Inspection on 21/11/07 for Waverley Lodge

This inspection was carried out on 21st November 2007.

CSCI found this care home to be providing an Adequate service.

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 10/05/07

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 NE15 8AY Lead Inspector Suzanne McKean Key Unannounced Inspection 09:30 6th December 2007 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.V353675.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.V353675.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Waverley Lodge Address Bewick Crescent Lemington Newcastle Upon Tyne NE15 8AY 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) 0191 264 7292 0191 264 7295 Waverley.Lodge@fshc.co.uk Bewick Waverley Ltd Position Vacant 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.V353675.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. 10th May 2007 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.V353675.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Summary: This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. How the inspection was carried out. Before the visit: We looked at: • Information we have received since the last visit on 25th May 2007. • How the service dealt with any complaints & concerns since the last visit. • Any changes to how the home is run. • The provider’s view of how well they care for people. • The views of people who use the service & their relatives, staff & other professionals. The Visit: An unannounced visit was made on 6th December 2007 and additional visits, which were pre-arranged, were carried out on 13th December 2007 and 11th January 2008. During the visit we: • • • • • • Talked with people who use the service, relatives, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around the building/parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager what we found. There were 15 requirements identified at the last inspection 10 of which have been fully met. Although there are 5 requirements identified at this inspection, there has been work carried out in all of these areas and it is expected that they will be achieved in the near future. Waverley Lodge DS0000000407.V353675.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Although improvements have been made to the care plans, particularly the day-to-day care being delivered, further improvements still need to be made. The registered person must ensure the care plans show the care beinggiven. A suitable environment must be provided for meals to encourage the residents to enjoy a good diet in a pleasant atmosphere. This should include improvements in the crockery and cutlery and the availability of condiments, sauces and utensils for the number of residents in the home. Waverley Lodge DS0000000407.V353675.R01.S.doc Version 5.2 Page 7 The redecoration and refurbishment programme must be completed as planned with particular attention to the carpets in communal areas and bedrooms and replacement of the damaged and worn furniture. Suitable chairs for the type of resident in the home should also be provided. The company must put forward an application for the manager to be registered with the Commission for Social Care Inspection. Also the home must ensure that any interest accrued is paid into individual accounts. This is an issue that is being agreed with the Commission for Social Care Inspection at a national level. 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.V353675.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.V353675.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. Good admission processes ensure residents needs are clearly identified and can be met before a placement is offered. EVIDENCE: All residents have detailed pre-admission assessments, which are carried out by the manager or senior staff. A new resident confirmed that she had met with a member of the staff prior to her admission and that her family were involved in choosing the home. She had not been able to visit herself but her relative had been to the home and had looked around. She had then been able to describe the home to her and tell her about the bedroom she would have if she choose to move in. Waverley Lodge DS0000000407.V353675.R01.S.doc Version 5.2 Page 10 In one instance the home had to arrange for specialist equipment to be available before admission was agreed and this was done in a reasonable time period. Where the assessment has also been carried out through a social services contract and 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.V353675.R01.S.doc Version 5.2 Page 11 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 good. This judgement has been made using available evidence including a visit to this service. Overall, good systems ensure that health and social care needs are planned and delivered in a respectful and person centred way. EVIDENCE: All residents have a care plan which includes an assessment and a plan of care. The care plans show that the personal and health care needs of the residents are being met. The majority of the care plans have 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 remain some gaps in the review process in some of the care plans looked at. The care records including the record of the care delivered on a daily basis have been improved and some are now completed to a good standard. Training is being given to the staff and each have been allocated responsibilities in the completion of the documentation. The differing skill Waverley Lodge DS0000000407.V353675.R01.S.doc Version 5.2 Page 12 levels of the staff as the training is being given results in some variety in the way these plans are managed. Some of them still have some work needed to bring them up to the necessary standard, although all have been brought up to an adequate level. Additional training around clinical issues has been arranged, including continence and pressure care/tissue viability training, which is being provided by a Tissue Viability Community nurse (NHS staff). Risk assessments are completed for: prevention of falls, wound care and moving and assisting. Care planning is in place for areas such as continence promotion. There is an assessment to look at residents’ food and fluid intake. The daily fluid balance and nutritional intake records were being completed for those residents at risk and they were up to date and well managed. 