Inspection on 31/05/05 for Waverley Lodge

This inspection was carried out on 31st May 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Waverley Lodge 21/11/07

Waverley Lodge 10/05/07

Waverley Lodge 21/06/06

Waverley Lodge 16/12/05

Waverley Lodge 16/09/04

Waverley Lodge 26/04/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Waverley Lodge Bewick Crescent Lemington Newcastle upon Tyne NE15 8AY Lead Inspector Irene Bowater Unannounced 31 May 2005 09:30 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 B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Waverley Lodge Address Bewick Crescent Lemington Newcastle upon Tyne NE15 8AY 0191 264 7292 0191 264 7295 waverley.lodge@fshc.co.uk Bewick Waverley Limited 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) Ms Ellen Raine CRH 45 Category(ies) of DE(E) Dementia - over 65 (19) registration, with number OP Old Age (26) of places Waverley Lodge B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None . Date of last inspection 16th September 2004 Brief Description of the Service: Wavererly Lodge is a purpose built care home that shares its site and is physically attatched to another home belonging to the same company. The home is set in large landscaped gardens, in a residential area,close to all local amenities. The home provides social and personal care for older people who have dementia on the ground floor and general nursing care for older people on the first floor. The ground floor dining room has access to the main kitchen and the upstairs dining room has a small kitchenette attatched. There are two lounge areas on each floor for residents to use. All of the bedrooms are for single occupancy and 28 of them have en-suite facilities. There are accessible toilets close to all lounges and dining rooms and each floor has adequete bathing facilities. Waverley Lodge B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place over six hours. The registered manager was available and assisted throughout the day. An Infection Control Nurse accompanied the Inspector from the Health protection Agency. The nurse gave feedback on her findings on the day and will produce a report with findings and recommendations for the manager to implement to ensure best practice in the home. The inspection focused on the requirements from the last inspection, assessment of the quality of life for the residents and examination of a range of records. Nine residents, seven staff, two visiting professional were spoken with throughout the day. The majority of the time was spent touring the home and spending time with the residents. What the service does well: What has improved since the last inspection? The home has resolved several requirements from previous inspection reports in regard to the environment, staff training and recruitment practices. The care planning and other records have improved especially on the Dementia Care Unit. Waverley Lodge B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 Page 6 The use of agency care and qualified nursing staff has reduced. This now provides a consistent staff team who are working together. 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 B53-B03 S407 Waverley V225019 310505 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 B53-B03 S407 Waverley V225019 310505 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 homes Statement of Purpose and Service User Guide do not provide residents and their representatives with the details needed to make an informed decision about admission to the home. The home has not yet produced a Statement of Terms and Conditions for residents who are self funding. Without this the rights and obligations of the resident and the provider is not clear. The admission procedures are comprehensive and ensure the staff can meet the residents’ needs on admission. EVIDENCE: The home has a corporate Statement of Purpose and Service User Guide. A welcome pack has been developed, however it does not include details of what is provided in the home. The welcome pack would be difficult for residents with dementia and sight loss to understand. The home still does not provide terms and conditions (or contracts) for residents who are self funding. Waverley Lodge B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 Page 9 Evidence from the care plans and other records show that the previous problems with assessments not being available have been resolved. Care management plans for residents being admitted were available in the care plans The admission records in the home were not always completed. Waverley Lodge B53-B03 S407 Waverley V225019 310505 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 There have been some improvements in the care planning process, however they are still not consistent to adequately provide staff with the detailed information they need to meet residents assessed needs. Lack of detail in assessing and reviewing residents’ nutritional needs has the potential to put their health care at risk The policies and procedures provided for the safe administration of medicines are not being followed placing residents at risk and harm. The staff have an understanding of residents needs and endeavour to promote their rights to privacy and dignity. EVIDENCE: Each resident has a care plan which is based on the care management assessment and the homes assessment. The home uses recognised nursing model and accredited risk assessments to implement the care plans. There has been a marked