Inspection on 12/02/07 for Waverley Lodge Nursing Home

This inspection was carried out on 12th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Waverley Lodge Nursing Home 20/11/08

Waverley Lodge Nursing Home 28/11/07

Waverley Lodge Nursing Home 29/11/05

Waverley Lodge Nursing Home 03/08/05

Waverley Lodge Nursing Home 21/12/04

Waverley Lodge Nursing Home 18/08/04

Waverley Lodge Nursing Home 07/05/03

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Waverley Lodge Nursing Home Dunwood Manor Nursing Centre Sherfield English Romsey Hampshire SO51 6FD Lead Inspector Anita Tengnah Unannounced Inspection 12th February 2007 10:00 X10029.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 Nursing Home DS0000011423.V330123.R03.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 and Care Homes for Adults 18 – 65*. 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 Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Waverley Lodge Nursing Home Address Dunwood Manor Nursing Centre Sherfield English Romsey Hampshire SO51 6FD 01794 513033 01794 519700 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) www.sentinel-healthcare.co.uk Sentinel Health Care Limited Mr Neil Young Care Home 26 Category(ies) of Old age, not falling within any other category registration, with number (26), Physical disability (26), Physical disability of places over 65 years of age (26), Terminally ill (26), Terminally ill over 65 years of age (26) Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The number of persons for whom accommodation and nursing care is provided at any one time shall not exceed 26 General Nursing Care: Elderly persons 60 years plus, Convalescent care, Respite care and Terminal care all 18 years plus. Specialist Nursing Care: Physical disability and Palliative care both 18 years plus 29th November 2005 Date of last inspection Brief Description of the Service: Waverley Lodge Nursing Home is located in Sherfield English with a sister home on the same site. The establishments are both owned by Sentinel Health Care Ltd. The home is registered to accommodate twenty-six service users in the categories of old age and adults from 18 years and older people in the categories of physical disability and terminal illness. Waverley Lodge was purpose built and shares some hotel service facilities with the sister home such as laundry and kitchen. The home has 2 floors and accommodation for residents is located on both of them, and a passenger lift and stairs provide access to the first floor. All bedrooms are singles and 24 have en-suite WCs. There is level access to landscaped gardens and there is a hydrotherapy pool on the site that is used by the home as well as by the three other care homes operated by the company. Located some 3 miles from the market town of Romsey, the home is situated on a bus route but also benefits form having a minibus that enables residents to access the amenities in the local community. The current fee charged is £508- £837 per week. Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit to the service was undertaken as part of the inspection on the 12th of February 2007. The process included a tour of the service where a number of the bedrooms, communal areas, laundry, and bathrooms were viewed. As part of case tracking 8 staff, 9 service users and 2 relatives views were sought and care records were looked at. Information gained from the pre inspection questionnaire was also used and included in this report, as was information gathered by the commission since the last inspection to contribute in assessing judgements in this report. The service provides care for people in the older and younger person categories. This inspection therefore was carried out in conjunction with the National Minimum Standards for Care Homes for Older People and Younger Adults. Positive comments were received from the service users regarding the care that they were receiving at the home. The commission received 9 comment cards from the service users, and all expressed satisfaction with the service that they were receiving. Care practices observed at the time of the visit showed that the staff and the service users had developed good relationships and they commented that the staff were very good. What the service does well: The service users spoken with say that they are very happy living at the home. It was evident from interaction between the staff and the service users that they have developed good relationship with each other. Service users say that they are supported and treated with respect. They enjoyed a high degree of support in accessing the local community. The pre admission assessment process was good and ensured that the home can meet the service users’ needs. The accommodation is in good state of repair, and the service users’ bedrooms are highly personalised. The meals and activities at the home were good and offered the service users choices and variety and met with their satisfaction. Comments from service users included ” the food is very good”. Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3,6 and 2 YA Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users are provided with the terms and condition of residency on admission. The pre assessment process is good and ensures that service users’ needs could be met. EVIDENCE: Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 9 The pre admission records of two newly admitted service users were seen as part of the case tracking. These were detailed and included risk assessments, moving and handling needs, communication and help required with personal care. One of the service users was admitted as an emergency admission and a care manager’s assessment was secured prior to admission. Service users are offered a contract and terms and conditions of residency. Comments received indicated that not all of the service users were aware of this and staff reported that mostly their relatives dealt with the paperwork. The service users are offered the opportunity to “test drive “ the service prior to admission and staff reported that the younger service users did visit for the day. The home’s pre-admission assessments were further developed post admission and comprehensive assessments of the resident’s needs were undertaken when they moved into the home. The service does not provide intermediate care. Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) 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, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10. 6,9,16,18,19,20 YA Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of the service users are well met. The service users are supported to take risks as part of daily living. The medication management is poor and can be to the detriment of the service users’ welfare. Service users have autonomy and choices with regards to their daily living. Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 11 EVIDENCE: A sample of five care records was seen as part of case tracking. This demonstrated that risk assessments are undertaken and care plans are put in place to show how the service users’ needs would be met. Risk assessments and care plans were detailed and contained a range of information to inform practice. These included personal care, communication, moving and handling, dietary needs and fall risk assessments and care plans. There was evidence that assessments of residents needs were reviewed regularly and revised as necessary when an individual’s circumstances had changed. A newly admitted service user’s needs had recently been reviewed involving a multi disciplinary team and care manager, looking at long term placement of the service user. The service user’s next of kin was also involved in the review and was hopeful that an appropriate placement would be found for his relative. Another service user who had been exhibiting challenging behaviour had been transferred. Comments included that the staff “do their best” in the interest of the service users. A relative who had been the main carer said that the home provided good care and “did not have to worry” any more about his relative’s welfare. The registered person discussed that a review of night care plans were being undertaken to ensure that detailed plans are in place for night care. There were a number of service users that required PEG feedings and treatment for these were prescribed. The care plans would benefit from more details about the feeds regime in order to inform practice. The responsible individual said that this would be rectified. The home has procedures in place for the management of medication. There was no service user who was self- administering medication at the time of the visit. The registered nurses were responsible for the medication at the home. A sample of Medication Administration Record (MAR) sheets was looked at as part of the visit. The controlled drugs were stored securely and accurate records were maintained. Records of MAR sheets seen indicated that the process of medication administration was poor. On a number of occasions prescribed drugs had not been signed for on the MAR sheets and staff could not say whether these medications had been administered. The process of medication ordering was also inadequate and resulted in some service users not receiving their prescribed medications, these included tablets, eye drops and ointments. One service user missed 9 dosages of her Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 12 medication and this was recorded on MAR sheet as not available. The record of drug received in the home needs to be reviewed as not all medications received were recorded. These shortfalls were brought of the attention of the person in charge as these have a detrimental effect on the service users’ welfare. It was further noted that the staff were using medication that were prescribed for other service users. These included aperients and ointment. This was discussed with staff as it is illegal to use medication prescribed for others and the use of others ointments pose an infection control risk. There was no record available of the fridge temperature to ensure that all relevant medications are stored appropriately. The staff are aware that the minimum and maximum temperature must be recorded. Service users spoken with said that the “care was good” and staff supported them as required. One service user told the inspector that he attended a day care centre every Friday and is assisted by staff. Service users are supported to exercise autonomy and choice in relation to the activities of daily living. A service user spoken with said that he usually does not get up till late and was planning to be up for lunch. All the service users were registered with the two local surgeries within their catchments area. Staff reported that the local health trust was supportive and the service users could access treatment as required. The GP undertook weekly visits and was available at other times. A service user had been referred to the speech therapist and staff reported that he had been provided with book/ cards to help with his communication. It was evident from interaction observed and service users spoken with that the staff and the service users had developed and maintained good relationships with each other. Comments included that the staff are all “very good and know what I need”. One service user said that he was treated with “respect always” and “this was a good home”. Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. 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 have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 and 12,13,15,17 YA Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users are supported in maintaining links with the local community and their families to their satisfaction. The social and cultural needs of the service users are well managed. The meals are well managed and service users are supported to take part in varied activities to suit their needs. Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 14 EVIDENCE: The service users are supported to maintain links with the local community and participated in a variety of leisure activities such as football matches, theatre trips, going to the local pub and days out. There is a planned programme of activities for them and the service users spoken with said that they enjoyed the games and activities. One of the service users said that she was looking forward to going to the hydrotherapy pool that afternoon and another service user was going to the pub for lunch. Another service user attended a day care centre on Fridays and was supported by staff. The home has its own minibus that they share with the sister homes and staff reported that the service users went out with others as the group. The local vicar visits the home on alternate Wednesdays and undertook a service and communion with the service users. The home has an open visiting policy and records of visitors as maintained by the home indicated that there was no restriction on visiting. Two relatives confirmed that they visited at different times of the day as it suited them. It was evident that the staff have developed good relationships with the relatives and they said that they were kept informed of any changes and are involved in their relatives care as appropriate. The service users were supported to bring in items of personal belongings and all the bedrooms seen were highly personalised. Two service users said that they liked their rooms and have their belongings around them. All five service users’ spoken with said that they are treated with respect and had their privacy respected. Staff were observed to knock prior to entering a service user’s bedroom. The home has a planned menu and the chef visited the service users on a daily basis and discussed the daily menu. The meals were well organised and offered the service users variety and choices. Comments received and the service users spoken within the day indicated that that the meals were “very good” and hot and cold drinks were available at all times as the home had a small kitchen where snacks and drinks could be made. Staff reported that some of the items on the menus could be better organised in order to cater for the younger persons taste. The responsible person said that this would be looked into. Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) 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 feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 and 22,23 YA Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users are confident that their complaints would be listened to. Staff have clear understanding of adult protection and ongoing training ensures that the service users are protected. EVIDENCE: The home has a complaint policy and procedure in place and the service users stated that they felt confident in using this. The home was in the process of producing a complaint procedure in other formats. Three service users spoken with said that they had no complaints and that they had “very good care” and that they would approach the staff if they were unhappy. A log of complaint received was maintained. The home had received 2 complaints since the last visit. One of the complaints was raised through social services. The operation manager reported that this had been investigated and resolved. The log should be reviewed to ensure that details of the investigation and its outcome are recorded. Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 16 The home has the Hampshire adult protection procedure and the staff spoken with demonstrated good knowledge of adult protection and action that they would take in the case of any alleged abuse. There had been two incidences at the home in December 2006 that had been referred to Social Services for investigations under adult protection. These had been investigated and were now closed. Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,24,26 and24, 30 YA. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Accommodation is provided in a warm and homely environment. Service users are provided with personalised rooms that meet their needs. The infection control procedures are good and protect the service users. Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 18 EVIDENCE: A tour of the building was undertaken as part of the visit where a number of the bedrooms, communal areas, bathrooms, and laundry were viewed. The manager reported that the home has an ongoing programme of refurbishment. The home was clean and homely. Furnishing was of a good standard and appropriate to the needs of the service users. The service users are provided with well-maintained communal areas where a variety of activities were undertaken. The service users’ bedrooms were highly personalised with pictures, televisions, computers and family photos. The home has a large well-maintained landscaped garden, with a decking area and extensive lawn garden and ornamental pond and was easily accessible for wheelchair users where seating was also provided. The home has information on infection control procedures. The staff practices observed at the time of the visit indicated that the staff were aware of this and used infection control equipment in their daily practices. There is an internal laundry that is shared with the sister home in the grounds. Staff spoken with said that this worked well. The beddings and towels seen were in good state of repair and staff reported that these are renewed regularly. There were appropriate washing machines and driers in place; the washing machines were fitted with a sluicing facility. The laundry was clean and in good decorative order, the flooring was impermeable and hand-washing facilities were available. Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 and 32,34,35 YA. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staffing numbers are adequate to meet the present needs of the service users. The home’s recruitment and training programme is good and ensures that the service users are protected and staff have the skills to deliver care effectively. EVIDENCE: The roster seen indicated the normal staffing level during waking hours, seven days a week, were 2 trained nurses and 4 carers on the morning shift. There was 1 trained nurse and 3 carers on the afternoon/ evening shift and night Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 20 duty had 3 waking staff that included 1 trained nurse and 2 carers. Staff and service users’ spoken with confirmed that there was adequate staff on duty. The home has student nurses from the local university and staff confirmed that they are extra to the required staff numbers. Three staff records were audited as part of this visit. These indicated that all staff completed an application form. All appropriate checks were undertaken and available on file to ensure that the service users are protected. Records of staff induction were also available. The responsible person has recently reviewed the induction programme and put in place the “Skills for Care” programme for all new staff. 5 of the 12 carers employed have completed National Vocational training (NVQ) at level 2 or above. The home has an ongoing staff training programme and staff reported that training was good and some training is shared with the sister homes. Some of the recent training included palliative care, stress management, food hygiene and mandatory health and safety training. Training in prevention of abuse was scheduled for later this month. Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. 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 a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 and 37,39,42 YA Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 22 The home has an effective quality assurance and monitoring system in place to ensure the home is run in the best interest of residents. The financial interests of the service users are protected. The health and safety of residents and staff is promoted. EVIDENCE: The home did not have a manager at the time of the visit and the senior sister was managing the home with the support of the responsible person. A new manager had been recruited and was due to start the following week. There is an internal auditing system in place that included quarterly service users’ meetings. Some other aspects of the home’s service were audited throughout the year such as care plans, medication administration, and falls/accident analysis. At a recent service users’ meeting they had requested a themed day meal and staff reported that this had been introduced. The commission also receives regular reports of Regulation 26 visits as undertaken by the representatives from the company. The service users personal allowance as managed by the sister home was seen and this indicated that receipts of all transactions were maintained. There were two service users at the home who had the provider as appointees for their financial affairs. The responsible person reported that these are held in the service users personal accounts. A sample of the servicing records and information indicated that there are regular reviews of policies and procedures to ensure that they meet current legislation/ guidelines. There has been no recent visit from the fire officer. There is an ongoing programme for the servicing of fire equipment, hoists, wheelchairs, lift and emergency lighting. Records seen showed that they were all completed in the last 6 months. The central heating system was checked in December 2006.The registered person is aware substances that are hazardous to health (COSHH) must be kept locked and keys removed from the cupboard. Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 3 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 3 Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 24 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 17(1) (a) Schedule 3 Requirement The registered person must ensure that records of all medicines received; administered to the service users and the date that they were administered are maintained. Medication prescribed must only be administered to the named service user. The registered person must ensure that staff adhere to procedures for receipt, handling and administration of medication at the home. Timescale for action 30/03/07 2. OP9 13(2) 30/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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. Extracts may not be used or reproduced without the express permission of CSCI. Waverley Lodge Nursing Home DS0000011423.V330123.R03.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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