Inspection on 30/04/07 for Waverley Lodge

This inspection was carried out on 30th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 24/10/05

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 Key Unannounced Inspection 11:00 30th April to 3rd May 2007 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000025934.V342863.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000025934.V342863.R01.S.doc Version 5.2 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 F/P 020 8518 4498 Mr Awtar Singh Johal Mrs Gloria Nadean Shakespeare Care Home 23 Category(ies) of Dementia (22), Dementia - over 65 years of age registration, with number (22), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (1), Old age, not falling within any other category (22) DS0000025934.V342863.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. One named person with a mental health disorder 22 beds to be used flexibly between categories OP, DE (E) and DE 60 years. No person with dementia under the age of 60 years to be admitted to the care home. 24th October 2005 Date of last inspection 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 generally reflects the ethnic diversity of the service user group and the locality in which the home is situated. Fees are charged between £490.00 and £500.00, which do not include hairdressing priced (£5.50-£20.00), newspapers (45 pence), toiletries (variable prices) and private chiropody (£12.50). A statement of purpose and service user guide is made available to service users once a decision is taken to live in the home. DS0000025934.V342863.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and a key inspection of the service. This meant that all key standards were covered as well as any other standard for which a requirement was made at the last inspection. It was carried out over two days beginning on the 30/4/07 at 11.00 a.m. and finished on the 03/5/07. It was noted that there are plans for developing the service to create more beds to the rear of the building. However, this had not progressed from an implementation point of view, and so the operations remained identical as at the last inspection. As part of the inspection three service users’ files were assessed including that of the most recently admitted service user. They formed part of case tracking. The inspection also entailed interviews with service users, staff, relatives and, where provided comments from external professionals. Records, policies and procedures and the facilities provided by the home were assessed. There were detailed discussions with the registered manager, deputy manager and two senior staff members. Comment cards from service users and staff were also considered and a tour of the environment was undertaken. At the time of the visit service users were going about their daily routines in a very happy and contented manner. Throughout the course of the inspection it was clear that they were continuing to receive a very good service. One of the comments received was; ‘A very caring environment – not institutionalized, they try to make it feel like home’. The feedback received from service users and their relatives was extremely positive and reflective of the quality of care provided in the home. To support this, there were very few areas that required improvements and as such the current and future outcomes for people using the services look positive. What the service does well: Service users continue to receive good and consistent care, support and stimulation from the staff, as staff spend most of their time engaging and interacting with them. There is strong commitment to ensuring that service users live a fulfilled life and this was clear from the content expressions on their faces throughout the visit. A stable staff team is maintained to ensure that consistent care and support is provided to service users. This is enhanced by the provision of appropriate training that is in line with the service objectives. DS0000025934.V342863.R01.S.doc Version 5.2 Page 6 Service users relatives continue to enjoy being able to participate and contribute to the wellbeing of their loved ones at Waverley Lodge. There is good evidence that the home is consistently meeting the nutritional requirements of service users and this includes their cultural needs. There is an ongoing commitment by the management and staff team to continue improving in what they do. 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 DS0000025934.V342863.R01.S.doc Version 5.2 Page 7 contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000025934.V342863.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000025934.V342863.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (1,2,3,6) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Detailed information is available to enable prospective service users to make an informed choice about living at Waverley Lodge. Service users have the benefit of receiving a statement of their terms and conditions for living in the home. They also benefit from having a comprehensive needs assessment carried out on them, to reduce the risk of choosing a home that is unable to meet their needs. The home does not provide intermediate care. EVIDENCE: An updated statement of purpose and service guide was available for inspection and there was evidence that one of the most recently admitted service users had access to it. It was in a print that was suitable to the service user group with the option of being translated into other forms e.g. audio, or an alternative language to meet the specific communication needs of service users. Service users and relatives spoken to were satisfied with the quality of information provided to them. In some cases social workers, who were supporting service users in finding a place to live had the benefit of this DS0000025934.V342863.R01.S.doc Version 5.2 Page 10 information, which they worked through with individuals in assessing the suitability of the home for the prospective individual. From those commenting, they reported that the information was crucial in helping their decision – making. The registered manager has demonstrated the capacity to keep information about the home under review. From assessing files, speaking with service