Inspection on 21/06/06 for Waverley Lodge

This inspection was carried out on 21st June 2006.

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

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

Other inspections for this house

Waverley Lodge 21/11/07

Waverley Lodge 10/05/07

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 Mrs Irene Bowater Key Unannounced Inspection 21st June 2006 09:00a 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.V290070.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.V290070.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.V290070.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. 16th December 2005 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. Current fee rates are £355 plus free nursing care element. Private fee rates are £410.There are no “top up” fees to be paid. Waverley Lodge DS0000000407.V290070.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key unannounced inspection that took place over seven hours. The registered manager and other staff assisted throughout the day. Over the course of the day a tour of the premises took place and nine residents, three relatives and ten staff were spoken to. Care records and other home records were also inspected. Surveys of residents were also carried out. Seven relative and visitor comment cards and six resident surveys were returned to the Commission. What the service does well: The staff have all the necessary information before any resident moves into the home to ensure they can meet their needs. There is a core of staff that have worked hard at the home for a considerable time. They are keen to improve the standards in the home and develop their skills. Relatives commented that the “staff work hard” and “they are always helpful”. There is communication with other professionals to ensure residents health care needs are met. The activities organiser works hard to provide activities inside and outside of the home. The meals are nutritious, nicely presented and choices are available. Residents said, “the meals are nice”, “I get plenty to eat”, Visitors are made welcome and there are good links with the local community. Relatives commented that “the staff are friendly and we are always made welcome”. Residents spoken with said they knew who to complain to should if they were unhappy. The staff receives the training they need to care for the residents needs. Waverley Lodge DS0000000407.V290070.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Improvements are needed to the medicine records. Review of the mealtimes is necessary to make sure residents preferences about when to eat is taken into account. Three residents said that they had to wait for breakfast which was late and if they ate it they would not be able to eat their dinner. The refurbishment and redecoration of the home needs to continue within given timescales to make sure the home is safe and comfortable for the residents. Infection control procedures must be followed at all times. Waverley Lodge DS0000000407.V290070.R01.S.doc Version 5.2 Page 7 The staffing levels must be constantly reviewed to ensure there are sufficient staff on duty at all times. The systems to enable residents receive interest on their money need to be resolved. The home must progress with the fitting of thermostatic mixing valves in all areas. The requirements from this report need to be actioned within the completion dates. 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. Waverley Lodge DS0000000407.V290070.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.V290070.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There is sufficient information for prospective residents to be clear about the services the home offers to provide. The admission assessments ensure the residents care needs will be met. EVIDENCE: The registered manager has improved the Service User Guide and Statement of Purpose since the last inspection. They now include photographs and clear information in large print. The Guide is available for residents and is given to potential residents and their representatives. All residents now have detailed admission assessments, which are carried out by the manager. 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 care plan process for longerterm outcomes for the resident. Waverley Lodge DS0000000407.V290070.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Improvements to the care plans mean that the staff have sufficient information to meet all of the residents assessed needs. The health needs of residents are currently being met. There is interagency working. The lack of detail on Medicine Administration Records has the potential to place residents at risk. Personal support is currently promoting residents right to privacy and dignity. EVIDENCE: Each resident has a care plan which is developed from the admission assessment. Waverley Lodge DS0000000407.V290070.R01.S.doc Version 5.2 Page 11 The staff have worked hard to improve the care plans and involve the residents in the process where possible. Seven care plans were inspected were completed to a satisfactory standard. The home uses recognised nursing model and accredited risk assessments to implement the care plans. There was evidence that assessment tools are in place for fall prevention, dependency, safe use of bed rails, nutrition and mental health status. Fluid balance and food charts were completed throughout the day. Resident’s positional changes were recorded as required. All of the residents have access to health care services including GP, dentists, opticians, and other community services. The residents who live on the Dementia Care Unit are supported by the District Nursing Services. Advice from the other professionals is sought regarding pressure sore care, continence, mental health status and nutrition. The home has comprehensive medication policies and procedures for staff to use. Records are in place for all medicines received, administered and disposed of. An audit of Controlled Drugs and the Medicine Administration Records (M.A.R.) showed no discrepancies. Not all handwritten directions on the M.A.R. had two witness signatures. None of the residents administer their own medication. Both of the units were very busy. Staff were observed to work hard to make sure residents rights to privacy and dignity was respected when giving personal care. Residents are able to maintain contact with their relatives and friends as they wish. There is easy access to a payphone and residents can have a phone in their own room. Waverley Lodge DS0000000407.V290070.