Inspection on 27/02/06 for Waverley Lodge

This inspection was carried out on 27th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 26/07/05

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 Waverley Lodge 17 Albert Road Clevedon North Somerset BS21 7RP Lead Inspector Patricia Hellier Unannounced Inspection 08:30 27th February 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 DS0000008073.V267218.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 DS0000008073.V267218.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Waverley Lodge Address Waverley Lodge 17 Albert Road Clevedon North Somerset BS21 7RP 01275 873942 01275 873942 waverley.lodge@claranet.co.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Mark Middleton Gostlin Mrs Catherine Jennifer Gostlin Mrs Doris Marsh Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Waverley Lodge DS0000008073.V267218.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. May accommodate up to 16 persons aged 50 years and over requiring pesonal care only 26th July 2005 Date of last inspection 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 DS0000008073.V267218.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over four and a half hours on 27 February 2006. 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. Since the last inspection the Commission has received a complaint about the use of bed rails in the home. The complaint was fully investigated and partially upheld. The manager has put new measures in place to ensure further difficulties with bed rails do not occur. The inspection focussed on the residents’ experience of the home; the care given and the way in which it is provided, to make sure residents are comfortable and care is being given to meet their needs in the best possible way. The inspector checked the medication and fire records, inspected 3 resident care files and 3 residents monies files. She read through the home’s policy and procedure files and risk assessments. Twelve residents, one relative, and three members of staff were spoken with during the inspection. All spoke highly of the home saying, “it is very homely and comfortable”. One resident said “it one of the best” What the service does well: The home has a group of staff who have worked at the home for some time providing continuity of care. They ensure the well being and comfort of the residents’ and treat them with great respect and kindness. Residents spoke of the “lively atmosphere” and “happy home.” Call bells are answered quickly and staff were seen to take initiative and stop what they were doing in order to check if residents were alright. The home is decorated and furnished to a high standard and there are many homely touches, like flower arrangements. The staff team manage the daily activities well and provide opportunities for residents to maintain links with the local community. All the residents spoken with were pleased with the choice and variety available. The home continues to provide high quality care with competent staff in a welldecorated, pleasant and homely environment Waverley Lodge DS0000008073.V267218.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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 DS0000008073.V267218.R01.S.doc Version 5.0 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 Outcomes Statutory Requirements Identified During the Inspection Waverley Lodge DS0000008073.V267218.R01.S.doc Version 5.0 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 the following standard(s): 2,3,4,5 The home’s assessment process is thorough and ensures that it is able to meet residents’ needs. The home encourages prospective residents and their relatives to visit the home prior to admission. Clear Terms and Conditions of residency are provided for the benefit of residents and their relatives. EVIDENCE: All residents were aware they had a contract of residency and were happy with the provision that they receive. This provides clarity of provision purchased for residents or relatives. Care needs are well met through a full assessment process that includes all the elements listed in the standard, and where appropriate Social Services assessment. Not all assessments were signed and dated by the person completing them. This is recommended as good practice for accountability of care provision and to be sure that it pertains to the correct resident. Residents stated that there needs are well met. The most recent resident said, “I am impressed”. Prospective residents are encouraged to visit the home prior to taking up residency. Waverley Lodge DS0000008073.V267218.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,9,10 Service users benefit from care plans that are well formulated and give clear information to enable staff to meet residents’ health and social care needs. Respect and dignity are well maintained by kind and caring staff. Medication administration systems are unclear as to the specific medication being given to residents. EVIDENCE: Individual records are kept for each of the residents and inspection of the records for three residents contained well-formulated risk assessments for Manual Handling and falls. Other personal and environmental risk assessments were present to ensure the safety of the resident while promoting independence as able. The care plans clearly identified health and social care needs and actions to meet these needs. Psychological needs were not identified and where they had been actions to meet these needs had not been written. On reading daily Kardex entries it became evident that staff are unaware of how to specifically meet emotional and psychological needs in a meaningful way. Training in this area is recommended. Care plans did not state any identified needs in relation to pressure sores and the potential to develop these. The home however has some awareness as one resident was seen using a pressure-relieving cushion. This however was Waverley Lodge DS0000008073.V267218.R01.S.doc Version 5.0 Page 10 not recorded in her care plan. The identification of this potential need and recording of actions to meet the need is recommended. Regular review of care plans was seen together with resident involvement. All care records should be signed and dated to provide accountability for information given about residents. 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’. Another resident said ‘they are absolutely lovely and I would always recommend here.’ Staff interviewed clearly knew the residents and their needs. 