Inspection on 24/10/05 for Waverley Lodge

This inspection was carried out on 24th October 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Waverley Lodge 30/04/07

Waverley Lodge 12/05/05

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 24 October 2005 16:00 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 DS0000025934.V260855.R01.S.doc Version 5.0 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 DS0000025934.V260855.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Waverley Lodge Address 36-38 Mansfield Road Ilford Essex IG1 3BD 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) 020 8518 4498 020 8518 4498 Mr Awtar Singh Johal Mrs Gloria Nadean Shakespeare Care Home 23 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (1), Old age, of places not falling within any other category (22) Waverley Lodge DS0000025934.V260855.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named person with a mental health disorder Date of last inspection 12th May 2005 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-building 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 on a rota basis, with an on-call system in place to provide out-of hours support to staff. The staff team reflects the ethnic diversity of the service user group and the locality in which the home is situated. Waverley Lodge DS0000025934.V260855.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place in just over four hours and was timed to observe the evening activities, including tea and to monitor the overall progress of the service. An assessment of the premises along with a number of records including: health and safety, food, recruitment, staff training, service user plans and policies were undertaken. Detailed discussions were held with eight service users and the registered manager about the quality of care provided at Waverley. Interviews were held with two members of staff, while others were engaged more in informal discussions regarding their practice at the home. At the time of the visit the registered persons made an application to provide care and support to service users with dementia. As such, a number of changes were in progress to facilitate this and according to the manager things were developing smoothly with little disruption to the existing service provision At the time of compiling this report, there was confirmation from the Commission’s Central Registration Team, that the variation application to provide Dementia Care in the home was successful. Findings at this inspection clearly indicated that Waverley Lodge is a vastly improved home, as evidenced by the significant reduction in requirements made in this report. In some cases, the registered persons exceeded the national minimum standards and were subsequently awarded scores of a four. This is a positive outcome for service users, staff and the management of the service. What the service does well: At Waverley service users could expect to be provided with good and consistent support and stimulation from staff, as most of the staff time is spent with service users. All service users and relatives spoken to were in full praise of the staffing efforts, which they described as ‘incredible’. The visit was unannounced and on arrival an activity involving most of the service users was in progress. More importantly the level of participation was high and from the expressions on their faces – they were enjoying what they were doing. There is also a strong involvement of relatives in the home, as they not only visit socially, but are also involved in fundraising and developing the service. At the time of the visit they were having a raffle in aid of obtaining a sit–in wheelchair scale and relatives were actively involved in this project. Waverley Lodge DS0000025934.V260855.R01.S.doc Version 5.0 Page 6 The registered persons have developed a keen interest in providing staff with training that is specific to the work they do e.g. dementia, oral care in the elderly. This is of significant benefit to all service users in the home. The registered persons are also demonstrating a strong commitment to improving the quality of the service through its own quality monitoring of the service and working positively with the Commission in complying with requirements. They were also in pursuit of the ‘Investors in People Award’ and at the time of compiling this report, there was confirmation from the registered manager that they had achieved it. This is a positive outcome not only for the management and staff at Waverley, but also the service users who are at the receiving end of care. What has improved since the last inspection? There have been a number of improvements since the last inspection and upon entering the home there was a buzz of positive activity from the service users right up to the management of the home. The environment was given a huge lift as new carpets were fitted throughout the home and service users were absolutely in love with it. Decorative works were also carried out around the home to include painting the doorframes and doors, which were also in relation to the newly developed Dementia aspect of the service. A sliding partition was scheduled for fitting shortly after the inspection to allow service users who wish not to be part of the main activity, to have an area to use alternatively as they choose. As part of improving the service and learning lessons from a previous incident last year, which resulted in a complaint investigation - a senior carer is now part of the night staffing arrangements at Waverley Lodge. This adds a bit more expertise to team and along with new on-call procedures – would not only reduce the risk of critical incidents occurring, but also result in more effective management of them. Again this is a positive outcome for all service users living in the home. There was strong evidence that staff were given more support to carry out their job, as formal staff supervision and annual staffing appraisals were now more frequently carried out. All staff confirmed that they felt supported by the management in carrying out their duties. Staff views and contributions for developing the service were carried via a staffing survey and a staff trainingneeds analysis is scheduled for completion in February 2006. Once this is acted upon, it would