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to the home. The social activities are well organised and creative. There are good links with the local community, which supports resident’s social opportunities. Residents are not always able to exercise choice and control over their lives. The menus offer choices and variety on a daily basis. 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. Records of all activities undertaken by the residents are recorded. Events include, bingo, board games, cookery, pet therapy and crafts. Residents who are able visit local pubs and enjoy shopping. Waverley Lodge DS0000000407.V290070.R01.S.doc Version 5.2 Page 13 Visitors are welcome at any time and residents are given opportunities to keep in touch with their friends and local community including churches as they wish. 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. Advocacy information is readily available in the reception area of the home. One resident has an Age Concern representative. Residents are encouraged to maintain control over their own money for as long as they are able. Residents’ have brought personal items with them on admission and their bedrooms are individualised and homely. 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 varied choice menu. The daily menu choices were not displayed in either dining room. Breakfast was not served until 9:45 am. Residents did say that they were given early morning tea but had been waiting since 8:00am for their breakfast. Once breakfast did arrive there was a good choice of cereals, cooked breakfast, toast, preserves and hot drinks. Breakfast did not finish until 11:00am and mid morning drinks were then served at 11:30 am. Residents were then being assisted back to the dining table from midday for lunch at 1:00pm.Seven residents did not know what was for lunch and the staff were unsure. Residents were able to have meals in their own rooms if they wish. The lunchtime meal was chicken, roast potatoes, broccoli, cauliflower with an alternative of liver and onions. Dessert was ginger sponge and custard and several residents chose to have ice cream. Hot and cold drinks were offered throughout the meal, which finished at 2pm. The dining room on the nursing unit was very busy and noisy with staff finding it difficult to manage the mealtime given the amount of assistance the residents needed. Despite the challenge on the day of inspection the staff had a good understanding of individual needs and gave assistance in a discreet manner. All of the residents said that the “food was good” and they “ I get plenty to eat”. Waverley Lodge DS0000000407.V290070.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome is good. This judgement has been made using available evidence including a visit to the service. The complaints procedure is clear. Residents are confident that their views are listened to. Arrangements for the Protection of Vulnerable Adults are satisfactory and protect residents from harm. 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 no reported complaints to the Commission since the last inspection. One concern from a relative on the day of the inspection was discussed with the registered manager for further investigation. Three residents and three relatives said that they felt able to use the procedure if necessary. 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. Training has included dealing with challenging behaviours and dementia care. It was confirmed that further external abuse training was being sourced. There has been one referral since the last inspection, which was well managed, and the issues resolved to the satisfaction of all involved. Waverley Lodge DS0000000407.V290070.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24,26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. There has been some investment in the home, which continues to improve the conditions for the people who live there. There are some requirements that have the potential to place residents at risk. EVIDENCE: 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. The manager said that a secure outside area and patio doors were in order. Following the last inspection a refurbishment programme has been produced and implemented with target dates. Many of the requirements from the last inspection have now been met. Waverley Lodge DS0000000407.V290070.R01.S.doc Version 5.2 Page 16 There are lounges and dining rooms on each floor, which are reasonably decorated and furnished. There is a new carpet in the reception area of the home. Several of the plastic radiator guards are still grimy with the plastic missing. 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. Since the last inspection the upstairs assisted bath has been replaced. Plumbing problems have prevented this bath from being used, however these problems were being resolved on the day of inspection. The problems had also caused water leakage to the bathroom downstairs ceiling. The enamel is again missing from the bath in bathroom 1. Two of the bathrooms cannot be used as they have domestic style baths in place, which the residents are unable to use. Flooring in the en-suite toilets, bathrooms and communal toilets are being replaced as part of the refurbishment programme. The bedrooms are all for single occupancy. Since the last inspection new bed linen, thirty bedroom armchairs, several over bed tables have been provided. Several bedrooms have also benefited from new carpets and redecoration. Residents have been encouraged to bring small items with them making their rooms homely. On the day of inspection the home was clean, tidy with no odours. The laundry was generally clean and organised. The soap dispenser and paper towel holder were empty. There were baskets of unnamed socks and tights stored in the laundry area. The sluices were locked and each floor has a disinfector. A secure clinical waste area has been provided since the last inspection. Staff cannot wash their hands properly as liquid soap and paper towels are not provided in all resident areas. Waverley Lodge DS0000000407.V290070.