Inspection on 12/05/05 for Waverley Lodge

This inspection was carried out on 12th May 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

Waverley Lodge 30/04/07

Waverley Lodge 24/10/05

Waverley Lodge 10/12/04

Waverley Lodge 08/07/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Waverley Lodge 36-38 Mansfield Road Ilford Essex IG1 3BD Lead Inspector Stanley Phipps Unannounced Inspection 12 May 2005 10:00 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. Waverley Lodge G55_S25934_Waverley Lodge_V222345_120505_Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Waverley Lodge Address 36-38 Mansfield Road, Ilford, Essex, IG1 3BD 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) 0208 518 4498 0208 518 4498 Mr Awtar Singh Johal Mrs Gloria Nadean Shakespeare CRH Care Home 23 Category(ies) of OP Old Age - 22 registration, with number MD(E) Mental Disorder (over 65) - 1 named of places person Waverley Lodge G55_S25934_Waverley Lodge_V222345_120505_Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named person with a mental health disorder Date of last inspection 10/12/05 Brief Description of the Service: Waverley Lodge is a privately owned care home, registered to accommodate 23 elderly people.The home is located in a residential area of Ilford, within walking distance of shops and public transport and approximately half a mile from Ilford town centre.The building is a converted property with recreational, bedroom and bathroom facilities on the ground and first floor. There is a lift to the first floor. Two of the bedrooms are large enough for shared occupancy, although are currently being used as single rooms. There is a garden with patio and grassed areas and out-buildings for the storage for food stocks and cleaning materials. The building is suitable to achieve the aims and objectives of the service, providing a comfortable and welcoming environment.Staff provide 24-hour care. The staff team reflects the ethnic diversity of the resident group and the locality in which the home is situated. Waverley Lodge G55_S25934_Waverley Lodge_V222345_120505_Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place in just under three hours and was timed to observe the evening activities, including tea and to follow up aspects of a complaint made by a relative to the local Authority’s Commissioning Department. The complaint was copied to the Commission and there was an inference that the home failed to adequately provide for the needs of a service user who was placed there for respite care. An assessment of the premises, fire, medication, health and safety and food records was undertaken. Seven service users were spoken to as well as the deputy manager. One staff was interviewed, while all others were engaged more in informal discussions regarding their practice at the home. What the service does well: What has improved since the last inspection? Although there has been no evidence of a programme of maintenance decoration and repair, there was evidence that the registered persons were addressing areas in the environment that were highlighted for improvement. This was done via a weekly walking route in which staff walk around the home picking up areas for improvement and recording it for the attention of the handy man, manager and registered provider. Some examples included new taps for the kitchen, new curtains, a new bath chair, a new mixer tap / shower-head, new light fittings in the upstairs lounge, new footstools with tables and chairs on order. Although the above represents improvement there are still areas for improvement and without the programme of redecoration, it was difficult to see how the registered persons would keep on top of them in order of priority. A random sample of staffing recruitment records indicated that the records required for the protection of service users had improved. Waverley Lodge G55_S25934_Waverley Lodge_V222345_120505_Stage 4.doc Version 1.20 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Waverley Lodge G55_S25934_Waverley Lodge_V222345_120505_Stage 4.doc Version 1.20 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 Waverley Lodge G55_S25934_Waverley Lodge_V222345_120505_Stage 4.doc Version 1.20 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) Generally the home has a good record of admitting service users whose needs are thoroughly assessed and would admit only if Waverly Lodge can meet their needs. The registered manager must maintain consistency in the admission process of the home, to ensure that the needs of service users admitted are safely met. EVIDENCE: Since the last inspection, a service user was admitted to the home for a period of respite and the individual was outside the registration category of the home. This meant hat her needs were more complex than the home could have provided for. An incident occurred the very night of the service users’ admission necessitating hospitalisation and according to the service user’s relative, this caused great distress to his mother and himself. Although this could be regarded as an isolated case, it was unsatisfactory that it was allowed to happen at all. Waverley Lodge G55_S25934_Waverley Lodge_V222345_120505_Stage 4.doc Version 1.20 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) (9) The health care needs of service users are satisfactorily provided and this includes the supervision and administration of medication. Service users can feel assured that the manager and staff would safely support them with their medication and this in turn would have a positive impact on their health and welfare. EVIDENCE: The medication records of a random sample of service users were examined and found in order. Staff were administering drugs as service users were not able to do so for themselves. Their