Inspection on 26/07/05 for Waverley Lodge

This inspection was carried out on 26th July 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 15/03/07

Waverley Lodge 27/02/06

Waverley Lodge 03/02/05

Waverley Lodge 21/06/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Waverley Lodge 17 Albert Road Clevedon North Somerset BS21 7RP Lead Inspector Patricia Hellier Announced 26 July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Waverley Lodge D53-D02 S8073 Waverley Lodge V229766 25.07.05 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Waverley Lodge Address 17 Albert Road Clevedon North Somerset BS21 7RP 01275 873942 01275 873942 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Mark Middleton Gostlin Mrs Catherine Jennifer Gostlin Mrs Doris Marsh Care Home - Personal Care Only 16 Category(ies) of Old Age - (16) registration, with number of places Waverley Lodge D53-D02 S8073 Waverley Lodge V229766 25.07.05 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 16 persons aged 50 years and over requiring personal care only. Date of last inspection 25 July 2005 Brief Description of the Service: Waverley Lodge is a Victorian building situated in a quiet residential area of Clevedon close to local facilities. It provides personal care for up to 16 elderly people. The Home is on three floors and there are stair lifts and a passenger shaft lift to access most levels of the home. The building and décor is of a high standard providing a comfortable and homely environment. The facilities include two lounges and a separate dining room. There are 16 bedrooms of varying size and design some with en suite facilities and all have a call bell system. Provision is made within the home for a variety of activities and outings which also enable close links with the local community to be maintained. All local facilities are within easy walking distance. The front garden allows for good weather activities outside. Garden furniture is provided. . Waverley Lodge D53-D02 S8073 Waverley Lodge V229766 25.07.05 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This announced inspection took place over five and a half hours on 26 July 2005. The Registered Manager, Doris Marsh, and the provider Mr Gostlin were present during the inspection. All residents and members of staff on duty also took part in the inspection. Before the inspection the information about the home was received from the pre inspection questionnaire and comment cards from relatives and residents. 3 out of 3 of the residents who returned cards were happy with the home and care provided. They were aware of the complaints process. They stated, “the surroundings and environment are very nice to be in”; “I am very satisfied”. 4 relatives returned comment cards and all stated they “were very satisfied” with the care of their relatives, one saying, “the home is excellent and gives wonderful attention”. The inspector toured the premises; spoke to 5 members of staff, 11 residents and 2 relatives. All residents and staff spoken with told the inspector that the home was very good and the staff very kind. What the service does well: What has improved since the last inspection? What they could do better: Fire doors to resident’s rooms while on self closure devices do not close flush to the door frames. Advice must be sought from the Fire Authority to ensure that this happens to maintain the safety of the residents. Residents or their relatives should be provided with a Terms and Conditions document outlining their tenancy arrangements. Waverley Lodge D53-D02 S8073 Waverley Lodge V229766 25.07.05 stage 4.doc Version 1.30 Page 6 Care plans need to include all changes to healthcare needs with documented actions and advised treatment. The advice and inclusion of other professionals should be sought at the earliest opportunity to ensure best practice provision of care. Staff are kind and caring. Members of staff interviewed while having some understanding of what abuse is did not demonstrate a working knowledge of the homes policies and procedures; therefore training is required. Written records to evidence the servicing and maintenance of the gas, water and electric systems are required to ensure the safety of residents. When administering medication staff must ensure they can identify the medications being administered. The home should develop with the local GP a policy for the administration of medicines bought over the counter. 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 D53-D02 S8073 Waverley Lodge V229766 25.07.05 stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Waverley Lodge D53-D02 S8073 Waverley Lodge V229766 25.07.05 stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3 The Residents’ booklet provides prospective residents with information to make an informed choice. Residents do not have a written statement of Terms and Conditions as contracts are made with Social Services who hold the copy. The home’s assessment process is thorough and ensures that it is able to meet residents’ needs. EVIDENCE: Residents are provided with a Residents’ booklet containing key information regarding the homes routines, aims and objectives. A Statement of Purpose was available on request however this does not contain all the information required by Schedule 1. Four residents’ files inspected contained contract agreements with Social Services regarding funding but there were no Terms and Conditions of residency agreements between the residents, or their relatives, and the home. Care needs are well met through a full assessment process and the completion of a care plan from this information. The assessment includes all the elements listed in the standard. Waverley Lodge D53-D02 S8073 Waverley Lodge V229766 25.07.05 stage 4.doc Version 1.30 Page 9 A comprehensive assessment was seen for a recently admitted resident. The resident when spoken to said ‘they are very kind, they know what I need and help me”. Waverley Lodge D53-D02 S8073 Waverley