Inspection on 20/08/07 for Heywood Lodge

This inspection was carried out on 20th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Heywood Lodge 14/09/06

Heywood Lodge 06/09/05

Heywood Lodge 25/04/05

Heywood Lodge 04/11/04

Heywood Lodge 23/04/04

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Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Heywood Lodge 43 Western Road Billericay Essex CM12 9DX Lead Inspector Jane Greaves Key Unannounced Inspection 20th August 2007 10:30 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 Heywood Lodge DS0000018056.V349131.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. Heywood Lodge DS0000018056.V349131.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Heywood Lodge Address 43 Western Road Billericay Essex CM12 9DX 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) 01277 659343 hideawaylake@hotmail.co.uk Mrs Gwendoline Ruby Heywood Mrs Gwendoline Ruby Heywood Care Home 7 Category(ies) of Old age, not falling within any other category registration, with number (7) of places Heywood Lodge DS0000018056.V349131.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th September 2006 Brief Description of the Service: Heywood Lodge is situated in a residential area, close to the town centre of Billericay and public bus and rail links. It is a detached family style home, which is registered for seven older people. The residents are accommodated on the ground floor and the upstairs of the premises is the private accommodation of the proprietor. There are seven single bedrooms, six with en suite facilities. There are two bathrooms, a dining room and a conservatory, which serves as the main lounge. There is an enclosed garden to the rear of the building and limited parking to the front of the building. Residents are offered the services of a physical therapist, a hairdresser, a nail technician and a chiropodist, all of which are included in the fees. The home has a vehicle to take the residents on outings. The home has an updated Statement of Purpose, Service User Guide and a copy of the last inspection report available in the dining area. The current scale of charges for care and accommodation as at August 2007 remains £450 per week. Heywood Lodge DS0000018056.V349131.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This site visit was unannounced and took place on 20th August 2007 lasting five hours. . An Annual Quality Assurance Assessment had been completed by the registered manager and returned to the commission prior to this visit. The inspection process included: discussions with the manager, 2 staff and 5 people living at the home; inspection of the premises, including a sample of bedrooms, bathrooms, communal areas and the laundry; and inspection of a sample of policies and records. At this visit 21 key National Minimum Standards and the outcomes of these for people living at the home were assessed. There were four areas where the service exceeded the National Minimum Standards four areas of shortfall were identified resulting in three legal requirements and one good practice recommendation. The registered manager is intending to retire at the end of the year; the plans are that the home will continue to exist as a residential care home under new management. What the service does well: What has improved since the last inspection? The home has changed the system of ordering medication for the people living at the home. It was now possible for the staff administering the medications to be sure they were giving the correct medication to people. Heywood Lodge DS0000018056.V349131.R01.S.doc Version 5.2 Page 6 What they could do better: 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. Heywood Lodge DS0000018056.V349131.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Heywood Lodge DS0000018056.V349131.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The people who may consider choosing Heywood Lodge as a place to live are provided with all the information needed to choose a home that will meet their needs. EVIDENCE: The home had an up to date Statement of Purpose and Service User Guide. A copy of these documents, together with the last inspection report, was displayed in the lounge area of the home. Feedback from residents and relatives indicated that they felt they had received enough information about the home to be able to make their decision to come to live there. The manager reported that experience had shown that if the home did not have a vacancy when a potential resident enquired it was not unusual for that individual to visit the home on a regular basis until a vacancy arose having got to know the staff and made friends with the established residents in the interim period. The registered manager reported that people considering Heywood Lodge DS0000018056.V349131.R01.S.doc Version 5.2 Page 9 moving into the home were shown the contract, a sample care plan, and daily records to ensure they could be confident that the home was run in a manner that upheld their welfare. Intermediate care is not offered by the home. Heywood Lodge DS0000018056.V349131.