users and their relatives, it was indeed clear that newly admitted service users continued to receive a statement of their terms and conditions for living in the home. As evidence of user involvement several were signed by service users or their relatives with the service user’s consent. This ensures that the service users, their relatives and/or advocates are clear about the obligations of the registered persons in relation to service users. Service users’ interests are therefore promoted and this is positive. As part of case tracking, recently admitted service users were assessed, and it was conclusive that they all had a comprehensive assessment carried out prior to their admission. The registered manager or a suitably qualified senior member of staff usually carries out the assessments to ensure that a consistent approach is undertaken. There was evidence that summary assessments were obtained as part of the admissions process to ensure that a detailed picture of needs is acquired, before a decision is taken. Service users spoken to described the admission’s process as being unrushed, which gave them reassurance that the home would be sensitive to meeting their needs. This is positive. DS0000025934.V342863.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (7,8,9,10) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users are assured that their personal, social and healthcare needs are well provided for, although some improvement is required to the support given with medication. Staff actively promote their privacy and all service users are pleased that they are respected at Waverley Lodge. EVIDENCE: Three service users’ plans were examined and they included those of the most recent service users, as well as service users who were part of case tracking. There is a good system of service user planning in the home, in that they generally detailed the health, personal and social care needs of service users. Where possible service users and their relatives are involved and they were reviewed at regular periods, although this could be carried out on a monthly basis. What was positive is that when a need changed, the plan reflected this change. There was one case however, where an individual’s religion was not recorded, despite the fact that he is supported to practice his religious persuasion. This was discussed and reported as an oversight, which was corrected. Staff were generally using this document as a working tool and, risk assessments to DS0000025934.V342863.R01.S.doc Version 5.2 Page 12 promote the safety and independence of service users were linked to the service user plans. All service users spoken to were aware of their individual plans. One service user candidly remarked; “my daughter looks after that and attends my review – so you see I am well taken care of”. Another remarked; “my care plan is about me and I can follow what is written in it”. There was evidence that all service users are registered with a GP and that they receive regular input from the dentist, opticians, chiropodist and where required the audiologist. Where required the services of the district nurse and continence advisor were also accessed. In one of the cases tracked, the service user’s health needs had changed and a review was held involving the GP, the service user and his family, the manager and staff. This resulted in the alternative arrangements put in place to improve the health of the individual. This is a positive outcome and was a good example of the home’s ability to meet his best interests. Other service users were observed with conditions such as diabetes and hypertension and adequate arrangements through diet, education, medication and liaison with the GPs ensured that individual needs were met. Another good example of health care promotion in the home was the pressure care management of service users. Despite the age and frailty of some service users, the incidence of pressure sores was extremely low. There was positive feedback from all relatives regarding their satisfaction with the home’s management of service users’ health. Comments received from service users also overwhelmingly confirmed their satisfaction with the support provided in meeting their healthcare needs. An integral part of promoting healthcare involved the use of various types of medication, in which staff were involved. All staff handling medication received appropriate training to enable them to so do. At the time of the visit none of the service users were independently managing their medication, although the home has a policy to promote this. Medication practices in the home continued to be generally of a high standard. Monthly audits are carried out by the pharmacist with recommendations made to improve practice. Feedback received from the pharmacist indicated that the home provided a good service to individuals living there. During an audit of the medication, it was observed that the support provided with an individual’s antibiotics could have been better. The individual did not have the drug on one of the days that two consecutive signatures were missing. Staff were not sure which day it was, as the drug was given on one of the days. The impact of this may have affected the service user’s treatment outcome and while this could not be pertinently established – the occurence created a risk. There was evidence that the manager does a monthly internal audit, however, staff needed to be extra vigilant in following safe medication practices to ensure the safety and wellbeing of the service user. The storage and disposal of medication was of a good standard. DS0000025934.V342863.R01.S.doc Version 5.2 Page 13 On both days of the inspection the staffing engagement with service users indicated that service users were respected and their privacy upheld. Service users were observed receiving personal support from staff and their privacy and dignity was preserved in all cases seen. Staff were spending most of their time engaged with service users, addressing them by their preferred names to which the service users were quite responsive. The staff demonstrated a caring attitude and worked in line with their induction standards and the General Social Care Council’s Code of Conduct. Staffing interventions were person centred and all feedback received from relatives strongly supported this. One of the relatives comments included ‘since my aunt has been in the home, she is so different and her old self. I can’t get over how well she is and so happy. I think this is because the staff are wonderful and help in every way’. Sound arrangements are in place should service users need to be seen in private and service users commenting were also pleased with this. This is a strong area of the homes operations. DS0000025934.V342863.