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Inspection on 25/04/05 for Heywood Lodge

Also see our care home review for Heywood Lodge for more information

This inspection was carried out on 25th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The staff at the home have worked there a long time and had a good understanding of each client`s needs. All the clients spoke positively about their life in the home and visitors commented on the "lovely homely feeling" and said it was "like having family around." A choice of menu is offered for all meals and they looked well portioned and appetising with fresh vegetables. The clients were very complimentary about the activities they enjoyed in the home with the hairdresser, physical therapist and nail technician coming on a weekly basis.

What has improved since the last inspection?

The training programme for the staff has been developed and all staff have now had dementia training. The manager has enrolled to start her NVQ level 4 in September 2005 and two members of staff are commencing NVQ level 3 in September 2005. All members of staff are at present doing a 12 week course in infection control.

What the care home could do better:

There have been three new clients admitted to the home since the last inspection and, although on speaking to them and visiting relatives, it was obvious that their care needs were being met, this was not always written on their notes and because they had not all signed them, it was not obvious that they had been involved in plans for their care. It was suggested that residents, visitors, staff and outside agencies might be approached more formally to contribute their ideas on how the home is run.

CARE HOMES FOR OLDER PEOPLE Heywood Lodge 43 Western Road Billericay Essex CM12 9DX Lead Inspector Christine Bennett Unannounced 25 April 2005 10:00am 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 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 I56-I06-S18056-Heywood Lodge-V223265250405-Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Heywood Lodge Address 43 Western Road, Billericay, Essex CM12 9DX Telephone number Fax number Email 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 Mrs Gwendoline Ruby Heywood Mrs Gwendoline Ruby Heywood CRH 7 Category(ies) of OP Old age 7 registration, with number of places Heywood Lodge I56-I06-S18056-Heywood Lodge-V223265250405-Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The home may accommodate 7 people of either sex who only fall into the catagory of Old Age Date of last inspection 4/11/04 Brief Description of the Service: Heywood Lodge is a detached family style home. Residents are accommodated on the ground floor. 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. The upstairs of the premises is the private accommodation of the proprieter. There is an enclosed garden to the rear 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 and it is near to local shops, bus and train services. Heywood Lodge I56-I06-S18056-Heywood Lodge-V223265250405-Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection on 25th April, 2005 which took place over 7 hours. The inspection process included discussions with the manager, a member of staff, 7 residents and 3 visitors. A tour of the premises was undertaken and an inspection of sample records and policies. Fifteen standards were covered and four requirements have been made. What the service does well: What has improved since the last inspection? The training programme for the staff has been developed and all staff have now had dementia training. The manager has enrolled to start her NVQ level 4 in September 2005 and two members of staff are commencing NVQ level 3 in September 2005. All members of staff are at present doing a 12 week course in infection control. Heywood Lodge I56-I06-S18056-Heywood Lodge-V223265250405-Stage 4.doc Version 1.30 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. Heywood Lodge I56-I06-S18056-Heywood Lodge-V223265250405-Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Heywood Lodge I56-I06-S18056-Heywood Lodge-V223265250405-Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 The home operates a thorough pre admission assessment with care and attention being given to ensure that individual needs can be met, ensuring appropriate admissions. EVIDENCE: The manager described a thorough pre admission process to ensure that a resident’s needs would be met. This was confirmed by documentation in the care plans. Visitors said they viewed the home and spoke to the manager before the resident came to the home for the day. When this had been successful, the resident was able to move into the home on a 4 week trial before a review was carried out to ensure all parties were satisfied that needs would be met. Heywood Lodge I56-I06-S18056-Heywood Lodge-V223265250405-Stage 4.doc Version 1.30 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9 The health needs of residents are well met with good multidisciplinary working taking place. The medication at the home is well managed promoting good health. Medication administration and storage was considered to be safe. Minor omissions in the care plans detract from the quality of care witnessed and substantiated by residents and visitors. EVIDENCE: Care plans for three new admissions to the home have no photo identification and although monthly reviews have taken place, two have not been signed by the residents to indicate that they were involved. Daily records examined were detailed and gave a good indication of the quality of care being given, which was confirmed by residents. The storage, recording and administration of medication was seen to be safe. Records for staff confirmed that pharmacy training had been given. Evidence in care plans confirmed appointments with health professionals outside the home and visitors confirmed prompt action in contacting the district nurse and obtaining GP appointments when necessary. Heywood Lodge I56-I06-S18056-Heywood Lodge-V223265250405-Stage 4.doc Version 1.30 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15 Residents experience