Inspection on 10/05/07 for Waverley Lodge

This inspection was carried out on 10th May 2007.

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.

Other inspections for this house

Waverley Lodge 21/11/07

Waverley Lodge 21/06/06

Waverley Lodge 16/12/05

Waverley Lodge 31/05/05

Waverley Lodge 16/09/04

Waverley Lodge 26/04/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Waverley Lodge Bewick Crescent Lemington Newcastle Upon Tyne Tyne & Wear NE15 8AY Lead Inspector Suzanne McKean Key Unannounced Inspection 25th May 2007 09:30 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 Waverley Lodge DS0000000407.V338151.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. Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Waverley Lodge Address Bewick Crescent Lemington Newcastle Upon Tyne Tyne & Wear NE15 8AY 0191 264 7292 0191 264 7295 Waverley.Lodge@fshc.co.uk 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) Bewick Waverley Ltd Ms Ellen Raine Care Home 45 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (26) of places Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 19 service users on the ground floor will be category DE(E). 26 service users on the first floor can receive either nursing or personal care. 21st June 2006 Date of last inspection Brief Description of the Service: Waverly Lodge is a purpose built care home that shares its site and is physically attached to another home belonging to the same company. The home is set in large landscaped gardens, in a residential area, close to all local amenities. The home provides social and personal care for older people who have dementia on the ground floor and general nursing care for older people on the first floor. The ground floor dining room has access to the main kitchen and the upstairs dining room has a small kitchenette attached. There are two lounge areas on each floor for residents to use. All of the bedrooms are for single occupancy and 28 of them have en-suite facilities. There are accessible toilets close to all lounges and dining rooms and each floor has adequate bathing facilities. The home charges fees of between £355 and £410 per week depending upon the needs and requirements of the individual residents. As the home provides nursing care the free nursing care element of the funding is provided in addition to the costs charged to the resident. The home provides information about the service through the service user guide. A copy of the last inspection report from The Commission for Social Care Inspection is available in the entrance to the home. Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit was carried out over a total of 15 hours during three visits. Twelve residents and five staff were spoken to at some length and others chatted to briefly. Three relatives were spoken to directly as there were in the home during the visits. Four care plans, and records for medication were examined. Also staff files, training records and health and safety documentation was looked at. During the inspection case tracking was undertaken. This is a detailed review of individual residents care. It includes examination of their care plans and observation of the care being given to them. Case tracking also involves interviewing the resident to find out how their views about living in the home, which is dependent upon their condition and ability to communicate. Their bedroom is also looked at. The Commission for Social Care Inspection pharmacy advisor undertook a specialist medication inspection. The second visit was mainly to look at the way the home organises the teatime meals and how the care is provided in the early evening. The third visit allowed the documentation to be examined. There were three requirements made at the last inspection, two of which have been met. One requirement is outstanding and additional time has been given to allow them to be met. Fourteen new requirements were made as a result of this inspection. What the service does well: The residents were very positive about the care staff and the way they are treated by them when being assisted in their day to day lives. An example of this was “the girls are lovely”. This was seen throughout the visits when staff and residents were seen chatting together in a pleasant way. The home’s décor is generally good with a number of the communal areas having been recently redecorated. Resident’s bedrooms were nicely personalised to the tastes of the individual occupant. The home is clean and was odour free on all of the visits and relatives were complementary about the way the home is maintained and kept pleasant for the relatives. Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The Manager must be supported to make the necessary improvements and to provide adequate management and leadership to the staff. The fire safety arrangements must be in place for detecting and containing fires for the safe evacuation from the home in the event of a fire. The care plans have been improved but must be further improved to ensure that they are kept under review. The staff must be provide residents with adequate fluids to ensure their health. Food and fluid charts must be kept to demonstrate that residents are being given satisfactory nutritional support. The medicines management must be improved, particularly the controlled drugs which must be recorded and stored correctly. Sufficient supplies of medicines must be available for administration. The medication records must be accurate so that staff can give medicines as they have been prescribed. They must also be stored at the appropriate temperature. The Manager must look at the way residents are given choice, particularly in relation to eating and drinking but also in other areas of their lives, and conduct the home in a way, which ensures the privacy and dignity of the resident. Meal times must be improved to ensure that there are adequate quantities of good quality food served hot, and presented well. And there must be a suitable environment for meals and adequate crockery, cutlery, and utensils for the number of residents in the home must be provided. Complaints made to the home must be recorded and investigated in line with the company policies. Staffing levels must be reviewed to ensure that there are sufficient numbers of staff to meet the needs of the residents. Training records and confirmation of validation of training for food hygiene, NVQ, first aid, moving and handling and dementia care must be available. Assisted bathing facilities must be provided in sufficient numbers and type to meet the needs of the residents. Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 7 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. Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 8 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 Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 9 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&6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is sufficient information for prospective residents to be clear about the services the home offers to provide. There are good admission assessments in place to ensure that residents care needs are identified before a placement is offered. EVIDENCE: All residents have detailed admission assessments, which are carried out by the manager or senior staff. Where the assessment has been undertaken through care management arrangements the home receives the assessment and a copy of the care plan. These records form the basis of the documentation process from which the care plans are developed. Waverley Lodge DS0000000407.V338151.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 10 & 11 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The care plans contain good information about the care needs of the residents and how the needs should be met. The supplementary information to show the care being provided on a daily basis is poor in relation to resident’s nutritional and fluid intake. The health care needs of the residents are being met with the exception of the provision of adequate fluids and appropriate food. There is a good medication policy but staff are not fully aware of its contents. Controlled drugs are not managed appropriately and the policies not always followed. Medication administration as a result is poor and may put people at risk. The residents are treated with respect and their privacy is being maintained by the staff when delivering care and in their day-to-day lives but some indiscreet comments do not maintain their dignity. Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 11 EVIDENCE: All residents have a care plan which includes a detailed assessment and a plan of care. The care plans were completed to a good standard. Risk assessments are completed for: prevention of falls, wound care, moving and assisting, and there is good care planning around areas such as continence promotion. There is an assessment to look at residents’ food and fluid intake although these do not clearly show if a fluid balance record is required. The care plans show that the personal and health care needs of the residents are being met with the exception of their food and fluid intake. The care plan had all been recently rewritten and the majority of the information was therefore recent. This meant that it was difficult to judge the review process and there were some gaps in the review process in the care plans looked at. Residents access NHS services and facilities as necessary. The care plans showed that specialist advisors are used for individual residents. The home liaises with the General Practitioners who provide care to the residents. The care was being given by staff who were pleasant and courteous and number of residents were enjoying the staffs company. The record of fluid intake was not satisfactory as it was not completed for periods of time and not accurate. The records could not determine if the fluids residents received through the day were adequate to maintain fluid balance. An immediate requirement was made for this to be addressed and it had improved to some extent by the second visit, by the third visit the records were satisfactory. Residents were dressed for the activities they were undertaking and looked smart and tidy. A number of residents were positive about the care being given. An example of this is “I’m happy here” and “the staff are nice”. Generally the staff are friendly toward the residents and attempt to engage them in conversation. However some comments were made regarding the intimate needs of the residents in the public areas in the hearing of both the resident and others in the area. Regarding medication, a copy of the Four Seasons Care Manual (2006) was available but no signed and dated list indicating staff have read the document was seen. The medication section includes a useful information sheet to support staff when administering prescribed ‘as required’ medicines. No examples of this were in use in either MAR chart folder at the time of the visit. Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 12 Training for senior staff authorised to handle and administer medicines has taken place within the last year. The manager carries out some supervision of trained staff but no evidence of competency assessments were available. The manager can only demonstrate that staff members are able to handle and administer medicines safely if a record of competency assessment outcomes is made. Administration • No one in the home managed his or her own medicines at the time of the visit but the home would support someone who wished to do this. • From an observation of the medicines administration process it became clear that some people living in the home were not being given all of their medicines as prescribed. For example, on the first floor, one person had received no codeine phosphate or paracetamol since 30th May as neither product was available. On the same floor, another person’s supply of furosemide 20mg tablets (dose 100mg daily) had run out on 31st May but had still not been