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (12,13,14,15) People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users enjoy a range of activities at Waverley Lodge that is in line with their social, recreational and religious interests. They also enjoy maintaining strong links with family, friends and the local community. Their lifestyle is enhanced by the enabling choice in their lives and the provision of meals that are suited to their needs. EVIDENCE: From observation and the wide range of feedback received during the inspection it was clear that all service users were given a choice in relation to their preferred interests including religious observance, meals, personal and social relationships, activities and routines in the home. This follows on from an individual assessment for each service user. Internally, service users benefited from reminiscence, quizzes, art, bingo, manicures, music, video shows, an internal library, keep fit and church services. Externally they have access to a day centre that two service users attend, the theatre, pubs and trips out. One of the recent trips was to see a musical on the 21/3 at the Kenneth More theatre. It was clear that most service users were supported to do what they did previously, despite new ideas being brought on stream e.g. getting specific input for art training. The staff worked positively to ensure that service users DS0000025934.V342863.R01.S.doc Version 5.2 Page 15 were given appropriate and individual opportunities to engage in leisure and recreational activities. It was not a case of one size fits all, but rather allowing individuals to engage in what they were comfortable with along with giving them a sense of fulfilment. One example is where a service user that was previously in education is supported to have access to reading material that is of interest to her. During one of the music sessions, one service user who loved dancing got up and moved over to another, held on and they both continued dancing. The staffing presence ensured that they were safe, whilst enjoying their moments. This is commendable. Service users had the experience of sharpening up their artistic skills with the input of an external professional. This led to their artwork being exhibited at the Kenneth More theatre and from talking to service users involved – they were delighted with from the experience. As a follow on, several pieces of their work now grace the walls of the home in a decorative manner, adding a more personal and homely feel to the environment. This includes a newspaper article about the exhibition. Service users described the experience as -rewarding and special. It was also noted that the ethnic mix of the staff enabled some them to converse in ‘patois’ with a service user from the West Indies. He is also able to speak and reflect on islands such as Barbados and Dominica, which keeps him in touch and appropriately stimulated. This is a strong area of the homes operations. The home has the capacity to enable service users to have conversations in private and undisturbed. Some service users were seen using this option, whilst others preferred to meet their visitors in the open. There is a clear and open visiting policy and every relative spoken to, commended the home’s management regarding the way in which the home facilitates visitors. Friends of service users were also interviewed and they shared the same sentiment. Moreover, they viewed the visiting arrangements, as having a positive impact on the lives of service users. Various church groups visit the home and some service users had friends from their church visit, which is quite positive. It was noted that membership with a local theatre had been arranged for service users. This is also a strong area of the home’s operations. There was evidence that service users were given support to exercise choice and control in their lives. From an interview held with one service user, she spoke about his experiences in the home in a positive manner. She spoke of being able to have a lie in when she wants to; to go down to the GP with support from staff, as opposed to seeing him in the home and, to follow her religious persuasion. Her room was adorned with her personal possessions as were all other bedrooms viewed during the visit. This is positive. All service users are given the opportunity to handle their finances, following a financial assessment and information on advocacy services are made available to them. Service user also benefit from knowing they could access their DS0000025934.V342863.R01.S.doc Version 5.2 Page 16 records as and when they need to, as good arrangements were in place to enable this. Lunch was observed on the first day of the visit and again they were found to be of a very high standard. The menu consisted of sausages or steamed fish, mixed vegetables, boiled or mashed potatoes, with gravy. Dessert comprised of apple and blueberry pie with custard or fresh fruit. One of the service users interviewed stated; “I am looking forward to lunch today”, - it turned out that it was one of her favourite dishes. The meal did reflect individual choice and was prepared in such a way to promote both the independence and nutritional requirements of service users. From observation, dining seemed a pleasurable experience, which was confirmed by all service users. Flowers were on the tables and the artwork of the service users adorned the walls. Service users also confirmed that they are given choices in all meals provided and this included fruits and drinks. A sample of menus was also examined and they were varied. One of the service users commented; “we get good food here”. Another remarked; “we never want for anything here, the food is exceptional”. All relatives expressed the view that the meals provided by the home were nutritious and met the needs of their loved ones. One service user from an ethnic minority had the benefit of having flying fish brought in for him, as this is one of the national dishes from his heritage. It obviously brought back memories for him, that were invaluable. At Waverley he also enjoys fishcakes and ochra, which is reflective of his choice and the home’s preparedness to meet diverse needs. Food was generally in good supply and stored appropriately. There was evidence of nutritional screening and monitoring where required. This is another strong area of the home’s operations. DS0000025934.V342863.