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People living at Heywood Lodge, and their families, can be confident that their health and personal care needs will be fully met in a way that protects and promotes their privacy and dignity. EVIDENCE: The people living at Heywood Lodge receive effective and personal healthcare support from a small, stable, experienced and knowledgeable staff team. Staff ensure that care is person centred and that personal support is flexible, consistent and appropriate to meet the changing needs of the people living at the home. Staff were observed to treat residents’ respectfully, and care practices promoted privacy and dignity. Heywood Lodge is a small and intimate family run home. The people that work there have a great deal of knowledge and contact with the people living there. There is very little emphasis placed on record keeping within the service. The registered manager is aware of this and intends to rectify the shortfall however reported that “the home exists as a family environment and as such all the details relating to daily life do not always get routinely recorded.” Heywood Lodge DS0000018056.V349131.R01.S.doc Version 5.2 Page 11 Two residents’ records were inspected for evidence of how the home plans and meets personal and healthcare needs. Documents were present to confirm that assessments were made prior to people moving into the home to ensure that the service could meet individuals identified needs. There was evidence of family involvement at the initial assessment stage and reports from healthcare professionals. There were a variety of assessment forms covering general needs, moving and handling, nutritional needs, mental health, behaviours, falls, etc., with appropriate information recorded. A ‘Needs and Preference’ form provided a care plan, with sections covering different needs (e.g. physical and mental abilities, health and hygiene, food and diet, etc.), and a subsequent page identifying ‘action plan’; some good information was recorded on the forms viewed, which help staff know how to meet people’s needs. Observation and discussion with the people living at the home indicated that the staff team were competent to provide care and support for vulnerable people however staff training had not been routinely provided to refresh their skills and update their knowledge. The registered manager reported difficulties experienced since the previous inspection visit in sourcing a reliable pharmacy service. It was reported that the home was to change to a blister pack system of medication administration. The previous inspection report identified that medication training for staff was in need of updating. This has not been done at the point of this visit. Heywood Lodge DS0000018056.V349131.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home promotes a lifestyle and a range of recreational activities that meet the expectations and preferences of the people who live there. EVIDENCE: The home has sought the views of the people living there and considered their varied interests when planning the routines of daily living. Individuals reported having choice over how and where they spent their day, when they got up and went to bed, and of what to eat at meal times. People were encouraged to exercise choice and control over their lives, including managing their own financial affairs where able. Access to records and information on advocacy services were not discussed on this occasion. It was noted that residents’ rooms were well personalised, and that they were able to bring personal possessions into the home with them. There continued to be a good range of activities available both in and out of the home. It was good to see the home continuing to encourage and enable people to go out, accessing the local community and supporting individual activities and interests. Residents reported there were generally games organised to occupy people during an afternoon, such as Hoopla, a Beetle drive, scrabble, bingo, cards or a quiz. Records were not always completed to reflect that these activities took Heywood Lodge DS0000018056.V349131.R01.S.doc Version 5.2 Page 13 place and who had participated. One person reported they were supported to attend a whist drive in the local community and being accompanied to the local shops. One person said they felt very lucky to have so many old neighbours and friends able pop in and visit. Residents described enjoying an outing to East Tilbury and a day trip to Southend, they particularly enjoyed having pub lunches on the days out. Residents spoken to continued to be happy with the quality and variety of meals offered to them, one person said “the food is nice, plenty enough for me, nice and hot and fresh”. Each person was offered a cooked breakfast daily and meals could be taken in the dining room, in private rooms or the lounge if people wished. The registered manager reported that there was always a minimum of two choices of main meal daily and nutritional records confirmed this. Heywood Lodge DS0000018056.V349131.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living at Heywood Lodge are protected by the home’s complaints procedure and staff knowledge of adult protection procedures. EVIDENCE: Care Inspection since the last inspection. People spoken to had no complaints or concerns about the home, but were clearly aware of whom to speak to if they had a concern, and were confident to do so. Staff spoken with reported, “Residents are very comfortable to tell us if they are not happy with anything we do”. Residents spoken with confirmed this statement. All staff spoken with had a good understanding of various forms of abuse, and how to report it. At the last inspection it was reported that staff training in this area was ongoing and all staff would attend the Protection of Vulnerable Adults (PoVA) training by the end of 2006, however this had not taken place. The registered manager confirmed that training was booked for the whole staff team in this important area. There have been no POVA issues in the home since the last inspection. People reported that they felt very ‘safe’ living at Heywood Lodge. Heywood Lodge DS0000018056.V349131.