replaced. Medication practices in the home must include checking systems to quickly reorder any medicines recurrently unavailable in order to prevent anyone living in the home from being put at risk. • Someone living on the ground floor of the home was given twice daily beclometasone doses from two separate inhalers (100mcg & 200mcg strengths). Examination of her records showed that only the 200mcg strength should be used. The 100cg strength had not been prescribed since March 2007. The current month’s MAR charts, filed copies of prescriptions, and a sample of care plans were examined. • • • A list of names and signatures of staff authorised to administer medicines is in each MAR chart folder. There are no significant gaps in the administration records on the MAR charts. Handwritten entries on the MAR charts are of variable quality, are not always signed or dated, and are not countersigned by a witness. One such entry for furosemide 20mg shows an undated alteration from ‘one’ tablet to ‘two’ tablets. The missing date means that it is not possible to prove what dose was given. Another handwritten entry states that paracetamol should be given three times a day but four administration times are specified. This means that this person may receive more or less paracetamol than the prescriber intended. Some MAR charts contain printed entries for medicines previously stopped by the doctor. The pharmacy should be told about these changes so that only current medicines are printed on the new MAR chart. • • Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 13 • Records of the medicines ordering process were examined but no records of return of unwanted medicines were made available to be checked. Medication records must be clear and be kept up to date to ensure that people living in the home receive the correct medication. Medicine Storage • Medicines are stored in locked trolleys and locked cupboards in a secure treatment room. Despite being spacious and well equipped the treatment room appeared untidy and cluttered. • The temperature in the treatment room at the time of the visit was 290C. Other temperatures greater than 250C had been recorded in the temperature-monitoring book with no indication of any action having been taken as a result. • Two oxygen cylinders were stored in the treatment room in conditions that do not meet Four Seasons safety policy requirements. A large full cylinder was securely stored in an upright position, and a small empty cylinder was freestanding next to it. Full and empty cylinders should be stored separately and small cylinders should be stored horizontally. No oxygen storage warning notice was displayed on the outside of the treatment room door or in the room itself. Controlled Drugs - Two separate packs of controlled drugs (CDs) were found in a locked cupboard on the shelf above the CD cabinet. One unopened pack contained 5x10mg Diamorphine Injections and the other opened pack contained 2x25mcg Fentanyl Patches. Both had been supplied for the same person in March 2006 but this person no longer lived in the home. Two CD registers were checked for evidence of receipt, storage and authority to possess these CDs but none was found. Newcastle PCT had already brought this matter to the manager’s attention following a visit from their Pharmacy staff. A letter dated 14th February 2007 from Newcastle PCT to the manager identified three separate CD packs stored incorrectly and gave clear advice about arrangements for destroying & returning unwanted CDs. Two of these packs remained in the home but no evidence of the destruction or return of the third pack was seen. The home should not have held the controlled medicines once they were no longer in use and at the request of the inspector were destroyed in line with the destruction of controlled medicines policy. Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 14 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 & 15 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The social activities are well organised and creative, offering the residents a choice of activities if they wish to participate. There are good links with the local community, and the resident’s families are encouraged to visit the home. The menus did not offer choices and variety on a daily basis and the standard of the food provided is not consistently good. Residents are not always able to exercise choice and control over their lives. EVIDENCE: The home continues to benefit from a designated activities organiser. She is enthusiastic and organises various events both within and outside of the home. Records of activities are displayed and there is photographic evidence of events, which the residents have enjoyed. Individual records are maintained by Ms Blackburn are up to date and detailed. The examples of events Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 15 organised are coffee mornings, wine and cheese parties, and visiting entertainers. Some information displayed which do not relate to her programme. It was not clear why this was available and the Manager was asked to clarify it and remove any that was not necessary. Residents said they could get up and go to bed when they wanted to. Many spent time in the lounges, some stayed in their own rooms and said this was their choice. There are large landscaped gardens surrounding the home. The residents who have mental health problems are not able to access the gardens unaccompanied, as there is no secure safe area. The home has a four-week choice menu, which showed variety and was balanced. However, the daily menu choices were not displayed in either dining room and there was inconsistency about the way the residents were being supported to make choices as to what they wanted. On the second visit, which was at 5pm, the teatime meal choice was sandwiches or chips and egg. The residents on the ground floor complained that the chips were cold and hard. The staff, after a number of complaints and the intervention of the inspector prepared an alternative but