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): (16,18) People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users and their relatives are assured by the management’s handling of complaints, that their concerns would be addressed as and when they arise. There are sound protocols and procedures in place for safeguarding adults at Waverley Lodge. EVIDENCE: “I know of the complaints policy as it has been discussed with us at our meeting. I also know of the complaint book”. “I know how to complain because they have facilities provided such as a complaint policy and a complaint book”. “There is a complaints policy and a complaints book and everyone knows about it”. These are just some of the responses given to service users’ awareness and experience of complaints. Service users’ awareness of complaints was overwhelmingly high and it was well advertised in the home in a manner that they could follow. It was also clear that the topic is raised in their meetings and from speaking with relatives they expressed the view that concerns are addressed at early stage by the management and staff in the home. There were no complaints recorded since the last inspection, however one relative recalled that when a complaint was raised some time back by his sister – that he too was notified of the outcome. He felt that the home was transparent in dealing with complaints. The culture in the home is one in which complaints are seen as a way of improving the service. Staff take an active part in ensuring that complaints are recorded, and there was evidence from the past that outcomes were also recorded. The complaints procedure is in a format that service users can identify and relate to. DS0000025934.V342863.R01.S.doc Version 5.2 Page 18 There have been no issues regarding the safeguarding of adults at Waverley Lodge. This is due to the management’s role in ensuring that, apart from staff having updated training - they are familiar with the policies and procedures regarding safeguarding adults. All staff interviewed knew how to respond in the event of an alert and there was evidence that this issue is discussed with staff in various forums. The management team is also aware as to when an incident needs to be referred to the Local Authority as part of the local safeguarding procedures. There was also an understanding of the boundaries when discussing incidents with external bodies. It was also noted that up to nine service users used had advocates – mostly relatives, but external advocacy is available to all service users. Relatives and service users interviewed showed an awareness of the notion of abuse and the overall feedback informed that individuals felt safe living at Waverley Lodge. Policies and procedures were in place for managing verbal and physical aggression, and in such cases a risk assessment and plan is put in place for safely managing them. Staff were very clear about the action they would take if they suspected abuse and this also ensures that people using the services are safe doing so. The manager is also proactive by ensuring that staff are made aware of new developments such as; ‘The Mental Capacity Act’ and its impact on their work with service users. This is a strong area of the homes operations. DS0000025934.V342863.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (19,21,24,25,26) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users continue to live in an environment that is designed to meet their needs, that is safe and well maintained. The facilities including toilets and baths are of a good standard. The personal spaces occupied by service users also meet their expectations and needs, which is special to them. Some repairs are needed to dining chairs to enhance both the safety and comfort in the home. EVIDENCE: Service users and their relatives were pleased about the standard of the accommodation with respect to both the private and communal spaces in the home. Importance is placed on ensuring that service users retain their independence and do so in a safe manner. A handyman regularly visits the home and deals with smaller items of maintenance that is recorded in the maintenance record, which is monitored by the manager and/or her deputy. On the day of the visit it was noted that a few of the dining chairs were unstable and this could be a risk to service users, which must be addressed. DS0000025934.V342863.R01.S.doc Version 5.2 Page 20 Records viewed indicated that the home was compliant with environmental health requirements (visit 21/2/07) and the local fire safety standards (visit 2/6/02). Generally the home was in a good state of repair and service users were observed comfortably and safely accessing various parts with and without staff support. Rails and other aids in baths were sited to promote the safety of service users. Toilets and bathrooms remained strategically located on both floors of the home and they were maintained to a good standard. A domestic is employed to ensure that they are kept in a hygienic state. Fixtures and fittings were secure and designed to promote the safety and independence of service users. The toilets and bathrooms also contained fittings to promote service users’ privacy. Relatives spoken to commented that staff are discreet and sensitive when supporting service users with their personal care needs and this is positive. A number of service users’ bedrooms were assessed with their agreement. Each of the bedrooms viewed was individually decorated and adorned with personal effects e.g. family pictures and personal