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home generally provided the people living there with a safe and wellmaintained environment that was homely and suitably furnished. EVIDENCE: The home was clean, tidy and free from unpleasant odour on the day of this visit. It was generally safe and well maintained, although some areas of the home would benefit from some attention. The home had a pleasant communal lounge and a separate dining room: these were homely and generally well furnished. Bathroom facilities were clean, pleasant and attractive places with one bathroom having the advantage of a walk in bath/shower. Kitchen facilities were clean, attractive and domestic in nature; a recent Environmental Health Inspection had deemed that the wooden cupboards were adequate at present however the home should consider upgrading to more commercial kitchen fittings in the future. Heywood Lodge DS0000018056.V349131.R01.S.doc Version 5.2 Page 16 Staff members had attended infection control training in 2005, the registered manager reported the intention to source refresher training in this area for the team. Heywood Lodge DS0000018056.V349131.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People living at the home benefited from an established staff team having worked at the home for many years consequently having a good understanding individuals’ needs, however peoples’ safety and welfare would be better protected by the staff attending refresher training to update their skills. EVIDENCE: On the day of this visit the home was appropriately staffed, with staff in suitable numbers meeting residents’ needs. People spoken with were happy with the staffing levels, and felt that their needs were being well met. No new care staff had been recruited since the previous visit to this service. Two staff files sampled contained evidence that Criminal Record Bureau checks were obtained to promote and protect the safety and welfare of the people living at the home. The staff training programme had slipped since the previous visit and refresher courses must be provided to update staff and give them the skills to perform their work. The registered manager reported an appointment had been made with the a training provider two weeks after this visit to arrange refresher training for the staff team in Medication administration, the Protection of Vulnerable Adults and Moving and handling. It was noted that first aid, Fire safety, food hygiene and infection control were also areas that staff needed refresher training. Staff reported that they had received training updates in Heywood Lodge DS0000018056.V349131.R01.S.doc Version 5.2 Page 18 some areas however certificates could not be produced and record keeping did not provide evidence of this. Staff supervision was reported to take place on a day-to-day basis however because the home is such a small and family environment some details were not routinely recorded. A discussion took place with the manager about the importance of record keeping. Staff felt very positive about their role at Heywood Lodge. One person reported, “This is the kind of home I would like my parents to move into” Residents spoken with praised the staff for the care and attention they provided, one person said, “The staff are very good and kind, I haven’t wanted for anything” Heywood Lodge DS0000018056.V349131.R01.S.doc Version 5.2 Page 19 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The registered manager is fit to be in charge and is competent to run the home. The home is run in the best interests of people living there. EVIDENCE: The registered manager demonstrates good awareness of the needs of older people, and a positive approach to promoting independence and fulfilment for the people living in the home. Staff and residents were all very positive about the manager, finding her supportive and approachable. The manager has not yet attained the Registered Manager’s Award however reported the intention to enrol for this qualification. The home does not have a formal quality assurance programme in place, the registered manager reported that due to the size of the home and the strong family involvement there is daily input from residents, relatives and staff and Heywood Lodge DS0000018056.V349131.R01.S.doc Version 5.2 Page 20 that any suggestions are acted on as, and when, they occur. A discussion was held around the need to formally record this activity in line with Regulation 24 of the Care Homes Regulations 2001. It was reported that the home does not hold money for any of the people living there. One person arranges her own finances with some support, and others have family who assist them. The home had a clear health and safety policy statement, and additional information and guidance on various aspects of health and safety. Records showed that appropriate servicing and checks were carried out on facilities and equipment (e.g. hoists and lift; fire alarms, emergency lighting and call systems; gas safety check; electrical installation and portable appliance testing; etc.). Records of internal checks on fire alarms, lighting and equipment were inspected on and found to be clear and accurate. Heywood Lodge DS0000018056.V349131.R01.S.doc Version 5.2 Page 21 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 X X 4 X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Heywood Lodge DS0000018056.V349131.R01.S.doc Version 5.2 Page 22 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 OP9 Regulation 13(2) Requirement All staff responsible for the administration of medicines must attend refresher training to update their knowledge and skills. The registered person must ensure that staff are trained and updated appropriately for the work they are to do. This is a repeat requirement that did not meet the previously agreed timescale of 31/12/06 The annual quality assurance system for reviewing and improving the quality of care provided must be developed. Timescale for action 30/11/07 2. OP30 OP18 OP26 OP38 18 (c )(1) 30/11/07 3. OP33 24 30/11/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Heywood Lodge DS0000018056.V349131.R01.S.doc Version 5.2 Page 23 No. 1. Refer to Standard OP31 Good Practice Recommendations It is recommended that the registered manager obtain the Registered Manager’s Award qualification. Heywood Lodge DS0000018056.V349131.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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. 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