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’. The medications standard was not fully inspected only the system for administration (NOMAD system) as this had been a requirement at the last inspection. Descriptors for the tablet in this system were poor or non-existent and staff were unable to identify medication being given to residents. The Commission Pharmacist inspector has been asked to visit to help the home rectify the difficulties. Waverley Lodge DS0000008073.V267218.R01.S.doc Version 5.0 Page 11 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): 12,14 Residents are happy with their lifestyle at Waverley Lodge and are able to make choices and follow their own interests. Contact with families and the wider community is encouraged EVIDENCE: An excellent range of activities is provided with posters displaying information of forthcoming events throughout the home. A monthly newsletter is displayed in the hall together with recent photographs of residents and special events. Residents have recently visited the theatre in Bristol and a trip to the cinema is planned. A new activities coordinator has been appointed who is know to a number of residents and staff. They are all looking forward to her contribution to the home. Residents told the inspector that they can see their visitors at any time. Relatives were seen popping in during the course of the morning and being welcomed by staff. One relative said, “I feel quite happy coming here and the staff are very good to us”. Residents’ choice of routine and activity during the day is well respected. Staff have taken the trouble to record the residents preferred daily routine and residents verified that their choices are respected and encouraged. Waverley Lodge DS0000008073.V267218.R01.S.doc Version 5.0 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 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 has been one complaint since the last inspection, which was resolved to the complainant’s satisfaction. The complaint was partially upheld and related to the use of bed rails. The manager has instigated a new risk assessment and training on the use of bed rails. Residents stated that if they were not happy about anything they would speak to the manager. Residents and staff 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”. Another said ‘any niggles I have I tell the girls and they see to it’. The home has a copy of the North Somerset ‘No Secrets’ Guide. A procedure for responding to allegations of abuse is available and staff were fully aware of it. Since the last inspection staff have received update training in recognising and dealing with situations of abuse. Staff said they had never seen any signs of abuse in the home. Three residents said, “The staff are very kind and take time”. “I can’t fault them”. Waverley Lodge DS0000008073.V267218.R01.S.doc Version 5.0 Page 13 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): 19,23,24,26 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. All residents said they “liked their rooms very much” and had personalised them to their wishes. 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. In the bathroom cakes of soap were seen on soap trays posing a risk of cross infection. These should be removed. Since the last inspection dispenser soap and paper towels have been installed in all communal bathroom and toilet areas. Staff interviewed and observed demonstrated good understanding of Infection control procedures and practices and maintained a clean and hygienic environment. Waverley Lodge DS0000008073.V267218.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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): 27,30 The numbers and skill mix of competent staff are sufficient to meet residents’ needs but should be kept under review. Training is viewed, as important and external training is regularly accessed to provide staff with skills to meet resident needs. EVIDENCE: Residents spoken to said that the staff were kind and caring and always there to help. 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. Ancillary staff that prepared meals and undertook domestic duties supported them. There are two members of staff at night. The inspector was told that when it is quiet, most nights, both staff are sleeping. This practice may not provide satisfactory levels of staff in such numbers as are appropriate for the health and welfare of residents and should be kept under review in accordance with the dependency of the residents and their needs. All staff have received first aid and fire safety training recently. Staff spoken to said that there was lots of training and records seen showed attendance at a variety of relevant training sessions. Staff spoke of regular supervision and assistance in gaining NVQ qualifications. One resident told the inspector “the staff are all marvellous, they have been so understanding, “they couldn’t have done more for me, I’m so much better”. Waverley Lodge DS0000008073.V267218.R01.S.doc Version 5.0 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 31,35.38 The manager provides clear leadership and guidance to staff to ensure residents receive consistent care in a safe environment Health and safety issues are monitored in the home to ensure that issues are identified and addressed where they arise. Residents monies are well managed and a clear audit trail seen. EVIDENCE: The manager is well qualified and gives clear leadership, guidance and direction to staff. Relatives and staff stated that the manager is good at her job, approachable and one relative said she ‘can’t do enough’ and ‘she is always helping’. Residents feel the manager is approachable, available and seeks to ensure all their needs are met. Residents’ pocket monies held by the home were inspected and found to be accurate and to have clear records with signatures for any transactions. Thus providing good safeguards for resident’s monies. Waverley Lodge DS0000008073.V267218.R01.S.doc Version 5.0 Page 16 Records inspected indicated regular safety and fire checks are carried out. Staff spoken to confirmed that regular fire instruction and drills had taken place. Some environmental risk assessments had been completed to ensure the safety of residents at all times. Some fire doors were seen to be ill fitting and thus not providing the safeguards required. Wedged open fire doors that were observed during the last inspection have now been fitted with self-closure devices. A full Fire Risk Assessment of the building has been completed Waverley Lodge DS0000008073.V267218.R01.S.doc Version 5.0 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. 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 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X 3 3 X 3 STAFFING Standard No Score 27 3 28 2 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 X X 1 Waverley Lodge DS0000008073.V267218.R01.S.doc Version 5.0 Page 18 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 OP9 Regulation 13.2 Requirement The registered person should ensure that NOMAD packs received into the home have clear descriptors for the safe administration of medications You should ensure that all fire doors close flush to frame to provide adequate protection for residents. Timescale for action 10/04/06 2. OP38 23.4 (c) (i) 10/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4 Refer to Standard OP7 OP7 OP7 OP9 Good Practice Recommendations To recognise resident’s psychological, spiritual and emotional needs and plan actions to meet these needs. To ensure that care plans include all risk assessment of potential for pressure sores and to provide care to plan to support actions and the use of specialist equipment. All entries in care records to be dated and signed to maintain accountability To complete a risk assessment for all resident who wish to self medicate. DS0000008073.V267218.R01.S.doc Version 5.0 Page 19 Waverley Lodge 5. 6 7. OP18 OP18 OP30 To obtain consent from resident or relative for the use of bed rails. Any requests from residents for a document stating they do not wish to be resuscitated must include the GP and a representative of the home. The development of a training plan to ensure training is matched to meet residents’ needs. Waverley Lodge DS0000008073.V267218.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Somerset Records Management Unit Ground Floor Riverside Chambers Castle Street 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 DS0000008073.V267218.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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