improvement in the care planning and other documentation on the dementia care unit. There was a lack of detail for social care, one resident who had fallen did not Waverley Lodge B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 Page 11 have a falls prevention plan. The plans showed that they were not always updated to reflect residents changing needs, for example if they had a chest infection the care to be delivered was not written for care staff to follow. The risk assessments for the safe use of bed rails were not updated. The care plans showed that the residents have regular access to all NHS services and facilities. The home has access to other specialist services as necessary. On the day if the visit the tissue viability nurse was visiting to review wound care and the district nurse was visiting a resident on the ground floor. Several of the residents have not been weighed nor had their care plans reviewed following weight loss. The home has policies and procedures for the safe administration of medicines. The treatment room was generally untidy, grimy and dusty and there were no paper towels to enable staff to wash their hands. The two first aid boxes had not been restocked and were practically empty. There is a drug fridge, which is used to store medication requiring specific temperatures. The daily recordings were not being kept daily and the fridge had not been defrosted for some time. The medicine administration records showed that handwritten directions did not have two signatures and abbreviations were being used. It was not possible to complete any audit as the drugs returns had not been completed for three months. There was a vast supply of thick and easy food supplements in a cupboard many of which were out of date. The administration and recording of Controlled Drugs was satisfactory. Throughout the day it was evident that the staff respected the residents rights to privacy and dignity especially in regard to personal care giving. The staff were observed knocking on doors before entering, using residents preferred names and ensuring that all personal care was given in the privacy of residents rooms, bathrooms and toilets. Waverley Lodge B53-B03 S407 Waverley V225019 310505 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) 12,13,14 The social care needs of residents currently meet their lifestyles and personal preferences. The home enables residents to maintain contact with family, representatives and the local community as far as they are able. The residents are supported to exercise choices and maintain control over their lives. EVIDENCE: The home has a designated activities organiser who is enthusiastic and has developed good relationships with the care team and residents. There is a programme of planned activities and there are detailed records available to confirm social and leisure events. In house events include bingo, board games, crafts, cookery and pet therapy. Residents that are able visit local pubs and enjoy shopping. The activities organiser is completing life histories for all residents. Visitors are welcome at any time and they confirmed that they are always made welcome. Residents are given the opportunity to maintain contacts with the local Waverley Lodge B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 Page 13 community on a group or individual basis. The residents said there were no restrictions about times for going to bed or getting up in the morning. Many of them choose to spend their day in the lounges, although some said they preferred their own company and stayed in their rooms. Despite having large landscaped gardens the home does not provide a safe garden area for residents with mental health problems. Residents are able to go out but only under supervision of the staff. Waverley Lodge B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 Page 14 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 The complaints procedures are satisfactory with evidence that residents and relatives feel that their views are listened to. The staff have had training in Adult Protection and would be able to use the procedures if necessary. EVIDENCE: The home has policies and procedures, which detail how to make a complaint. The records showed that complaints are taken seriously and are appropriately documented. Currently the Commission for Social Care Inspection is investigating two complaints made by relatives. The home is assisting in the investigation process. The policies and procedures for the Protection of Vulnerable Adults is in place and staff were able to discuss what to do should there bean allegation of abuse. Currently 27 staff have received in house training and further training is planned through “Care Alliance” training. Waverley Lodge B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 Page 15 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) 19,20,21,24,26 The home is suitable for the residents who live there, however there are no safe outdoor garden areas for residents to use safely and freely. The majority of the previous requirements concerning condition in the building have not been resolved therefore there are some potential hazards to resident safety. The staff are not trained and do not follow infection control policies, which place residents, staff and visitors at, risk. Currently the home does not provide a clean, odour free living place for the residents. The quality of some of the furnishings and fittings is poor and has the potential to