Lodge V229766 25.07.05 stage 4.doc Version 1.30 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 standard(s) 7,8,9,10 Service users benefit from care plans that are well formulated, however clear information regarding changes in health and social care needs are not always documented to enable staff to fully meet residents’ needs. Personal and environmental risks were observed to be well managed but with little documentary evidence to support practice. Respect and dignity are well maintained by kind and caring staff. EVIDENCE: Individual records are kept for each of the residents and inspection of the records contained assessment information, a plan of care, medication records and good records of other professionals’ visits and appointments. In one of the three care plans the development of a pressure sore and its treatment had been documented in the daily notes but had not been transferred to the care plan. This appeared to have led to a delay in informing the District nurse that treatment was not being effective. Risk assessment documentation was present in all care plans but had not been fully completed. Practice observed during the inspection showed risks to be well managed and staff interviewed demonstrated a good understanding of the ways of managing risks to maintain residents safety. In two care plans involvement of other professionals was well documented and showed timely and appropriate intervention to meet residents’ needs. The Waverley Lodge D53-D02 S8073 Waverley Lodge V229766 25.07.05 stage 4.doc Version 1.30 Page 11 home also assists residents in accessing healthcare services such as chiropodist, audiologist, optician and dentist. Residents spoken to confirmed the staff were well aware of their needs and did everything to meet them. For example one resident said ‘they notice when you are unwell and come and help you’. A short-stay resident said ‘they are absolutely lovely and I would always come back here.’ The homes policy for the administration of medication is very clear and concise. The home does not have a policy for the administration of medication bought over the counter “Homely Remedies”. The inspector recommended that this be developed. The medication system supplied from the local pharmacy did not have descriptions for all medications to be administered and staff were therefore unaware of exactly what they were giving potentially putting residents at risk. The inspector recommended that immediate action to rectify this was taken. The interactions of the care staff observed demonstrated respect for individuals and their right to privacy. Residents spoken to said ‘the staff are very thoughtful and kind and treat you very well’. Waverley Lodge D53-D02 S8073 Waverley Lodge V229766 25.07.05 stage 4.doc Version 1.30 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 standard(s) 12,13,15 Social activities and meals are both well managed, creative and provide daily variation and interest for people living in the home. The food is varied and nutritious. Friendly staff always welcomes relatives and visitors EVIDENCE: An excellent range of activities is provided with posters displaying information of forthcoming events throughout the home. Residents spoken with said, “we have plenty of choice and variety, there are quizzes and things to help keep your mind active, and we enjoy the outings” “The staff are always willing to accommodate what we want”. Several visitors were seen coming and going during the inspection. Relatives spoken with said they could come any time and felt that their relatives were well looked after by friendly staff. A number of people living in the home were spoken to and everyone who commented on the food said how good it is and that they welcomed the daily choices offered. Menus and mealtime arrangements are flexible enough to accommodate individual preferences and needs. Waverley Lodge D53-D02 S8073 Waverley Lodge V229766 25.07.05 stage 4.doc Version 1.30 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 Residents are confident that they are listened to and their requests acted upon. Residents are protected from abuse by knowledgeable and competent staff EVIDENCE: The home has a comprehensive complaints procedure a copy of which is included in the information given to residents on arrival; it is not displayed. There have been three complaints since the last inspection, which have been resolved to the complainant’s satisfaction within the home. Residents stated that if they were not happy about anything they would speak to the manager. Staff and residents spoken to, say the manager is very approachable and understanding. One resident said ‘I’ve nothing to complain about, it’s the best home I’ve been in”. A well developed policy and procedure for responding to allegations of abuse is available, however it does not refer to the possibility of including, or referring to the police. This should be included to comply with the local Adult Protection policy and protection of residents. The home also has a Whislteblowing policy and staff said they would report any concerns to the manager. Staff were not able to tell the inspector who outside of the establishment they could contact. Staff said they had never seen any signs of abuse in the home and demonstrated understanding of what abuse is. All three staff interviewed stated they had not received formal Adult Protection training. Training is therefore required. Waverley Lodge D53-D02 S8073 Waverley Lodge V229766 25.07.05 stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,22,26 Residents are provided with safe, homely and comfortable surroundings. The home has suitable equipment to maximise resident independence. Robust Infection control practices are followed. EVIDENCE: The property is well maintained, with homely and comfortable communal spaces. The living accommodation is well decorated and homely. Residents’ rooms are personalised and comfortable. Redecoration and refurbishment of the first floor