by this stage some residents were not prepared to wait or had become agitated and unhappy. It is positive that the residents felt able to complain and that they felt that this was a poorer standard than they usually received, however the food was poor and the meal time not effectively managed. A number of residents said that the food was “usually okay but not always” and “I am still hungry but have some biscuits in my room”. There was no choice offered of the type of drink they could have. The milk was put into all of the cups and they tea added, there were no discussion with residents as to what they wanted. On the first floor the residents were given more choice and generally it was a better experience. However one lady, who could not sit at her usual table, was sat with two residents who were agitated and either shouted or repeatedly rapped a spoon against the table or wheelchair. The lady was upset by this and found the mealtime less than satisfactory. It is acknowledged that the two residents on the table were not aware of the effect their behaviour was having but this was not managed effectively. The staff worked hard to try to make sure residents were given assistance in a discreet manner. The dining rooms were not effectively prepared to give a good dining experience. There no condiments on the tables, no sugar so residents could be supported to add it themselves. There was also insufficient crockery and Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 16 cutlery, resulting in staff having to wash items or go to the kitchen to get more. The soft diet offered to those residents who were unable to take a normal diet were given braised steak which some could not manage to eat. There was some confusion about the times that meal times and staff were not clear about the new times that had been introduced in an attempt to improve the meal time organisation. Although it is a company policy to offer fluids to the residents on a regular basis, drinks were not given to the residents mid morning. This resulted in residents going from breakfast to lunch without a drink. This was particularly of concern as it was a warm day and a number of the residents are not able to get drinks without assistance. Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 17 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 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The complaints procedure is clear and is made available in a number of places. Residents are confident that their views are listened to. However not all expressions of concern are recorded as part of the complaints procedure. Arrangements for the Protection of Vulnerable Adults are satisfactory and protect residents from harm, however it is not clear if all staff have received training in this area. EVIDENCE: The home has policies and procedures for residents and staff to use should they have any concern or complaint about the care or other services. There have been two reported complaints to the home since the last inspection, which had been investigated appropriately. A concern was made from a relative on the day of the inspection this was discussed with the registered manager who suggested that she would usually not have recorded it formally. There have been other complaints, which were discussed with the staff or raised by families during the inspection which were not dealt with through the complaint process. She was advised that even when the complaint is not in writing but was brought to her for investigation by the family it should be formally recorded. This could then be used for quality Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 18 assurance purposes and to ensure that it can be resolved formally to the satisfaction of the complainant. Policies and procedures are in place to protect residents. Staff have continued to receive training and said they would know what to do should there be any allegation of abuse. However the records of the training provide were not clear and it was not possible to be sure that all of the staff had received the training. Certificates were not in place for individual staff. It was also not clear how the verification of the quality of the training had been achieved. (see staffing section of the report). There is an investigation being carried out in the home by another manager from within the company as part of the Protection of Vulnerable Adults process. The outcome of this has not been determined. This should be shared with Commission for Social Care Inspection when available, along with any action plan devised as a result. Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The general standard of cleanliness is good and the building is well maintained. The necessary specialist equipment for the control of infection is provided in the home and the staff were aware of their responsibilities in this respect. The environment is generally good and there is a programme in place to ensure it remains in good repair and pleasant. It is appropriate for the residents who live there. However, the lack of appropriate bathing facilities results in the residents not having access to suitable baths for their needs. EVIDENCE: The home was purpose built for the client group and as a result has good-sized corridors and is designed to allow service users to use the entire home with ease and in safety. The decoration is in-keeping with the style of the home and the furnishings are suitable for the residents living in the home. The company Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 20 has an ongoing redecoration plan and has identified equipment and furnishings needed to maintain the standards. There have been improvements made in the last year. The home is set in large well kept landscaped gardens. There is no easy access or safe garden area for residents who have dementia and those in wheelchairs would find it difficult to access the vast grassed areas. There have been plans in place for some time to improve the access and provide adequate outside areas