have a significant impact on improving the service provision at Waverley Lodge. The registered persons have also prepared their development plan for 2005/2006 covering areas such as service user planning, maintenance and replacements, staffing recruitment training and development as well as the development of a new risk assessment tool. Waverley Lodge DS0000025934.V260855.R01.S.doc Version 5.0 Page 7 In discussion with the manager she emphasised the home’s drive to involve the relatives of service users increasingly in the home and this has taken off on a positive note. Two of the relatives apart from attending service users meetings are now reportedly assisting with compiling the minutes. This is really positive as an outcome for the service users at Waverley. In addition to the above the registered person complied with the six requirements made at the last inspection in May 2005. These improvements included admitting service users in line with the home’s statement of purpose, producing a programme of maintenance and redecoration for the home, developing a clear on-call system for the benefit of staff, recruited staff in line with regulatory guidance and promoting the health and safety of service users in the home. This is clear evidence that the registered persons are working positively with the Commission to improving the quality of services at Waverley Lodge. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Waverley Lodge DS0000025934.V260855.R01.S.doc Version 5.0 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 DS0000025934.V260855.R01.S.doc Version 5.0 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): (1,2,3,4,5,6) Service users and/or their representatives are assured of receiving information they need to make informed choices about moving into Waverley Lodge and the needs of service users are assessed prior to admission. Written contracts setting out the terms and conditions of occupancy are provided to each service user following their admission to the home. This process ensures their protection in relation the obligations of the registered persons. EVIDENCE: An updated statement of purpose was available to all service users at the time of the visit, although it was envisaged that this would need reviewing, once the Dementia Care application had been completed in it’s entirety. All service users including those recently admitted, had a copy of their statement of terms and conditions on their file. The relatives of service users were involved in ensuring that this document promoted their interests by signing on their (service users) behalf. This was generally the case, where relatives were involved. In the absence of relatives and is some cases advocates e.g. social workers would ensure that this document was in the service users best interests. As part of the admission process a thorough needs assessment on each prospective service user is undertaken to ensure that the home could meet the identified needs of the individual concerned. It was noted that there was an Waverley Lodge DS0000025934.V260855.R01.S.doc Version 5.0 Page 10 improvement in this area, as the needs of the current service user group were in line with the home’s statement of purpose and hence they were able to safely provide for them. Evidence to support that needs were satisfactorily met included little service users and their relatives expressing their satisfaction with the quality of care provided in the home, an extremely low incidence of complaints regarding the quality of care and significantly low instances of critical incidents occurring in the home since the last inspection. As part of the admission process, service users and/or their relatives have the opportunity to visit the home to assess its suitability in providing for the needs of the service user. This also gives them an opportunity to meet the staff and current service users, giving them a flavour as to how things are done in the home. Service users spoken to, during previous visits are happy with the opportunity of getting a look inside the home prior to making a decision to live there. Intermediate care is not a service provided at Waverley Lodge. The home’s Statement of Purpose, staffing levels, policies and procedures and the physical environment would all need to be reviewed if the proprietor intends, at any time in the future, to provide the specialist intensive provision required for short-term intermediate care. Waverley Lodge DS0000025934.V260855.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (7,8,10,11) The personal, social and health care needs of service users are not only welldocumented in individual service user files, but were satisfactorily provided for at Waverley Lodge. Service users are assured that staff would be sensitive to their needs and wishes and hence, treat them with dignity and respect. EVIDENCE: From assessing a random sample of service user plans it was clear that the needs’ of service users were well documented. They were updated and reflected the current needs of the respective individuals covering areas like physical health, religion, dietary preferences, oral health, mobility, speech and language and leisure pursuits – and this is not exhaustive. There was also evidence of risk assessments that were carried out on service users and they were linked to individual service user plans. This ensures that interventions made with service users are undertaken in manner that minimises risks to the service user and subsequently the staff working with them. At the time of the visit the registered manager was in the process of developing the service user plan as a tool with the view to enhancing this document. It would be of benefit for both the staff using the document and the service users for whom it is intended. Waverley Lodge DS0000025934.V260855.R01.S.doc Version 5.0 Page 12 All service users were registered with a GP and there was evidence of regular visits to service users from the opticians and the dentist. Where required, a referral would be made to a district nurse, continence advisor, psychogeriatrician or chiropodist depending on need. Service users and their relatives spoken to expressed satisfaction with the home’s ability to meet their needs. Staffing interventions and support provided to service users were observed throughout