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to the service. The lack of a consistent staff team has had a detrimental impact on the quality of care provision in the home. Staff are receiving training to meet residents care needs. Recruitment procedures are in place to ensure residents are fully protected. EVIDENCE: The home has a core staff team who have worked at the home for some considerable time. Since the last inspection the staffing levels have been reduced according to occupancy. There have been previous concerns raised about the night staffing levels in the home. It had become practice that one carer from the Dementia Care unit went upstairs at a certain time to assist the nurse and the carer with residents personal care needs leaving one senior carer downstairs. This poor practice was discussed with the Responsible Individual and the Commission was informed that it would not happen again. Waverley Lodge DS0000000407.V290070.R01.S.doc Version 5.2 Page 18 On the day of inspection all staff raised concerns about the staffing levels especially when residents needed two staff to assist then with all care needs. The staffing problems were again discussed with the registered manager, regional manager and the Responsible Individual. It was confirmed in writing that the night staffing levels on the nursing unit would be increased to two carers and one qualified nurse leaving one senior carer and one carer on duty on the Dementia Care unit overnight. Staffing levels during the day are one qualified nurse and three carers on the nursing unit and one senior carer and one carer on the Dementia Care unit. The administration post is job shared over five days and there is an activities organiser and maintenance person. There are domestic and laundry staff over a seven day period. Difficulties happen when there are holidays and sickness. It was confirmed that on two days that week that only one domestic was available for two days from 8:30 until 1:00pm. The kitchen staff are shared with the adjoining home. NVQ level 2 training has restarted and there is evidence that 63 of staff have completed this training. There are recruitment and selection procedures for staff to follow. Five staff records were inspected. All showed that two references, Criminal Record Bureau checks, proof of identity, application form and staff contracts were available. 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 home has a training and development programme. Staff have received training in safe working practices, catheter care, challenging behaviours, dementia care, accountability, record keeping, administration of medicines and palliative care. Waverley Lodge DS0000000407.V290070.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The registered manager is showing guidance and direction to staff, which should promote a quality service. The systems for consultation and quality monitoring are in place with evidence that views of residents and their representatives are sought to develop the home. 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.V290070.R01.S.doc Version 5.2 Page 20 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. She is aware of her responsibilities and is making some progress in resolving outstanding requirements and other issues regarding the service. Monthly visits and reports from the Company’s representatives are completed. The registered manager has carried out resident and relative surveys and has received thirty-four replies. The surveys focused on named nurse, key worker, complaints, and GP involvement. It is expected that the results will be published in the Service User Guide. The Company carried out a quality monitoring survey in February 2006.The results are available in the home. 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. Resident’s personal allowances are held in a central non-interest bearing account. The Company is planning to change this system to enable residents to get interest on their own money. This has not happened yet. The home maintains detailed records of all transactions with cross-referenced receipts. All transactions are signed by two people and descriptions of purchases provided. The manager has implemented supervision for staff with records kept. She has now delegated supervisions to the appropriate senior staff. The staff have received training in safe working practices. Several of the thermostatic mixing valves still require replacing. Accident recording and monthly analysis is satisfactory and could be crossreferenced to care plans. Risk assessments for the safe use of bedrails are now up to date. Steredent tablets if used, are now safely stored. The contracts maintenance records were available and the in house records were organised, dated and signed. Waverley Lodge DS0000000407.V290070.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 2 2 X 2 X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 3 X 2 Waverley Lodge DS0000000407.V290070.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP9 Regulation 13,17 Requirement The home must ensure that all handwritten directions on the Medicine Administration Records have two signatures. The registered persons must ensure that the wishes, feelings and choices of residents are taken into account at all times. The registered persons must continue with the planned refurbishment programme. All the radiators and guards require cleaning the plastic on the guards repaired or the guards replaced. Timescale of 31/03/06 not met. The registered persons must ensure that the bath in room 1 be re enamelled or replaced. The new assisted bath must be operational and the water damage to the ceiling repaired. The registered persons must ensure that ongoing refurbishment of bedrooms continues. Timescale of 01/10/05 not met. DS0000000407.V290070.R01.S.doc Timescale for action 31/08/06 2 OP14 12(3) 31/08/06 3. OP19 16,23 01/10/06 4. OP21 23 31/08/06 5. OP24 16,23 01/10/06 Waverley Lodge Version 5.2 Page 23 6. OP26 13,16 7. OP27 18 8. OP35 12,17,20 9. OP38 23 The registered persons must ensure that there is liquid soap and paper towels available in all resident areas to enable effective hand washing. The registered persons must ensure that at all times there are sufficient night staff on duty according to the assessed needs of the residents and taking the geography of the home into account. The home must ensure that any interest accrued is paid into individual accounts. Timescale of 31/03/06 not met. The registered persons must ensure that all thermostatic mixing valves are fitted to prevent risks of scalding. Timescale of 31/03/06 not met. 31/08/06 31/08/06 31/08/06 01/09/06 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. 2. Refer to Standard OP22 OP27 Good Practice Recommendations The registered persons should provide a safe garden area for residents with dementia care needs. The registered persons should review the timing of meals. Waverley Lodge DS0000000407.V290070.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Remington Area Office Northumbria House Manor Walks Remington Northumberland NE23 6UR 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 DS0000000407.V290070.R01.S.doc Version 5.2 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!