a stimulating and varied life in the home and visitors are encouraged. Meals are well managed, varied meet the nutritional needs of the residents. EVIDENCE: The residents spoke enthusiastically about their life in the home. They enjoy visits on a weekly basis from the hairdresser, nail technician and mobility exerciser. There was evidence of knitting and a resident was being taken to the local butterfly farm for lunch the following day as a special treat for their birthday. The home has a vehicle to take residents out and plans are being made to take them out when the weather improves for a cream tea at some local stables. Visitors confirmed that they are always made to feel welcome in the home and can visit freely. They are also welcome to join their relative for a meal in the home. The kitchen was well stocked with an abundance of fresh vegetables. Residents have a choice at all meals and the menu was varied and nutritional. All the residents commented on the quality of the food. One relative, whose mother was undernourished on admission, commented “the food is brilliant, Mum has put on two stone since being here.” Lunch was observed, where all the residents sat at the dining table chatting and laughing. Heywood Lodge I56-I06-S18056-Heywood Lodge-V223265250405-Stage 4.doc Version 1.30 Page 11 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Arrangements for protecting residents and responding to their concerns are satisfactory. EVIDENCE: Residents’, visitors and staff comments showed that people feel comfortable discussing concerns with the manager. No complaints have been received by the home or CSCI. Staff training records evidenced prevention of Abuse training and/or understanding of Adult Abuse. Staff had a good understanding of reporting abuse. Heywood Lodge I56-I06-S18056-Heywood Lodge-V223265250405-Stage 4.doc Version 1.30 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 26 A clean and comfortable environment is provided for the residents. EVIDENCE: In general the home is clean and pleasant. Care staff are responsible for cleaning of the home. There were no offensive odours in the home. Heywood Lodge I56-I06-S18056-Heywood Lodge-V223265250405-Stage 4.doc Version 1.30 Page 13 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Staff at the home are well trained and employed in sufficient numbers to meet the residents’ needs. EVIDENCE: The home is fully staffed and benefits from a mix of staff who have worked at the home for many years. No agency staff are used. CRB checks have been done for all staff members. However the recruitment files do not provide proof of identification in the form of picture confirmation. Training is well planned and all staff members have achieved NVQ level 2, with two members commencing NVQ level 3 in September 2005. Staff confirmed that the manager was supportive of any additional training they wish to undertake. Evidence in the files confirmed recent dementia training and all staff are currently attending a 12 week course on Infection Control. Heywood Lodge I56-I06-S18056-Heywood Lodge-V223265250405-Stage 4.doc Version 1.30 Page 14 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,38 The manager provides leadership, guidance and direction to the staff to ensure residents receive consistent quality care. Records should be kept that staff, residents and visitors are consulted on the running of the home. EVIDENCE: The manager has been working in the care sector for forty years and is commencing her NVQ level 4 in September 2005. Residents, visitors and staff made positive comments about the management of the home and as the manager has a hands on approach, is frequently working alongside the staff giving them ongoing support. The home does not document formally a programme of self review, and consultations with the residents, relatives and staff in order to evidence that it is committed to review it’s performance on a regular basis. Discussion took place with the manager, who recognised that this was an area that could be improved. The residents in the home all have their bedroom doors closed at night and the manager has therefore not implemented automatic door closures. She is going Heywood Lodge I56-I06-S18056-Heywood Lodge-V223265250405-Stage 4.doc Version 1.30 Page 15 to discuss the necessity for these with the fire officer, who is due to visit the home soon. Heywood Lodge I56-I06-S18056-Heywood Lodge-V223265250405-Stage 4.doc Version 1.30 Page 16 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 4 COMPLAINTS AND PROTECTION x x x x x x x 3 STAFFING Standard No Score 27 3 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x 2 x x x x 2 Heywood Lodge I56-I06-S18056-Heywood Lodge-V223265250405-Stage 4.doc Version 1.30 Page 17 YES Are there any outstanding requirements from the last inspection? 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 7 Regulation 15, 17 Requirement Timescale for action 31/5/05 2. 29 19 3. 33 24 4. 38 23 The registered person shall after consultation with the service user or representative revise the service user plan and keep a photograph of the service user on record The registered person shall keep 31/5/05 a record in the home proof of identity including a recent photograph of any person working in the home The registered person shall 1/7/05 establish and maintain a system for reviewing quality of care (Timescale of 20/1/05 not met) The registered person shall make 31/05/05 adequate arrangements for reviewing fire precautions(Timescale of 20/12/04 not met) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Heywood Lodge I56-I06-S18056-Heywood Lodge-V223265250405-Stage 4.doc Version 1.30 Page 18 Refer to Standard Good Practice Recommendations Heywood Lodge I56-I06-S18056-Heywood Lodge-V223265250405-Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection Kingswood House Baxter Avenue Southend on Sea Essex SS2 6BG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Heywood Lodge I56-I06-S18056-Heywood Lodge-V223265250405-Stage 4.doc Version 1.30 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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