for the residents but as yet they have not been actioned. The residents spoken to were happy with the decoration and maintenance standards. The home is clean and was generally odour free. The residents’ bedrooms were personalised reflecting individual choices and preferences and three residents asked about their bedrooms said they were happy with the decoration and that they were kept clean by the staff. The laundry was clean, organised and well equipped. The sluices were tidy, clean and odour free and the disinfectors operational. Staff followed infection control policies throughout the day. The light and emergency call cords were all clean and all emergency cords reached skirting level. The first floor has only one bath, which is being used; the other is closed and used for storage. There are showering facilities on this floor for resident use. Bathing facilities are not provided in adequate numbers in the home. Bathrooms, which are not suitable for assisted bathing, are being used for storage limiting the choices available to the residents. There are toilets and bathrooms close to the communal areas and twenty-eight bedrooms have an en-suite facility. There is no central heating within the communal bathing and en-suite areas. The home has provided wall mounted blow heaters to ensure the correct temperatures are maintained. There are records in place to show that the maintenance contracts cover all of the necessary areas. There is a system in place for these to be renewed as necessary and the equipment in the home to be regularly inspected by outside contractors. The internal maintenance records were available and were organised, dated and signed. Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 21 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 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The staff are recruited and selected using a good system, which ensures that they do not present a risk to the residents and have the necessary skills and qualifications to care for them. All staff are given a good induction programme. Training is given in line with the companies policies, but the evidence to ensure that it is up to date or accredited was not available, including moving and handling, fire, protection of vulnerable adults and health and safety and first aid. EVIDENCE: On the first day of the inspection the following staff were on duty• Manager – Mrs Ellen Raine • 2 Registered nurses • 7 care staff • 1 domestic • 1 cook • 3 kitchen assistants Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 22 Staff records are completed in line with the company policies and procedures, including two references and a completed application form. The requirement to have a CRB and POVA check in place is applied to all of the staff in the home. Qualified nurses have their personal identity number checked to make sure they are able to practice and staff who are employed from overseas have work permits. The training records allow the Manager to plan training; this was difficult to examine. Although there was a training matrix identifying the training that had taken place the certificates to evidence this were not in the staff files. This included both statutory and clinical training. This also meant that there was no verification of quality of the training provided. All of the relatives spoken to were very complimentary about the staff but thought that there was insufficient numbers to care for current residents. There was no suggestion by any that they were not having their needs met but that the staff could have more time to care for them in a less hurried and stressful way. This was supported by the failure to provide the mid morning drinks or have time to make the dining experience pleasurable for the residents. There are domestic and laundry staff over a seven day period. The kitchen staff are shared with the adjoining home. Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 23 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 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The management and leadership in the home is not sufficient to ensure that the home is operating in the best interests of residents and in line with the company policies and procedures. There are good systems for quality monitoring set up by the company, which attempts made to elicit the views of residents and their representatives. However in practice this is not improving the standard of the service. Residents personal accounts are not managed to ensure their best interests are protected. There are some health and safety practices, which pose potential risks to residents. Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 24 EVIDENCE: The registered manager has been in post since January 2004.She is a 1st Level General and Mental Health nurse. Other qualifications include Care of the Elderly, BA in Education and a Diploma. She has completed the Registered Managers Award. The home does not have a deputy manager. It was noted that the registered manager is undertaking a number of management task herself without delegating them to senior member of the staff team. It is not clear if this is due to the skills of the staff or that Mrs Raine is choosing to remain responsibility for these areas of the home. Monthly visits and reports from the Company’s representatives are completed. The registered manager has carried out resident and relative surveys. The surveys focused on the quality of the food. The manager is preparing an action plan to address the issues raised. The Manager has recently completed an extensive internal audit of the quality of the service provided. This is a self-assessment tool and the home achieved a high score for a number of areas, which were judged in this inspection to be of poor standard e.g. medicines. This audit has been analysed by the company and will be repeated as part of the process of assessing improvements. The action plan is being developed to make the improvements as identified. Relative and resident meetings are held every