landing and the provision of an ensuite facility for room 8 have been completed. There are plans for redecoration that are not documented. A maintenance plan is recommended to evidence the ongoing routine maintenance and renewal of the fabric for the benefit of residents. The home has grab rails situated at relevant points, also a shaft lift that is easily used to assist resident mobility and aid independence within the home. A stair lift is also available for some levels of the home. All resident rooms are provided with locks that are accessible to staff in an emergency. Waverley Lodge D53-D02 S8073 Waverley Lodge V229766 25.07.05 stage 4.doc Version 1.30 Page 15 The home was clean and free from offensive odours throughout. The laundry facilities were well organised with impermeable and washable flooring and walls to maintain cleanliness and prevent the spread of infection. Staff interviewed and observed demonstrated good understanding of Infection control procedures and practices and maintained a clean and hygienic environment. Waverley Lodge D53-D02 S8073 Waverley Lodge V229766 25.07.05 stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 The numbers and skill mix of competent staff are sufficient to meet residents’ needs. The procedures for the recruitment of staff are robust and provide the safeguards to offer protection to people living in the home. EVIDENCE: Residents spoken to said that the staff were ‘kind and caring’ and ‘always had time to help in an unhurried way’. During the visit staff were observed spending time with residents and call bells were answered quickly. The number of care staff on duty was adequate to meet the needs of those accommodated. They were supported by ancillary staff who prepared meals and undertook domestic duties Personnel files for 3 new members of staff inspected showed robust recruitment procedures thus ensuring all the safeguards to protect vulnerable residents had been provided. Evidence of induction programmes was seen and staff interviewed confirmed that they had been supervised in practice until police checks had been confirmed and they were competent to practice alone. Waverley Lodge D53-D02 S8073 Waverley Lodge V229766 25.07.05 stage 4.doc Version 1.30 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,33,38 The manager provides clear leadership and guidance to staff to ensure residents receive consistent care in a safe environment. There is a good system for residents’ consultation and residents feel their views are heard and acted upon. The safety of residents is not always risk assessed for their protection. EVIDENCE: Residents and staff stated that the manager is good at her job, approachable and one resident said she ‘can’t do enough’, ‘she is always helping.’ Residents feel the manager is approachable and available. Residents felt that their views were asked for and acted upon. Residents meetings are held regularly and evidence was seen of actions being taken following these. A more formal process of an annual questionnaire has recently been completed and clearly showed resident satisfaction with all aspects of the home. Comments seen were “staff spend a lot of one to one time”, “staff are very good, welcoming and friendly”. Arrangements to Waverley Lodge D53-D02 S8073 Waverley Lodge V229766 25.07.05 stage 4.doc Version 1.30 Page 18 formally feedback these results to residents and their relatives are not in place at present. The manager said she would plan how best to do this. Records inspected indicated regular fire checks are carried out. The provider told the inspector that regular safety checks for the gas, water and electricity are carried out but no documentary evidence was seen. The inspector recommended that these records are kept to evidence safety controls for the benefit of residents. Staff spoken to confirmed that regular fire instruction and drills had taken place. Some environmental and individual risk assessments had not been completed to ensure the safety of residents at all times. The manager said she is progressing environmental risk assessments. Waverley Lodge D53-D02 S8073 Waverley Lodge V229766 25.07.05 stage 4.doc Version 1.30 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 2 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x 3 x x x 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x 3 3 x x x x 2 Waverley Lodge D53-D02 S8073 Waverley Lodge V229766 25.07.05 stage 4.doc Version 1.30 Page 20 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 7 Regulation 23.4 (c) (i) Requirement The registered person shall after consultation with the Fire Authority (c) make adequate arrangements (i) for decting, containing and extinguishing fires. This relates to the fires doors that do not close flush to the frames. Timescale for action 15/09/05 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. 3. 4. 5. Refer to Standard 2 7 9 9 18 Good Practice Recommendations To provide all residents with a Terms and Conditions of residency document, that is signed by both parties. To ensure that care plans include all health changes noted and actions to meet these needs. When checking medication into the home to ensure that the packs contain a full description of all tablets to be administered. To develop a Homely Remedy policy in conjunction with the GP To provide formal training for staff in Adult Protection issues, and to ensure reference to the police is included in D53-D02 S8073 Waverley Lodge V229766 25.07.05 stage 4.doc Version 1.30 Page 21 Waverley Lodge 6. 38 the homes Adult Protection policy.. To maintain written records of safety checks carried out in the home. Waverley Lodge D53-D02 S8073 Waverley Lodge V229766 25.07.05 stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Riverside Chambers Castle Street Tangier Taunton TA1 4AL 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 D53-D02 S8073 Waverley Lodge V229766 25.07.05 stage 4.doc Version 1.30 Page 23 - 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!