Inspection on 06/09/05 for Heywood Lodge

This inspection was carried out on 6th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 20/08/07

Heywood Lodge 14/09/06

Heywood Lodge 25/04/05

Heywood Lodge 04/11/04

Heywood Lodge 23/04/04

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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 Christine Bennett Unannounced Tuesday 6 September 2005 th 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 V247906 060905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Heywood Lodge Address 43 Western Road Billericay Essex CM12 9DX 01277 659343 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) Mrs Gwendoline Ruby Heywood Mrs Gwendoline Ruby Heywood CRH Care Home 7 Category(ies) of OP Old Age (7) registration, with number of places Heywood Lodge I56 I06 S18056 Heywood Lodge V247906 060905 Stage 4.doc Version 1.40 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 25th April 2005 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 proprietor. 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 the local shops, bus and train services. Heywood Lodge I56 I06 S18056 Heywood Lodge V247906 060905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection on 6th September 2005 which took place over 6 hours. The inspection process included discussions with 2 members of staff, 6 residents and 3 visitors. A tour of the premises was undertaken and an inspection of sample records and policies. The manager was not available on the day of inspection and a request was made for further documentation to be forwarded to the inspector. What the service does well: What has improved since the last inspection? 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 V247906 060905 Stage 4.doc Version 1.40 Page 6 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 V247906 060905 Stage 4.doc Version 1.40 Page 7 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) 1,6 The home’s Statement of Purpose and Service User’s Guide enables an informed decision to be made prior to admission to the home. EVIDENCE: The home has a Statement of Purpose and Service User’s Guide which give sufficient information for prospective residents and their families to be clear about the services the home provides to meet their needs. Minor amendments are needed to update the information regarding the accommodation in the home and the CSCI. The home does not offer intermediate care. Heywood Lodge I56 I06 S18056 Heywood Lodge V247906 060905 Stage 4.doc Version 1.40 Page 8 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) 7,10 Minor omissions in care plans do not evidence that residents/relatives views are sought. Support is offered to promote residents’ privacy, dignity and independence. EVIDENCE: The care plans and daily diaries were examined for two residents, neither of which had photo identification. Although regular reviews by the home were evidenced, there was no indication that residents or their relatives had been involved in these reviews and had agreed how their needs would be met. This was substantiated when speaking to both residents and relatives, although they confirmed that they were happy with the quality of the care given with comments, “very good, can’t find any fault”, and “very attentive”. The home encourages the residents to be as independent as possible and a physical therapist visits the home twice a week to encourage optimum mobility. Two residents have a personal phone in their bedrooms and the other residents have the use of the home’s phone in private if they wish. Residents confirmed that they can choose to spend time in the lounge or in the privacy of their bedroom and that staff treat them respectfully. One resident said, “the staff always knock on the door before entering”, and the same resident said that the staff are respectful when helping her with her personal care. Heywood Lodge I56 I06 S18056 Heywood Lodge V247906 060905 Stage 4.doc Version 1.40 Page 9 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) 12,13,14,15 Residents experience a stimulating and varied life in the home, with the ability to make choices as to how they spend their days. The home offers food in sufficient quantity and quality to provide a nutritious diet for residents. EVIDENCE: Residents were very complimentary about their life in the home. The previous week they had gone on an outing to Southend and enjoyed an ice cream on the seafront. They said they had enjoyed spending time in the garden during the summer, and spoke of quizzes, scrabble, knitting, nail therapy and other pastimes. Visitors are encouraged and can visit at any time, and can also have a meal at the home. One resident is taken out on a regular basis by the local church and two residents spoke of parties that the home had organised to celebrate birthdays. One resident told of life in the home, saying they could get up whenever they wanted and can then choose whatever they want for breakfast. They are encouraged to personalise their rooms and can bring items of furniture into the home as well as other smaller items. There are no lockable facilities on the bedroom doors. This resident handles her own financial affairs and a relative confirmed that he handles his mother’s finances. Heywood Lodge I56 I06 S18056 Heywood Lodge V247906 060905 Stage 4.doc Version 1.40 Page 10 Residents and visitors enthused about the food that is provided in the home, and individual tastes are catered for. There is a choice at each meal and snacks are available between meals if required. Fruit and sweets are on display in the dining room for residents