two to three months but these are not well attended. There is a suggestion box and a comments book at reception should anyone wish to comment on any part of the service. Accident recording and monthly analysis is satisfactory and could be crossreferenced to care plans. The home completes a weekly report to the company, which is monitored centrally. During the first visit the fire exit at main entrance, which leads to the rear of the building, was obstructed with boxes of incontinence pads, which had been delivered that day. They remained there for the duration of the day. Two other fire exits were also obstructed with furniture suggesting that although the pads may have be temporarily there the staff were not aware of the importance of maintaining a clear exit from the building. An immediate requirement notice was issued to ensure that these exits were cleared. When the next visit was undertaken the exits were clear and staff had been reminded through a staff meeting of the importance of this. Door wedges were being used in a number of bedrooms and in some inappropriate items were being used to hold the doors open. In one example Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 25 this was a heavy chest of drawers, which were removed at the request of the inspector. Although it is acknowledged that some residents prefer to have their bedroom doors open this presents an increased fire risk both to the individual resident and to the others in the home. Alternative devises are available in the home, which activate to allow the door to open on the sound of the fire alarm, however they were not being used in all instances in which the doors were held open. A fire prevention officer was contacted and asked to attend and assess the fire prevention strategies and give advice. This had been carried out by the time of the second visit and he identified improvements, which were given to the home to address. The personnel records kept in the home of residents who are receiving assistance to manage their finances are detailed, logical and appropriate. Receipts were in place for purchases made on behalf of residents and signatures of either two staff or one and the service user were in place. The personal allowance records examined allowed the audit of individual residents moneys to ensure that it is being managed effectively. The home is awaiting guidance to ensure that all residents’ money is kept in a way, which can make sure that they can accrue interest on their savings. The home have taken steps to limit the amount of money held by them and have sought alternative ways of achieving this depending upon the individual residents financial situations. Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 26 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X X 1 X X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X 2 X X 1 Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 27 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 OP7 Regulation 15 (2) Requirement The registered person must ensure the care plans are kept under review. Food and fluid charts must be kept to demonstrate that residents are being given satisfactory nutritional support. Fluids must be provided to the residents to ensure the health of the service users. Medicines must be • Controlled drugs must be recorded and stored correctly. • Sufficient supplies must be available for administration. • Medication records must be accurate so that staff can give medicines as prescribed. • Medicines must be stored at the appropriate temperature. The care home must be DS0000000407.V338151.R01.S.doc Timescale for action 01/08/07 2. OP7 15 26/05/07 3. OP8 12 & 16 26/05/07 4. OP9 13 (2) 01/08/07 5. OP10 12 (4) 01/08/07 Version 5.2 Page 28 Waverley Lodge conducted in a way, which ensures the privacy and dignity of the resident. 6. OP14 12 The Manager must look at the way residents are given choice, particularly in relation to eating and drinking but also in other areas of their lives. The home must provide a suitable environment for meals and adequate crockery, cutlery, and utensils for the number of residents in the home. 01/08/07 7. OP15 16 (2) 01/08/07 8. OP15 16 (3) The home must provide 01/08/07 adequate quantities, suitable, wholesome and nutritious, varied food for the residents. Complaints made to the home must be recorded and investigated in line with the company policies. Staffing levels must be reviewed to ensure that there are sufficient numbers of staff to meet the needs of the residents. 01/08/07 9. OP16 22 10. OP27 18 01/08/07 11. OP22 23 (2) (j) Assisted bathing facilities must 01/10/07 be provided in sufficient numbers and type to meet the needs of the residents. Training records and confirmation of validation of accredited training for food hygiene, NVQ, first aid, moving and handling and dementia care must be available. The Manager must be supported to make the necessary improvements and to provide adequate management and leadership to the staff. DS0000000407.V338151.R01.S.doc 12. OP26 18 01/09/07 13. OP31 10 01/08/07 Waverley Lodge Version 5.2 Page 29 14. OP35 12,17,20 The home must ensure that any interest accrued is paid into individual accounts. Timescale of 31/03/06 not met. Fire safety arrangements must be in place for detecting and containing fires for the safe evacuation from the home in the event of a fire. 01/09/07 15. OP38 13 (4) 26/05/07 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 OP22 Good Practice Recommendations The registered persons should provide a safe garden area for residents with dementia care needs. Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Cramlington Area Office Northumbria House Manor Walks Cramlington Northumberland NE23 6UR 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. Extracts may not be used or reproduced without the express permission of CSCI Waverley Lodge DS0000000407.V338151.R01.S.doc Version 5.2 Page 31 - 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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