interests like teddy bears, televisions, radios and the like. It was clear that they reflected the culture of the individuals, which is diverse. All service users were able to identify and locate their bedrooms. Bedrooms were furnished and equipped to meet the needs of service users and there was evidence of one service user being offered a bedroom on the ground floor that was more suited to meeting his needs. Service users remained proud of their bedrooms and this remained a very popular part of the accommodation for most. There was continued high regard to the safety of service users in relation to the environment. Hot water controls, heating and lighting were well within acceptable and safe limits. Service users could have their room temperatures adjusted to suit their individual needs. All rooms, bar the hairdressing room, have a source of natural lighting and ventilation throughout the home was quite good. The safety of the environment is maintained through a walking route, which identifies areas that are below standards. This is monitored against a checklist for the manager’s attention and dealt with expeditiously. Emergency lighting is cited throughout the home and good systems are in place to control the risk of Legionella. Pre-set valves are in place to ensure that water is supplied to service users and staff at safe temperatures. The home was clean, tidy and free from offensive odours. An infection control policy is in place and staff are taken through this as part of their induction training. Hand washing facilities are cited throughout the building and the arrangements for laundering soiled linen were more than adequate. The laundry floor is impermeable and staff working in this department, were adequately trained to so do. The home complies with environmental standards and this ensures that service users are safe in the home. DS0000025934.V342863.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (27,28,29,30) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Generally service users receive a good standard of care from a team that is motivated, skilled, trained and, in adequate numbers to meet their needs. Service users’ safety is also assured by the home’s robust recruitment practices and they receive care and support from a team that is well managed. EVIDENCE: At the time of the visit there were twenty-one service users in the home and from examining the staffing rotas there was evidence that the numbers on shift were adequate for meeting the needs of the service user group. This included the need to take individuals out, which was observed throughout the course of the inspection. From examining past and current rosters and, considering comments from relatives and service users – it was abundantly clear that the staffing numbers and the mix was based on the needs of service users. One service commented; “staff are around night and day when I need them”. All staff that commented also supported the fact that there is adequate staffing on duty at all times. Ancillary staff are employed to ensure that care staff focus on work with service users. From examining then training records, it was observed that over ninety percent of the staff had achieved an NVQ level 2 in care, and in that ratio a few were aspiring for the level 3, with the deputy manager in pursuit of her level 4 DS0000025934.V342863.R01.S.doc Version 5.2 Page 22 qualification. This exceeds the minimum set by this standard. In essence most of the staff team had a sound understanding in the provision of good basic care, which was translated into practice during their engagement with service users. This is indeed positive as an outcome for the service users living at Waverley Lodge. The recruitment files of three of the most recently recruited staff were examined and it was clear that the home’s management was operating in line with their procedures. Detailed application forms were appropriately checked, there was close monitoring of references and appropriate Criminal Records Bureau checks to ensure the safety of service users. All staff had the experience of being interviewed and were not employed unless the registered persons were satisfied that they are fit to work with the service user group. All staff had a statement of their terms and conditions, as well as a copy of the GSCC code of conduct – which details the standards expected when working with service users. Service users were not involved in recruitment, but this is worth aspiring to. All staff were in receipt of an induction and the most recently recruited had theirs in line with Skills for Care Induction standards. Staff also had the benefit of foundation training as well as training that enabled them to improve and achieve outcomes for people using the service. Up to eight staff were known to have a first aid certificate and so the opportunities for receiving emergency support in the home is quite high. Some of the training that was provided over the last twelve months included; oral hygiene, first aid, dementia, medication, moving and handling, care planning, safeguarding adults, oral hygiene and fire. There is a training and development needs analysis for staff, which identifies what is needed and the priority, which is based on delivering a safe service. A training plan is in place and, apart from key refresher areas, included; – equality and diversity, nutrition and health, infection control, health and safety and further NVQ training. Feedback from external professionals supported the view that staff worked well in relation to meeting service users’ objectives and this sentiment was also supported by the feedback received from relatives. It was positive to see the level of confidence among the staff team throughout their engagement with service users. DS0000025934.V342863.