to help themselves. The dining table is laid with cloth serviettes and lunch was seen to be a pleasant time with staff chatting to the residents. Heywood Lodge I56 I06 S18056 Heywood Lodge V247906 060905 Stage 4.doc Version 1.40 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: The home has a complaints procedure but no complaints have been received by the home or by CSCI. Residents and relatives confirmed that they feel the manager is approachable and any concerns would be addressed. Staff had a good understanding of reporting abuse and training has been undertaken regarding abuse and challenging behaviour. Heywood Lodge I56 I06 S18056 Heywood Lodge V247906 060905 Stage 4.doc Version 1.40 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) 19,20,21,22,25,26 The home creates a comfortable and safe environment for residents and their visitors. EVIDENCE: The home is clean and comfortable, providing a homely environment for the residents. The garden is secure and accessible with a seating area for residents to enjoy. The home has two bathrooms for residents’ use, one of which has a hoist. Various aids are provided for residents, and a visitor confirmed that his relative has recently been given a zimmer frame to aid her mobility. There are no unpleasant smells in the home and bedrooms have been personalised with personal items of furniture and possessions. Care staff are responsible for the cleaning of the home. The home must consult with the local fire service regarding the use of wedges in doors. Heywood Lodge I56 I06 S18056 Heywood Lodge V247906 060905 Stage 4.doc Version 1.40 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) 27,28,29 Staff in the home are employed in sufficient numbers to meet the residents needs. EVIDENCE: The home benefits from having a staff complement who have worked at the home for many years. Agency staff are not used and therefore the residents are cared for by staff who have a good understanding of their needs. All staff members have achieved NVQ level 2 in care. Staff morale is high with one staff member stating, “I feel like part of the family”. Staff confirmed that they have time to sit and talk to residents and their visitors. There has been no recruitment of staff since the last inspection. Existing staff files now have picture identification but still require further proof of identification. Heywood Lodge I56 I06 S18056 Heywood Lodge V247906 060905 Stage 4.doc Version 1.40 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) 31,32,33,35,38 The manager provides leadership and guidance to staff ensuring optimum care is given to residents. Lack of records relating to auditing the service provided does not evidence the quality of care being given. Compliance with fire regulations must be addressed to ensure safety of staff and residents. EVIDENCE: The manager has worked in the care sector for forty years and has recently completed a 12 week course in infection control in order to update her knowledge. Residents and staff were very positive about the manager and feel their views are valued. The home does not document formally a programme of self review, and consultations with residents, relatives and staff in order to evidence that it is committed to review its performance on a regular basis. This was discussed with the manager at the last inspection. The doors to the home were wedged open and the implementation of automatic door closures was discussed previously and the manager has been Heywood Lodge I56 I06 S18056 Heywood Lodge V247906 060905 Stage 4.doc Version 1.40 Page 15 asked to provide CSCI details of the last inspection from the fire officer. No evidence could be found that fire drills take place at regular intervals. The manager confirmed that she does not handle residents’ money. Heywood Lodge I56 I06 S18056 Heywood Lodge V247906 060905 Stage 4.doc Version 1.40 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 3 x x x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION 2 3 3 3 x x 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 3 2 x 3 x x 2 Heywood Lodge I56 I06 S18056 Heywood Lodge V247906 060905 Stage 4.doc Version 1.40 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 The registered person must after consultation with the service user or representative revise the care plan and keep a photograph of the service user on record (Timescale of 31/5/05 not met) The registered person must keep a record in the home of proof of identity of any person working in the home (Timescale of 31/5/05 not met) The registered person must make adequate arrangements for reviewing fire precautions (Timescale of 20/12/04 not met) The registered person must establish and maintain a system for reviewing quality of care (Timescale of 20/1/05 not met) Timescale for action 31/12/05 2. 29 19 31/12/05 3. 19,38 23(4) 30/11/05 4. 33 24 31/12/05 Heywood Lodge I56 I06 S18056 Heywood Lodge V247906 060905 Stage 4.doc Version 1.40 Page 18 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. Refer to Standard 1 Good Practice Recommendations The Statement of Purpose and Service Users Guide should be updated to include up to date information. Residents should be consulted regarding the provision of locks on bedroom doors and their wishes documented . Staff supervision should be recorded formally. 36 2. 24 3. Heywood Lodge I56 I06 S18056 Heywood Lodge V247906 060905 Stage 4.doc Version 1.40 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 V247906 060905 Stage 4.doc Version 1.40 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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