the visit and it was clear that the staff took care in working with them. One good example was where one service user had a swallowing difficulty and required assistance with feeding and this was done in manner that promoted the dignity of the service user. The staff sat alongside her and appropriately checked at intervals that the service user was okay. More importantly she was sat at a table with everyone else and did not stand out as being different, despite having a need that was different to others sitting at the table. This is of great value not only to the service user who benefited, but was reassuring to others within the same environment. From interviews held with staff it was deduced that more could be done with staff around their understanding of the notion of confidentiality in terms of respecting it without either crossing professional boundaries or compromising the safety of service users. This area was discussed individually with the manager and staff on the day of the visit. From the records examined at the inspection, there was evidence to confirm that where possible, service users’ relatives are involved in ensuring that their wishes around death and dying are honoured. Training records bore evidence that had attended a course on caring for the bereaved. There was a policy and procedure in place for the management of death and dying and staff spoken to, at the time of the inspection showed an awareness of the policy. Waverley Lodge DS0000025934.V260855.R01.S.doc Version 5.0 Page 13 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): (12,13,15) The management and staff are flexible and responsive in ensuring that service user preferences are respected and carried out as set out in the home’s statement of purpose and in each individual’s agreed plan of care. These preferences extend to the food they eat, the friends they have, the activities they engage in and how their private spaces are decorated. In essence, service users enjoy being actively involved in life in their home. All standards assessed in this group exceeded the national minimum standards. EVIDENCE: There was good evidence to confirm that the lifestyles of individual service users were reflective of their cultural, religious and social interests and choice. One example could be drawn from the fact that one service user who is from African/Caribbean origins confirmed that he is given West Indian food if he asked for it. He stated that he also enjoyed English cuisine, but felt that the home was flexible in meeting his dietary preferences and that of others in the home. The same service user showed his room to the inspector and it was fitted out with effects of his choice and taste. One example could be drawn from the fact that he loves music and he was given the opportunity to have a sound system of his own and compact discs of his genre e.g. Louis Armstrong John Holt and Jimmy Cliff – just a part of his collection. The service user is also supported to maintain his relationship with his mother back in the West Indies via the telephone and he is really happy with his life at Waverley Lodge. Waverley Lodge DS0000025934.V260855.R01.S.doc Version 5.0 Page 14 There was evidence that another service user attends a Wesleyan Day Centre in Leytonstone and this is specific to black elders. In discussion with the service user concerned, he expressed satisfaction in being able to go there and meet with elders of his faith. Another service user attends a day centre that is culturally specific and at the time of the inspection he informed that they were enjoying various celebrations put on in conjunction with ‘Black History Month’. This was really positive for the service users concerned. In discussion with another service user of English descent, she commented on the fact that the registered manager has introduced a video library to the home and she was very pleased to see what she thought was a book – the title of a film called ‘Shadow Lands’. She recounted the film and its star – Anthony Hopkins and expressed her desire to see the movie again. Arrangements were made for her to so do. The service user concerned also loved reading and was happy that the home provided material that was of interest to her. All nine service users spoken to confirmed that their religious needs were met, while living at Waverley and there were several faiths including: Seven Day Adventists, Church of England and Roman Catholic. As a matter of fact it was disclosed that every Wednesday two pastors visited the home and the service users look forward to this. One service user actually goes out to Church with the support of staff. Along with the existing internal activities in the home, the registered manager had introduced Reminiscence to the home. This group was in its early stages, but up to five service users stated that they enjoyed it. Service users also enjoy going to the pub, theatre and social events inside the home. From the activities’ record, one service user had been to the London Eye with her relatives, eight service users visited the theatre on the 11/10/05, five went on the 25/8/05 to see a musical and four were scheduled to go the Cinderella Ballet. The Christmas party was booked for the 29/11/05 and all the service users were looking forward to it. It was clear that service users were given adequate stimulation to lead a fulfilling life at Waverley Lodge. The home is very strong in involving the relatives of service users in activities and developments in the interests of service users. They involved in a fund raising event, which raised over five hundred pounds in aid of purchasing a specialist scale for the benefit of the service user group. Up to two relatives are involved in supporting service users to minute the outcomes of service user meetings and this is positive. Relatives spoken to at the inspection confirmed that the management and staff were very caring and made them feel welcome in the home and in the care of their loved ones. Meals were observed and found to be of an exceptional standard in every aspect. This included content, variety, presentation, storage and support given to service users in: consuming the meal and making informed choices of what they would like to eat. On the day of the visit the menu was a variety of Waverley Lodge