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 and support as necessary. The care was being given by staff that were pleasant and courteous and number of residents were obviously enjoying their company. An example of resident’s comments about the staff was “the girls are lovely and kind” and “the staff are really good and couldn’t be better”. Residents were dressed for the activities they were undertaking and looked smart and tidy. During the visits the staff were being friendly toward the residents and engaging them in conversation during the activities they were involved in. The treatment room was being decorated during the inspection visit and so it was not possible to judge how well organised it would be during a normal working day. The systems for managing medicines in the home are in line with safe working practice guidelines and the company have good policies and procedures. The staff record the medicines being ordered, the prescriptions are then checked on receipt from the General Practitioners and are then sent to the Chemist for dispensing. The medicines are then again checked against the records when received into the home so that any errors can be picked up. The management of the controlled medication is particularly good. No residents are currently managing their own medication. Staff are currently going through an internal assessment process to ensure their competence and to identify any training needs. Waverley Lodge DS0000000407.V353675.R01.S.doc Version 5.2 Page 13 The home have taken on the end of life care pathway protocols and have used it in the care of residents with the support of the primary health care team, including the MacMillan nurses. The manager, four qualified nurses and four carers have completed the NHS Primary Care Trust training in the end of life pathways training and the they were enthusiastic about improving the service they give in this area of practice. The records of this were good. Waverley Lodge DS0000000407.V353675.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 good. This judgement has been made using available evidence including a visit to this service. Residents are well supported to continue to keep control over decision making about lifestyle choices, keeping community contacts and engaging in activities. EVIDENCE: Residents said that they are encouraged to take control of their daily routines in simple but important ways including “the time they get up”, and what and when they eat or how they spend their time. The home continues to benefit from a designated activities organiser. The hours of this post will be increased January 2008 to full time. She is enthusiastic and organises various events both within and outside of the home. Individual records are kept are up to date and detailed. The examples of events organised are coffee mornings, wine and cheese parties, and visiting entertainers. 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. Waverley Lodge DS0000000407.V353675.R01.S.doc Version 5.2 Page 15 There are large landscaped gardens surrounding the home. The residents are not able to access the gardens unaccompanied, as there is no secure/safe area. One resident commented in her Commission for Social Care Inspection questionnaire that she felt that she was unable to go out and she missed this. The home has a four-week choice menu, which showed variety and was balanced. The residents were being supported to make choices as to what they wanted, but there is still inconsistency about the way they are being made aware of them. There was no information displayed in either the dining rooms or the communal areas about the menus. There was choice offered of the type of drink they could have and staff were responsive to requests made by the residents as to what they wanted or did not want. There are still improvements that can be made in the way the dining rooms are set out to make them a more suitable place to give a positive experience. The dining rooms were not effectively prepared and there were no condiments, sauces or sugar on the tables so allow residents to add them themselves. It is acknowledged that some would not be able to do this or would be at risk of adding things inappropriately or to excess but that could be managed by the staff. It is a company policy to offer fluids to the residents on a regular basis, and drinks were given to the residents mid morning and in the afternoon. This was recorded on individual fluid balance records. The Manager was particularly vigilant in ensuring that the staff were aware of the need for residents to have an adequate food and fluid intake. Waverley Lodge DS0000000407.V353675.R01.S.doc Version 5.2 Page 16 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 good. This judgement has been made using available evidence including a visit to this service. There are good complaints and protection of vulnerable adults policies, which are well managed and give the residents the opportunity to have their concerns dealt with and their safety maintained. 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. The records for the complaints made to the home since the manager has come into post show that she has investigated them and taken appropriate action in response to the findings. She has introduced a method for recording them so that they can be audited and used in the homes quality assurance process. There have been three complaints addressed and the records showed that they have been completed satisfactorily. There are no ongoing complainants at this time. 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. The records of the training provide were clear and the manager is currently undertaking an audit of the training to be sure that all of the staff are up to date. Waverley Lodge DS0000000407.V353675.R01.S.doc Version 5.2 Page 17 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): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is clean, well maintained and suitably designed to meet the needs of residents, which ensures that the residents live in safe and pleasant surroundings. EVIDENCE: The home was purpose built for people who have a physical disability and as a result has wide corridors and is designed to allow people living in the home 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. However, it is now in need of a programme to improve it as there are areas where the carpets are worn or stained and the paintwork and walls are damaged or grubby. The company has an ongoing redecoration plan and Waverley Lodge DS0000000407.V353675.R01.S.doc Version 5.2 Page 18 this has identified equipment and furnishings needed to maintain the standards. There have been some improvements made in the last year. The home is set in large well kept landscaped gardens. However, 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. Two residents specifically sited the outdoor space as things they would like to see improve to make their quality of life better. 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 way they were kept clean by the staff one said that she was looking forward to being transferred to a new room, as it would have been decorated before she moved in. Some of the carpets in the bedrooms are shabby and stained and the staff are now unable to clean them to a satisfactory standard. Some bedroom furniture is also damaged or worn and in need of replacement to ensure that it can be used safely and that the residents can have pleasant and comfortable rooms. 