatives tend to complete these on their behalf. These are then sent to head office who provide feedback. The feedback seen during the inspection was not presented in a meaningful way and did not appear to be of much use. The manager said that any negative feedback is dealt with on an immediate basis and in an appropriate way. Staff are also involved in an annual questionnaire but no feedback was seen. Monthly visits are made to the home by the Area manager and issues of concern are generally raised and dealt with at this time.Bywater LodgePage 7 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for action 1 25 OP34 The accounts of the home must be made available for inspection For the next annual inspection24,5,6OP1The statement of purpose and function must be more specific to reflect the specialist nature of the home. This and the service user guide must be in a format suitable for the service user groupAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Bywater LodgePage 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for action 1 25 OP34 The accounts of the home must be made available for inspection The statement of Purpose must be specific to the home and needs to reflect the specialist nature of the services provided. This and the service user guide must be in a format suitable for the user group. For the next annual inspection24,5,6OP101.01.05RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard ** Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Bywater LodgePage 9 PART BINSPECTION METHODS & FINDINGSYES YES NO YES YES YES NO NO YES NO YES NO YES YES YES NO NO YES YES YES 3 0 0 NO NO YES YES 18 X 25/08/04 09.30 3.5The following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)Bywater LodgePage 10 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Bywater LodgePage 11 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) X To (£) XAny charges for extrasNOIf yes, please state what the extras are: 2 Key findings/Evidence Standard met? There is a Statement of purpose available for all service users but it is a general one produced by the company who owns the home and is not specific to this particular home. Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 3 Key findings/Evidence Standard met? Individual contracts are kept on the service users files and these contain the terms and conditions of the home.Bywater LodgePage 12 Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspectionStandard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 3 Key findings/Evidence Standard met? Prospective service users visit the home prior to admission and the manager completes a pre-admission form at this time. Initially everyone is admitted for six weeks at the end of which a review is held. The service user, family, social worker and someone from the home attend these reviews. Records are then kept on the service users file. There are no emergency admissions to the home. Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short term intensive rehabilitation and enable service users to return home. 0 Key findings/Evidence Standard met? The home does not provide intermediate care.Bywater LodgePage 13 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 0 Key findings/Evidence Standard met? Not assessed at this inspection Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) Key findings/Evidence This standard was not assessed at this inspection X X Standard met?0Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 0 Key findings/Evidence Standard Met? This standard was not assessed at this inspectionBywater LodgePage 14 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? All bedrooms have en suite facilities and are big enough to allow the use of walking frames. Specialises bathing facilities are available within the home. Service users use their own room if they wish to meet with someone privately. Relatives are allowed time following a bereavement before they are expected to empty the bedroom of their relative.Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? Service users wished regarding arrangements following their death are recorded on their file. Religious ministers are welcome to visit service users if this is their choice.Bywater LodgePage 15 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? The meal being served at lunchtime was well presented and was nutritious. Service users were observed making their own choice and amount of food on offer. Staff were seen to be offering support to service users who required it and there was use of plate guards to enable people to be independent whilst eating.Bywater LodgePage 16 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence This standard was not assessed at this inspection X X X X X X X 0Standard met?Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? Postal voting is available and service users are actively encouraged to make use of this.Bywater LodgePage 17 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence This standard was not assessed at this inspection Standard met? YES X0Bywater LodgePage 18 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspectionStandard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? All bedrooms have en suite facilities for washing and toilet need. There are assisted bathing facilities in the home.Bywater LodgePage 19 Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection. Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite YES NO NO 20 20 X X420 XX X X XKey findings/Evidence Standard met? All bedrooms are of a good size and have en suite facilitiesBywater LodgePage 20 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? There are two lounge areas within the home which are well furnished and comfortable. The bedrooms are all furnished and decorated to a high standard. Service users are allowed to bring their own personal things when they come to live at the home. Bedrooms are kept locked during the day with service users or relatives permission but this does not prevent people going into their room if they so wish. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? The building was very clean and bright. Windows were open to allow free flow of air throughout the home. The hallways and corridors were free of clutter and there was sufficient lighting in all areas. Water supplies were found to be at the correct temperature. Nothing was observed which could present danger to the service users.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection.Bywater LodgePage 21 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X X0 X X Standard met?0Key findings/Evidence This standard was not assessed at this inspectionBywater LodgePage 22 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence This standard was not assessed at this inspection X X Standard met? 0Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? There is a robust recruitment system in place. Following a successful interview, two written references are requested (One being from the last employer) and CRB checks are carried out before a person is allowed to start working. Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspectionBywater LodgePage 23 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspectionStandard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 3 Key findings/Evidence Standard met? The manager works with the service users on a daily basis and is very involved in their care. She appeared to know all the service users very well and interacted with them in a totally appropriate manner. The staff members spoken to all spoke highly of her and felt she was most supportive. Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 3 Key findings/Evidence Standard met? Service users receive a questionnaire on an annual basis although the manager felt that their relatives often completed them. The questionnaires go to the head office where they are collated and the results sent back to the home. The report seen was not thought to be very useful, as the results were not presented in any meaningful way. Any negative feedback from the questionnaires is dealt with on an immediate basis. Staff are also involved in an annual questionnaire.Bywater LodgePage 24 Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders Key findings/Evidence This standard was not assessed at this inspection Standard met?0X X XStandard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspection Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspectionStandard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 0 Key findings/Evidence Standard met? This standard was not assessed at this inspectionBywater LodgePage 25 PART C(where applicable) Condition CommentsCOMPLIANCE WITH CONDITIONSComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager Date Public reportsKathleen Firth Sheila Grant 12th October 2004Signature Signature SignatureIt should be noted that all CSCI inspection reports are public documents.Bywater LodgePage 26 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 25th August 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleBywater LodgePage 27 Action taken by the CSCI in response to provider comments: Amendments to the report were necessaryComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office.Bywater LodgePage 28 D.2 Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here Bywater LodgePage 29 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Lawrence Tomlinson of Bywater Lodge confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Bywater LodgePage 30 Bywater Lodge / 25th August 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000001623.V181904.R01© This report may only be used in its entirety. 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