place residents at risk. EVIDENCE: The home is set in large well kept landscaped gardens, which residents can access. There is no safe garden area for the residents who have dementia and those in wheelchairs would find it difficult to access the vast grassed areas. The entry and exit to the home is by locked front doors, which the staff have, Waverley Lodge B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 Page 16 to open and close. This system caused some disruption for staff in terms of time and noise for everyone. The home has lounges and dining rooms on each floor, which are reasonably decorated. There is some damage to armchairs and several of the coffee tables are damaged and worn. The guards on the radiators cannot be easily removed and there was evidence of tea spillage and dust on the radiators, which have not been cleaned for some time. The dining room chairs do not have arms nor ski glides which make them unsafe for residents who have physical disabilities. There are toilets and bathrooms close to the lounges and dining rooms and twenty-eight bedrooms have an en-suite facility. There is no central heating within the communal bathing bathroom and ensuite areas. The home has provided wall mounted blow heaters to ensure the correct temperatures are maintained. The assisted bath upstairs has been repaired but is again out of action. Toilet 7 the flooring is badly stained’ Toilet 14 the extractor fan was broken Bathroom 1 the enamel is worn and missing, The shelving in the en-suites is worn and difficult to clean, The flooring in several of the en-suites is stained, The shower facility does not enable disabled access. The bathrooms were used as storage for soiled and clean linen and other items. Several of the bins did not have lids, nor were they foot operated. The light and emergency call cords were grimy and the call cords did not reach floor level. The bedroom inspected were personalised according to residents, preferences and lifestyles. Several of the bedrooms were malodorous and grimy. Many of the mattresses and bed bases are stained and soiled Chairs were stained and soiled with body fluids, The radiators were stained and dirty and the plastic missing off many of the radiator guards. The bedrail protectors were generally marked and dirty. The bed linen was not always fresh and the towels were ragged and frayed. Several of the bed tables were damaged and worn. The home has comprehensive infection control policies and procedures in place. On the day of inspection these were not being followed and staff were unable to discuss what action they would take should there be any outbreak of Waverley Lodge B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 Page 17 infection in the home. It was confirmed that infection control training has not progressed in the home. There is a lack of domestic staff in the home and the care staff have to carry out other domestic duties especially at weekends. The sluice disinfector was broken and staff were cleaning commodes with Hibiscrub and a toilet brush. Many of the urinals, commode pots were stained and soiled. The storage shelf for commodes and urinal was split and marked. Several of the raised toilet seats were stored on the floor. The commodes were generally stained, the plastic worn and the metal legs corroded. The staff were unable to discuss the safe storage and labelling of the sharps boxes The clinical waste bags were over full and there is no safe storage area outside for clinical waste. The laundry was generally tidy, however there was a build up of dust and debris behind the machines. The laundry staff do not have suitable protective clothing when decanting detergents. The linen room was stacked high with many items stored on the floors. There is no sluice disinfector on the nursing floor and staff tip waste products down an open hopper. There is no liquid soap or paper towels in all bedrooms to enable staff the effectively wash their hands. The staff were wearing watches, rings and other jewellery, which reduces effective hand washing. There is no detailed schedule in place to check the effectiveness of the cleaning of the home An Infection Control Nurse form the Health Protection Agency and the matters of concern discussed with the manager on the day of the visit supported the inspector. The Infection Control Nurse has produced a report for the home, which should assist in addressing the problems encountered. Waverley Lodge B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 Page 18 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) 27,29,30 The home is adequately staffed with qualified nurses and care staff. Only limited progress has been made in addressing the shortages of domestic and laundry staff which has a detrimental impact on the standards of hygiene and care provision in the home. The standard of selection and recruitment of staff is satisfactory and ensures residents are protected from harm. The provision of training for staff continues to progress, however lack of training in safe working practices has the potential to place residents and staff at risk. EVIDENCE: The home is currently staffed as follows. 