DS0000025934.V260855.R01.S.doc Version 5.0 Page 15 sandwiches to include cheese, egg and fish with a salad option. Service users informed that they were extremely happy with the food at Waverley Lodge. One service user had a love for curry and rice and this was made available to him. In fact he felt expressed the view that the food in the home was really ‘tops’. Waverley Lodge DS0000025934.V260855.R01.S.doc Version 5.0 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (18) Satisfactory adult protection guidelines and protocols are in place to provide a protective framework for all service users living at Waverley Lodge. EVIDENCE: Staff demonstrated a satisfactory understanding of the concept of elder abuse and there was evidence to demonstrate that training on adult protection/abuse awareness has taken place for all staff in the home. Further training was scheduled for the 28/10/05 and up to two staff members were attending this, as part of their refresher training. The manager confirmed that the London Borough of Redbridge provided this training. In addition, the process of NVQ training includes elements relating to adult protection and most of the staff had either started their NVQ either at level 2or 3. There were no adult protection issues in the home over the last inspection year. Waverley Lodge DS0000025934.V260855.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (19,20,21,22,23,24,25) The home offers a comfortable and clean environment to all service users living there and this gives them a positive outlook on it. Service users are actively encouraged and supported to determine the décor of the home and this promotes a greater sense of comfort for them. Recently redecorated to facilitate the admission of service users with Dementia, Waverley Lodge remains fit for its purpose. EVIDENCE: There have been improvements to the environment that has made it a safer place for service users, as there was a major change in the carpets throughout the home. All service users spoken to were pleased with the change as one service user joyously remarked that the patterns on the carpet had ‘royal features’. Service users were observed safely accessing various parts of the building, some independently others with staffing support. There were rails in strategic parts of the home that facilitated this and the environment had been professionally assessed by an occupational therapist in the past. There were adequate toilets and bathrooms that were strategically located on both floors of the building i.e. proximate to the dining, lounge and bedroom areas of the home. The fixtures and fittings enable service users to maintain Waverley Lodge DS0000025934.V260855.R01.S.doc Version 5.0 Page 18 their independence, privacy and safety as far as practically possible. The home is well ventilated and has heating facilities that provide service users with adequate warmth and comfort. A handyman is employed to take care of minor areas of repair and redecoration and a system is in place to report and have larger jobs undertaken. Health and safety of the environment is maintained via a walking route, which is assessed against a checklist and areas identified are notified to the manager for action. This process has been successful and the registered persons ensure that other areas of safety e.g. gas, electrics and electrical appliances and the lift are maintained through service agreements. A very strong area of the home’s operations is the personalisation of service users bedrooms, as they were all individual and in line with service users culture and choice. The range of personal effects included valuable family photos, music, nostalgic pictures and bedroom linen that represented the individual taste of each service user. Service users were so proud of their personal spaces that they volunteered to take you on a tour of their bedroom. On entering Waverley Lodge there is warm and welcome feel to the home and service users and their relatives echoed this. Throughout the inspection visitors came in and out and were made to feel ‘at home’ and this is a positive outcome for service users. In discussion with staff they were confident that admitting service users with Dementia in the future would have little or no impact on the ambience of the home. Waverley Lodge DS0000025934.V260855.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (27,28,29,30) Service users have the reassurance that staff working with them, are adequate in number, committed, competent and have their interest at heart. They also reassured that the recruitment procedures undertaken by the registered persons, offers them a safe place at Waverley Lodge. Two of the standards assessed in this group have exceeded the National Minimum Standards. EVIDENCE: From assessing the rota and staff training records, it was clear that the staffing numbers and skill mix on duty is adequate in meeting the needs of the service user group. The manager was clear that the staffing numbers are to be kept under review, including, upon the admission of service users with Dementia. However, it must be said that she has already started preparing her staff for this development, in that they all have had a three-day training on Dementia Awareness. Staff interviewed felt confident about providing care and support to service users with Dementia as a result of the training they received. They were also confident in the assessment process used by the home, which facilitates admission of service users within the criteria set out by the home’s statement of purpose. This is really positive. There have been improvements made in the staffing arrangements, particularly on night duty as a senior carer is now on shift at nights. It must be said that there is a positive work ethic among the staff that are supportive of each other and the management of the home. This is evidenced by: the low levels of staff turnover and low levels of sick leave at Waverley Lodge. One staff member left in September 2005 and arrangements were in place to recruit a suitable individual to fill that position. All service users spoken to were Waverley Lodge DS0000025934.V260855.R01.S.doc Version 5.0 Page 20 extremely complimentary about the staff team and this was evident from the statements like – ‘those girls are really caring, they are like angels, and we