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): (31,33,35,36,38) People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit to this service. Service users benefit from a home that has sound management practices, which positively impacts on the quality care they receive. Adequate quality assurance systems and a staff team that is well supported provide positive outcomes for people who use the service. Regular monthly provider monitoring visits are required to enhance quality outcomes. The health and safety and, financial best interests of service users are well provided for at Waverley Lodge. EVIDENCE: The manager is experienced and suitably qualified for the role in which she is entrusted. As such she demonstrates a clear understanding of the needs of the service user group and focus of the service. She works with the registered provider in ensuring that the financial and strategic objectives of the service DS0000025934.V342863.R01.S.doc Version 5.2 Page 24 are met. Service users, relatives and staff were extremely commendable about her management of the service, which is enhanced by having clear systems for staff to follow. She continues to be proactive for her professional development and this includes acquiring professional support. She fully meets the standards required as the registered manager and her contribution to the outcomes for service users is best described in a relative’s comment: ‘you could not find a better home’. More importantly she is aware of current developments both nationally and by the Commission. This is a strong aspect of the homes operations. There were adequate mechanisms to promote quality assurance in the home and again the manager is proactive in ensuring that systems were in place to identify development areas and bring about change. Evidence of this can be drawn from the fact that she reviewed the quality of care in September 2006 involving the views of service users, relatives and external professionals, has an annual development plan in place for the service and was in the process of preparing for another review of the service. Policies and procedures were updated and there was evidence of staff being brought up to speed with new developments regarding caring for the elderly. The manager in the course of her duty complies with the GSCC code of conduct, which ensures quality outcomes for service users. Her efforts could be enhanced by regular monthly-provider monitoring visits – something that was lacking between December 2006 and May 2007. This has been discussed with the responsible person and assurance was given that this would be complied with. Once undertaken service users are likely to receive an enhanced quality of services at Waverley Lodge. Had the providers undertaken their statutory monthly visits, this section of the report would have achieved a quality outcome rating of excellent. The financial and accounting interests of service users were satisfactorily safeguarded at Waverley Lodge. Records were assessed where monies are handled on behalf of service users, and they were found in order. A random check on balances held for service users was also satisfactory. Financial guidelines were in place to direct how all finance is to be handled. It was noted that one service user had a power of attorney with another subjected to Guardianship. An accurate audit trail was available in relation to how the service users’ financial interests are promoted. Relatives commenting, spoke with assurance of the home’s ability in safeguarding service users finances. A secure facility is available for storing the service user’s valuable possessions. Staff were positive about the support and direction they received at the home. They were generally regularly supervised and their work appraised. This allowed them opportunities to get feedback on their work, make contributions towards developing the service and their professional development. Staff also had the benefit of regular team meetings and were able to informally approach the manager or her deputy, with personal or work-related issues. To enhance DS0000025934.V342863.R01.S.doc Version 5.2 Page 25 consistency in communication – a communication book is also used, which staff found helpful. It was clear adequate systems were in place to ensure that staff are monitored and given good support in providing quality outcomes for people using the services. An updated health and safety policy is in place for staff to follow in promoting the safety of service users. They also receive training to ensure that theory is put into practice and good arrangements such as random monitoring are in place to enable this. The health and safety files were assessed and found to be in order e.g. PAT testing, fire drills, call point testing, the safe disposal of controlled waste (February 2007) and Legionella monitoring. Health and safety signs were appropriately posted and arrangements for infection control were satisfactory. Risk assessments were also in place for first aid, fire, food hygiene, moving and handling and infection control. Satisfactory arrangements were in place for gas and electrical safety, as well as for the lift maintenance and other equipment used in the home. A health and safety inspection was carried out in December 2006 and a positive outcome was achieved. It was clear that health and safety was actively promoted at Waverley Lodge. DS0000025934.V342863.R01.S.doc Version 5.2 Page 26 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 4 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 4 2 x 3 x x 4 3 3 STAFFING Standard No Score 27 3 28 4 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X 3 3 x 3 DS0000025934.V342863.R01.S.doc Version 5.2 Page 27 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. 1. Standard OP9 Regulation 13 Requirement The registered persons are required to ensure that; service users receive their prescribed medication and, that staff rigorously follow medication guidelines in relation to recording, at all times. The registered persons are required to make the dining room chairs safer and more comfortable for service users. The registered provider is required to ensure that monthly monitoring visits are carried out in line with the Care Homes Regulations 2001. Timescale for action 31/07/07 2. OP19 23 31/07/07 3. OP33 26 31/07/07 DS0000025934.V342863.R01.S.doc Version 5.2 Page 28 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 OP29 Good Practice Recommendations The registered persons should consider providing opportunities to involve service users in staff recruitment. DS0000025934.V342863.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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