1 Registered General Nurse over 24 hours: 6 carers including a senior carer 8am to 8pm 4 carers overnight. An administrator, maintenance person, activities organiser, cooks, kitchen assistant’s laundry and domestic staff are employed. The manager confirmed that there are vacancies for a full time domestic and part time laundry assistant. Currently there are only five days which are covered` by laundry staff and there are some days when only one domestic is on duty for the whole home. The staff confirmed that they often have to do both laundry and domestic duties especially at weekends. Waverley Lodge B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 Page 19 A sample of the staff files showed that the recruitment and selection procedures are now being followed. Evidence showed that Criminal Record Bureau checks, two references, proof of identity and medical clearance is sought before staff are employed. The manager has introduced a training plan in partnership with Gateshead College and the Care Alliance. Some aspects of training including Moving and Handling are carried out in house. Staff have received training in mental health care, care planning, report writing and dealing with aggression. The manager is working with the Psychologist to commence further training for staff in dealing with dementia. Staff have not competed training in infection control and fire training is not up to date. Waverley Lodge B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 Page 20 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) 31,36,38 The management of the home is satisfactory and the manager has a good understanding of the areas, which need to improve. The staff receive suitable supervision from senior staff, which is improving the quality of care for residents. The lack of staff training in safe practices, issues in the maintenance of the building and outstanding requirements from previous reports pose potential risks to residents, staff and visitors health and safety. EVIDENCE: The registered manager has been in post since January 2004.She is a duel qualified first level registered general and mental health nurse. Other qualification s include Care of the Elderly, BA in education and a diploma. She has completed the Registered Managers Award. She is aware of her responsibilities and pressing issues regarding the service and has made some progress in resolving requirements from previous reports. Waverley Lodge B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 Page 21 The manager has implemented supervision for staff six times a year with records kept. She is endeavouring to complete all supervisions and appraisals herself which is not practical and will result in the targets not being met. The fire records were satisfactory although staff have not received the required training of four times a year for night staff and twice a year for day staff. The fire risk assessment has not been reviewed or up dated for the current year. There was evidence that fire doors were being held open by wooden chocks, furniture or bespoke metal doorstoppers. The accident recording and monthly analysis was satisfactory and could be cross-referenced to the care plans for individual residents. The seat of the sitting scales has not yet been repaired. Many of the call cords were not easily accessible and residents who did not have a call bell due to dementia did not have a risk assessment completed. The home uses bed rails and protective covers. The maintenance records for there safe use did not follow the required guidance. Many of the residents use Steradent to clean their dentures. The storage in ensuites and bedrooms was not been risk assessed. As stated in other standards the staff have not been trained, nor were they following infection control procedures. Staff have received training in moving and handling and first aid. The kitchenette on the nursing unit had no washing up materials, the storage cupboard was stained with food debris, and the toaster full of burnt crumbs and the microwave was dirty and covered in food splashes. The fridge temperature is not monitored nor are the temperatures recorded. The staff did not know whose responsibility this was. Waverley Lodge B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 Page 22 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 2 1 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 x COMPLAINTS AND PROTECTION 2 2 2 x x 1 x 1 STAFFING Standard No Score 27 2 28 x 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 3 x x x x 3 x 1 Waverley Lodge B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 Page 23 YES 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 OP 1 Regulation 4,5 Requirement The Service User Guide must be detailed and include all aspects as set out in Schedule 1. Copies must be available for all residents and their representatives.It must be in a suitable format for the assessed needs of the residents. OUTSTANDING SINCE 16.09.04 The home must provide Terms and Conditions of Residency for those who are self funding. OUTSTANDING SINCE 31.07.04 The care plans must set out the detail the action to be taken to ensure all aspects of health,social and personal care needs of residents are met. All risk assessments must be regularly reviewed and up dated to meet residents changing needs. Nutritional screening must be undertaken for those assessed at risk.Nutrititional care plans must be in place,advice from dieticians implemented,weights recorded and weight loss or gain reviewed and actions recorded. The staff must follow policies and procedures for the safe Timescale for action 1ST September 2005 2. OP 2 17 1ST September 2005 1st September 2005 3. OP 7 15 4. OP 8 13,14,17 1st Septemner 2005 5. OP 9 13,17 31st May 2005 Page 24 Waverley Lodge B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 administration of medicines.All medicines brought into the home and returned to pharmacy must be accurately recorded.The pharmacist must sign for all drugs returned. All hand written directions on the MAR sheets must have two signatures. All directions must be written in full.Abbreviations must not be used. The treatment room must be regularly cleaned and be organised.Liquid soap and paper towels must be provided for handwashing. The first aid boxes must be replenished and kept well stocked. The drug fridge must have the temperature recorded daily and be defrosted regularly. The overstocking of food supplements must be reviewed,stock must be used in rotation and out of date stock returned to pharmacy. Any preparations held in ensuites must be risk assessed. 