practice was in line with the home’s policies and procedures on medication and all staff handling drugs have had training to so do. The home is supported by visits from the local pharmacist. He visits regularly to check stocks and advises staff on any changes in medication. Waverley Lodge G55_S25934_Waverley Lodge_V222345_120505_Stage 4.doc Version 1.20 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) (13, 14) Service users enjoy a lifestyle that is best suited to their needs and choices and this give them a sense of individuality and satisfaction. Wherever possible service users are supported and encouraged to maintain networks with their relatives. This, for some helps them to retain a sense of belonging whist for others something to look forward to. EVIDENCE: The grandchildren of one service user said, “Look at him now, he is one hundred per cent better off since he has been here. He is eating, smiling, has dentures and is wearing spectacles. They have done a marvellous job with him”. It was pleasing to both hear and see the joy on the faces of both relatives and the service user spoken about. The visitor’s policy is quite flexible and it encourages and promotes visiting. The staff was also referred to by relatives as being pleasant to work with. Visitors were observed making their way in and out throughout the course of the visit. Service users, interviewed informed that they are encouraged and supported to make choices regarding their lives and one example could be taken from two gentlemen of West Indian origin who attends a ‘Praise of worship‘ on a Mondays and Wednesdays. This was in keeping with their religious belief and practice. Waverley Lodge G55_S25934_Waverley Lodge_V222345_120505_Stage 4.doc Version 1.20 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) (16,17) Service users and their relatives are reassured that they can voice their concerns if and when they arise. All service users are given opportunities and relevant support to exercise their civic right and this gives them the opportunity make choices in the wider community. EVIDENCE: Service users and some relatives spoken to were clear on how and who to complain to. They informed that the manager deals with complaints at an early stage and this is in line with the complaints procedures of the home. The complaints record was examined and there were no complaints since the last visit. All service users are encouraged, supported and given opportunities to participate in the civic process while living at Waverly Lodge. This enables them to exercise a basic right. Speaking to a group of service users, they confirmed that they were supported by the manager and staff to take part in the general elections on 5/5/05. A positive feature of their experience was that they were very excited and vocal about taking part and although it was just a few that actually voted, it meant a lot to them. They described going to the local polling station and for some service users it was clear that the outcome wasn’t quite what they wanted. However it was clear that their political interest was high and that the manager and staff responded to that. Waverley Lodge G55_S25934_Waverley Lodge_V222345_120505_Stage 4.doc Version 1.20 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, 25, 26) The home offers a comfortable and clean environment to all service users living there and this gives them a positive outlook on it. This could be further enhanced by ensuring that repair and re-decoration works once identified, are prioritized and undertaken. EVIDENCE: The environment at Waverly Lodge is friendly, clean and warm. The home despite its size is generally kept tidy and service users spoken to expressed their satisfaction with it. The registered persons were required to carry out replacement and re-decorative works to building at the last inspection and this work has started. They were also required to provide a programme of maintenance, decoration and repair, which has not been forthcoming. This meant that when this visit was undertaken the worn carpets had deteriorated further. In some parts of the home for example between the main lounge and the corridor, where the two pieces of carpet met, the decorative strip was missing leaving the ends of the carpet dangerously exposed. This is unsafe and the deputy manager was asked to cover the joint with some form of tape as Waverley Lodge G55_S25934_Waverley Lodge_V222345_120505_Stage 4.doc Version 1.20 Page 13 service users with walking aids were at risk of falls. This piece of work needed prioritising. There was also no work done to the exterior of the home e.g. the flaking windowsills and no indication as to when this would be done. It is imperative that the registered persons demonstrate their intention through their programme of maintenance, redecoration and repair to carry out the works identified in order of priority. In preparing this programme, the registered persons need to include the decoration of the ground floor ceiling. Waverley Lodge G55_S25934_Waverley Lodge_V222345_120505_Stage 4.doc Version 1.20 Page 14 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) (28, 29) Service users cannot be certain that they are in safe hands at all times, as records required to be held for their protection and the admission process are not in accordance with regulatory guidance. EVIDENCE: Following a complaint that copied to the Commission, an examination of the admission process for the relevant service user was undertaken and the findings were unsatisfactory. The registered manager admitted a service user outside her registration category, with specialist needs that could not be met by the home. The result of this was that staff were unable to adequately provide for the service user’s needs and ended up with