do not know what we would do without them’. One visitor at the time of the inspection commented that, at times when he has visited in the past, he observed staff dealing with ‘difficult’ service users i.e. service users who refuse to cooperate in their best interest, and the staff would skilfully and patiently carry on working with them in a dignified manner. He was of the view that the staff were immaculate. This position is reinforced by the efforts of the registered persons who have invested in training for staff and this has become a very strong area of the home’s operations. At the time of the visit three of the staff were doing their NVQ Level 2 in Care; three were undertaking Level 3 in Care and the deputy manager – doing NVQ Level 4. The registered manager has already achieved her NVQ level 4 and hence the overall expertise of the staff team is growing from strength to strength. From assessing the recruitment records held on staff, there was evidence that significant improvements were made by ensuring that the information held on staff for the protection of service users were adequate. They were in line with Regulation 19 of the Care Homes Regulations 2001 and as such, the safety of service users was in effect, enhanced when compared to the last visit. The manager has taken it a step further by reviewing the home’s application form and in some respects, the recruitment process. A copy of this document was made available to the Commission and it went a long way into pulling together all the relevant guidance on the safe recruitment of staff in care homes. As such staffing recruitment is anticipated to be more robust thereby offering service users more safety. Waverley Lodge DS0000025934.V260855.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): (31,32,33,36,38) There are now sound management systems in place at Waverley Lodge to develop and maintain the service in the interests of individuals that use it. This is enhanced by having a dedicated manager and staff team who are keen to provide a high standard of care that leaves service users safe, comfortable and fulfilled. Two standards in this group have exceeded the national minimum requirements. EVIDENCE: A sound framework of policies and procedures are in place to guide staff in carrying out their duties. One of the improvements recently made was the revision of the on-call guidance, which is available to all staff, so that support is available out of normal hours (9a.m.-5p.m.) if and when needed. This back up is important to enable safe practice in the home on a twenty-four hour basis. The manager is experienced in working with the service user group and has been proactive in her own professional development and that of her staff and leads by example. She is well aware of the ageing process and diseases Waverley Lodge DS0000025934.V260855.R01.S.doc Version 5.0 Page 22 associated with the elderly, and is able to impart her expertise to the staff team to in the promotion of good practice in the home. Service users, relatives and the staff on duty spoke highly of her and there was a positive feeling throughout the home on the day of the visit. They all felt that she was accessible to them and that they could approach her to discuss almost anything. Relatives informed that they were always kept informed about developments in the home and issues around the service users with whom they are related to. Another major improvement that has impacted upon the quality of care in the home is the regular monthly monitoring of the service by the registered provider, who from the reports embraces the opportunity to speak with service users and staff. Actions required from these visits are followed through on a monthly basis and this has made a significant difference to the quality of service provision at Waverley Lodge. The drive by the registered persons to aspire and achieve the Investors in People award has also contributed to the positive feeling throughout the home, as both the management and staff were happy to be a part of that process – it give them something else that was positive to look forward to. Improvements in quality monitoring have also been undertaken through a service user survey that was held on 19/10/05 and a Relative Quality Assurance audit on the 22/6/05. It was reported that that results of the two surveys are to be incorporated into the home’s Annual Development Plan 2005/2006. There was evidence that all staff were in receipt of regular supervision and that the manager also received supervision from the registered provider on a regular basis. Service users therefore benefit from a well-supported staff team who carry out their duties effectively through: training and professional development, team meetings, informal meetings and appraisals. The registered manager had also started a training needs analysis, which is due for completion in February 2006.This is yet another key staff developmental tool from which both the staff and service users could benefit. Progress has been noted at this visit in relation to the promotion of health and safety in the home, as the registered persons carried out all outstanding actions identified at the last inspection. Service users and the staff team could now feel assured that Waverley Lodge provides a safe environment for all who use it. Waverley Lodge DS0000025934.V260855.R01.S.doc Version 5.0 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 X 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 x 17 X 18 3 3 3 3 3 3 3 3 x STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 3 4 X X 3 X 3 Waverley Lodge DS0000025934.V260855.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? NO 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. Standard Regulation Requirement Timescale for action 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 OP10 Good Practice Recommendations The registered manager should review at team meetings or at individual supervision staff awareness of the boundaries of confidentiality. Waverley Lodge DS0000025934.V260855.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford 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 DS0000025934.V260855.R01.S.doc Version 5.0 Page 26 - 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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