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. Bathing facilities have been recently improved and they are now being provided in adequate numbers for the number and needs of the residents in the home. 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 not up to date on the first visit as there had been a new handyman employed and he was not fully training in his role. However, by the last visit of the inspection they he had received the necessary training and the records were available and had been brought up to date. Waverley Lodge DS0000000407.V353675.R01.S.doc Version 5.2 Page 19 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 good. This judgement has been made using available evidence including a visit to this service. Staffing levels and systems around recruitment, selection and training of staff are good and meet the diverse needs of the people using the service. EVIDENCE: Staff recruitment and selection records were complete 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. The interviews are recorded formally in the staff record giving the Manager a record of the full process. The staffing rota’s showed that sufficient numbers of staff are scheduled to work however very occasionally sickness can result in periods when there are insufficient numbers for some of the time. Generally the staff cover absences amongst themselves by picking up extra shifts. This is monitored by the Manager to ensure that staff do not work unacceptably long hours. The manager confirmed that she has ensured that the staff are up to date with moving and handling, first aid, and fire training. They also are offered a number of other training opportunities including pressure area care; continence training and end of life care. The staff are encouraged to undertake Waverley Lodge DS0000000407.V353675.R01.S.doc Version 5.2 Page 20 National Vocational Qualifications (NVQ 2) once they have had their induction training. The records show that the training programme is up to date. Waverley Lodge DS0000000407.V353675.R01.S.doc Version 5.2 Page 21 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 good. This judgement has been made using available evidence including a visit to this service. The home is well managed and showing signs of systemic improvement following the appointment of a new manager. This ensures that the home is run in the best interests of people using the service. EVIDENCE: There is now a new manager in the home who is a registered nurse and has experience in the management of homes of this type. At the time of the first visit she had been in post for about ten weeks. There have been improvements in the leadership in the home both in the way the care is being delivered to the residents and in the way the home was being organised. Waverley Lodge DS0000000407.V353675.R01.S.doc Version 5.2 Page 22 Staff training records are in place and the manager is currently undertaking an audit to ensure that all of the training is recorded appropriately and to identify any training gaps. Additional training has been provided or organised for both nursing and care staff and this has been well received by them. The staff are very positive about the way the manager has made the changes and felt that the Manager has listened to their views. They said that they now felt confident that they would be given the equipment and support to provide good care to the residents. The Manager has undertaken supervision of all of the staff herself so that she can assess the team and to assist her in making decisions about the way the home can be improved. The nurses are being encouraged to give leadership on a day-to-day basis to the care staff and this has resulted in staff focusing on the needs of the residents rather than concentrating on completing tasks. The staff continue to work hard, but said that they now felt that they were able to give good care in a calmer, more pleasant atmosphere and that the staff team were more positive about working in the home. Relatives were complementary about the staff and felt that they could talk to the Manager and the other staff. One said that they felt that the communication had improved since the arrival of the new manager and felt that they could approach her if they had any concerns or views. The personal records kept in the home of residents who are receiving assistance to manage their finances detailed, logical and appropriate. Receipts are in place for purchases made on behalf of residents and signatures of either two staff or one and the service user were in place. However, there is still a shared bank account in place, which results in residents not getting interest on their money even if they have a significant amount. This is the subject of ongoing discussion between the company and Commission for Social Care Inspection with agreement and further guidance awaited. The staff, residents and relatives were confident that their views were listened to and valued by the Manager. The new manager is repeating the internal quality assurance process, which is a comprehensive self-assessment document as she felt that the one in place did not accurately reflect the situation in the home. Waverley Lodge DS0000000407.V353675.R01.S.doc Version 5.2 Page 23 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 3 9 3 10 3 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 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 X X 3 Waverley Lodge DS0000000407.V353675.R01.S.doc Version 5.2 Page 24 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 further improved to reflect the care being delivered. A suitable environment must be provided for meals to encourage an adequate nutritional intake. There must be adequate crockery, cutlery, condiments, sauces and utensils for the number of residents in the home. Timescale for action 01/04/08 2. OP15 16 (2) 01/04/08 3. OP19 23 The redecoration and 01/10/08 refurbishment programme must be completed as planned with particular attention to the: • Carpets in communal areas • Carpets in bedrooms • Replacement of damaged and worn furniture • Provision of suitable chairs for the type of resident in the home. The company must put forward an application for the manager to be registered with the DS0000000407.V353675.R01.S.doc 4. OP31 9 01/04/08 Waverley Lodge Version 5.2 Page 25 Commission for Social Care Inspection. 5. OP35 20 The home must ensure that any interest accrued is paid into individual accounts. Timescale of 31/03/06 not met. 01/04/08 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 to allow them to enjoy an outside space in safety. Waverley Lodge DS0000000407.V353675.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern No1, Hopetown Studios Brinkburn Road Darlington DL3 6DS 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.V353675.R01.S.doc Version 5.2 Page 27 - 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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