6. 7. OP 19 OP 20 16,23 16,23 The home must review the access and exit to the home. The home must replace the worn, stained and damaged lounge chairs. The damaged occasional furniture requires replacing. The home must provide suitable dining chairs for resident safety. All the radiators and guards require cleaning and the plastic on the guards repaired. The home must repair or replace the assisted bath. Bathrooms must not be used to store soiled and clean linen. 1st September 2005 1st September 2005 8. OP 21 23 1st October 2005 Waverley Lodge B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 Page 25 9. OP24 23 10. OP 24 23 11. OP 26 13,23 12. OP 26 13,26 Items must not be stored on bathroom floors. The home must audit all flooring in bathrooms,toilets and ensuites and replace stained worn vinyl. The wooden shelving must be repainted or revarnished to enable easy cleaning. The bath in room 1 must be re enamelled or replaced. All bins must have suitable lids. All bathrooms,bedrooms and toilets must have liquid soap and paper towels. All emergency call cords must reach floor level. Both light cords and emergency cords must be sheathed to enable daily cleaning. The home must continue to replace damaged bedside tables and repair or replace damaged,lifting bedroom carpets. OUTSTANDING SINCE 22.04.04 The home must replace all stained,damaged beds and mattresses. The home must replace the bedroom chairs that are stained and worn. All of the radiators and guards must be cleaned. All bedrooms must be cleaned on a daily basis. The bedlinenand towels which are worn and frayed must be replaced. The home must repair the sluice disinfector on the ground floor.A disinfector must be provided on the nursing unit. OUTSTANDING SINCE 22.04.04 Infection Control training for all staff must be implemented. All staff must follow the Infection Control policies and procedures. 1 st October 2005 1ST September 2005 1st October 2005 1st October 2005 Waverley Lodge B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 Page 26 13. OP 27 18 14. OP 30 12,18 15. OP38 13,23 A cleaning schedule must be introduced to ensure the home is cleaned and kept free from odours. The sluices must be regularly cleaned and commodes cleaned following the homes procedures. Commodes and urinals that cannot be cleaned must be replaced. The commode chairs which are stained and the legs corroded must be replaced. The clinical waste must be appropriately bagged and a secure outside area provided. The bedrails and protective covers must be cleaned as necessary. Clean linen must not be stored on the floor. The debris and fluff from behind the washing and drying machines must be removed. Staff must be provided with protective clothing when decanting laundry solutions. The home must ensure that there are sufficient domestic and laundry staff employed at all times to ensure the home is maintained in a clean and hygienic state,free from odours and dirt. The home must ensure that all staff recieve training in all safe working practices especially infection control and fire training The home must ensure that fire training is carried out at the required intervals. The fire risk assessment must be reviewed and up dated for the current year. The home must not hold fire doors open with wooden chocks or other artificial means. The home must liase with the 1st Septemner 2005 1st September 2005 1st September 2005 Waverley Lodge B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 Page 27 Fire Officer regarding appropriate door closures. Risk assessments and records for the safe use of bed rails must follow MDA guidance. The sitting scales require the seat repairing. The kitchette requires cleaning,food to be covered and the equipment kept clean and free from spillages. The fridge temperature must be recorded daily. Risk assessments must be in place for residents who cannot use the call system. 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. Refer to Standard OP 14 OP 19 OP 26 Good Practice Recommendations The home should provide a safe secure garden area for residents with dementia care needs. The home should produce a planned refurbishment and programme .The home should consider alternative methods of door security and easier access and exit. The home should implement the recommendations of the Infection Control Nurses report. Waverley Lodge B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection Northumbria House Manor Walks, Cramlington Northumberland NE23 6UR 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 B53-B03 S407 Waverley V225019 310505 Stage 4.doc Version 1.30 Page 29 - 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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