the service user in hospital, following an incident in the home. Service users are also not safe as a result of the lack of compliance to hold specific details on all staff in accordance with regulation 19 (Schedule 2) of the Care Home Regulations 2001. Due to the vulnerability of the service user group it is imperative that the registered persons improve both the areas identified in this report. Waverley Lodge G55_S25934_Waverley Lodge_V222345_120505_Stage 4.doc Version 1.20 Page 15 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) (33,34,35,37,38) The financial monitoring systems offer adequate protection to service users and hence their interest are safeguarded. However other monitoring required e.g. monthly provider visits do not offer a similar safeguard. EVIDENCE: From records seen and discussions with the deputy manager and service users, it was clear that most service users were unable to manage their own finances. They however had the support of their relatives in most cases and staff worked well in supporting these arrangements to the benefit of service users. A sample of records viewed, were accurate safe, well maintained and they were managed in line with the financial procedures of the home. Whilst the financial interests of service users were safeguarded, other types of monitoring did not provide a similar safeguard. One good example of this is where there is a continual lack of monthly monitoring visits completed on the service at Waverly Lodge. This is a great loss to both service users and staff, Waverley Lodge G55_S25934_Waverley Lodge_V222345_120505_Stage 4.doc Version 1.20 Page 16 as it would give them both an opportunity to speak directly to the registered provider. It would also pick up on what pick up on work priorities that are missed e.g. making the carpet safe for service users to walk on. The Commission would now proceed along the lines of a statutory enforcement notice to achieve compliance of this requirement. As important, is the business of providing evidence to the Commission that the service is financially viable. It should be noted that the registered provider had several opportunities to provide this evidence to the Commission and yet has failed to so do. Although it is accepted that there were no constraints on petty cash, food and the payment of bill, the Commission cannot be confident that the business is financially viable. Inference can be drawn from the fact that much needed repair and redecoration work required and identified for improvement has not been carried out. Furthermore there is no indication as to when they would be done, particularly the priority work e.g. loose and unprotected worn carpet at the doorway of the main lounge (ground floor). Generally the health safety and welfare of service users is satisfactory, but with some aspects of the re-decorative works required, this was not the case. Another good example where the health, safety and welfare of service users were not safeguarded was where a service user was admitted outside the home’s category as well as the staffing capacity to provide for the needs of the service user concerned. The service user became difficult to manage and attempted to leave the home, fell and injured herself on her first night at the home. To make matters worse there was no evidence that the staff used the on-call/back up system to gain support in managing the service user. This was unsatisfactory. Waverley Lodge G55_S25934_Waverley Lodge_V222345_120505_Stage 4.doc Version 1.20 Page 17 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 x 8 x 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION 2 x x x x x 2 3 STAFFING Standard No Score 27 x 28 2 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 3 x x x 2 3 3 x 3 2 Waverley Lodge G55_S25934_Waverley Lodge_V222345_120505_Stage 4.doc Version 1.20 Page 18 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 OP 3 Regulation 12, 13 Requirement The registered manager is required to admit service users both in line with their statement of purpose and registratio catergory at all times. The registered person(s) must produce a programme of maintenance, decoration and repair,prioritising for urgent attention those aspects which have safety implications. (Previous timescale of 31/1/05 not met). The registered manager is required to ensure that all staff areappraised of the importance of when to use the on-call system. The registered person must demonstrate evidence of a robust recruitment procedure, in accordance with regulatory requirements. (Previous timescale of 31/1/05 not met). The registered person must ensure that unannounced visits are made to the home each month, in accordance with regulatory requirements, and the report of each visit is forwarded to the Commission for Social Timescale for action From 12th May 2005 and Ongoing 31st July 2005 2. OP 19 23(2)(b) 3. OP28 19 20th July 2005 4. OP 29 19 31st July 2005 5. OP 33 26 31st July 2005 Waverley Lodge G55_S25934_Waverley Lodge_V222345_120505_Stage 4.doc Version 1.20 Page 19 6. OP 38 12, 13 Inspection.(Previous timescale of 31/1/05 not met). The registered persons are required to demonstrate that the health, safety and welfare of service users are safeguarded at all times. From 12 th May 2005 and Ongoing 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 Good Practice Recommendations Waverley Lodge G55_S25934_Waverley Lodge_V222345_120505_Stage 4.doc Version 1.20 Page 20 Commission for Social Care Inspection Ferguson House 113 Cranbrook Road Ilford, Essex IG1 4PU 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 Waverley Lodge G55_S25934_Waverley Lodge_V222345_120505_Stage 4.doc Version 1.20 Page 21 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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