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Inspection on 29/11/05 for Waverley Lodge Nursing Home

Also see our care home review for Waverley Lodge Nursing Home for more information

This inspection was carried out on 29th November 2005.

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

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

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The standard of care in the home was good and was based on comprehensive assessments of the needs of both potential existing residents. These resulted in plans of care that ensured that residents received the support and help that they required. A range of comprehensive up to date written policies and procedures helped to inform staff practice. The home promoted the right of residents to make choices for themselves and exercise personal autonomy as far as was reasonably possible, including managing their own financial affairs and participation in the civic process. Management systems and procedures in the home worked well including, managing medication, monitoring the quality of the service provided, staff recruitment and training, record keeping and health and safety. Residents described their bedroom accommodation positively.

What has improved since the last inspection?

There was a small increase in the number of health care assistants working in the home who had obtained a National Vocational Qualification (NVQ) or its equivalent, to at least level 2 in care. Consequently there were more staff in the home that had been formally assessed as having the competence and skills to be able to provide the care and support required by residents living there

What the care home could do better:

Although record keeping by the home was generally good with those being kept being up to date. There were no records available of furniture that residents had brought into the home with them. A record of any furniture brought by a resident into accommodation occupied by them must also be kept to ensure that the interest of the person concerned is protected.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Waverley Lodge Nursing Home Dunwood Manor Nursing Centre Sherfield English Romsey Hampshire SO51 6FD Lead Inspector Tim Inkson Unannounced Inspection 29th November 2005 09:30 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.V269555.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People 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.V269555.R01.S.doc Version 5.0 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) 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.V269555.R01.S.doc Version 5.0 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 3rd August 2005 Date of last inspection Brief Description of the Service: Waverley Lodge Nursing Home is located in Sherfield English. It is on the same site as it’s sister home Dunwood Manor. The establishments are both owned by Sentinel Health Care Ltd (the company). Waverley Lodge was purpose built and shares some hotel service facilities with Dunwood Manor i.e. laundry and kitchen. The home has 2 floors and accommodation for residents is located on the both of them, and a passenger lift provides access the first floor. All bedrooms are singles and 24 have en-suite WCs. The home is provided with assisted bathing facilities and the communal/shared rooms comprise, a lounge and dining room, a kitchenette, a smoking room and an activities room. 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. Waverley Lodge is located some 3 miles from the market town of Romsey. The home is situated on a bus route but also benefits from having the use of a minibus that enables residents to access the amenities in the local community. Waverley Lodge Nursing Home DS0000011423.V269555.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second of two inspections of the home that must be undertaken in the 12-month period beginning on 1st April 2005. It started at 09:10 hours and finished at 14:05 hours. The inspection procedure included viewing a sample of some bedrooms (6), an examination of documents and records, observation of staff practices where this was possible without being intrusive and discussion with residents (5), and staff (3). At the time of the inspection the home was accommodating 25 residents and of these 15 were male and 10 were female and their ages ranged from 37 to 97 years. No resident was from a minority ethnic group. There was no registered manager in post due to the previous manager leaving earlier in the year. The home’s new acting manager and Sentinel Healthcare’s operations director were both available during the visit, to provide assistance and information when required. What the service does well: What has improved since the last inspection? There was a small increase in the number of health care assistants working in the home who had obtained a National Vocational Qualification (NVQ) or its equivalent, to at least level 2 in care. Consequently there were more staff in the home that had been formally assessed as having the competence and skills to be able to provide the care and support required by residents living there. Waverley Lodge Nursing Home DS0000011423.V269555.R01.S.doc Version 5.0 Page 6 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 Nursing Home DS0000011423.V269555.R01.S.doc Version 5.0 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.V269555.R01.S.doc Version 5.0 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 to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 The home’s admission procedures included good assessments of the needs of potential residents before they moved into the home to ensure that the home could provide the care and support that individuals required. EVIDENCE: The home had written policies and procedures concerned with the admission of new residents to the home and also the assessment of the needs of potential residents. The records of 3 residents were examined and these included copies of detailed assessments that the home had arranged of the needs of the individuals concerned. On this occasion as at the last inspection of the home on 3rd August 2005, it was apparent from discussion with residents and from the documents Waverley Lodge Nursing Home DS0000011423.V269555.R01.S.doc Version 5.0 Page 9 examined that the needs of potential residents were identified before the persons moved into the home. Where individuals had been admitted to the home through care management arrangements copies of the assessments and care plans of the relevant local authority were also available. The home’s pre-admission assessments were complemented by more thorough and comprehensive assessments of a resident’s needs when they actually moved into the home. There was documentary evidence that assessments of residents needs were reviewed regularly and revised as necessary when an individual’s circumstances had changed. At the time of the inspection a potential resident was visiting the home to view the premises and obtain some information about the service provided. He was accompanied by a relative and also by a healthcare professional. He was staying for the day and was being provided with lunch. The visit would also enable the home’s staff to assess the person’s needs. Waverley Lodge Nursing Home DS0000011423.V269555.R01.S.doc Version 5.0 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 to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 9 There were good plans of care in place that ensured that residents received the help and support that they needed. Good procedures and systems were also in place to ensure that medication was administered safely. EVIDENCE: On this occasion as at the last inspection of the home on 3rd August 2005, a sample of the care plans of residents were examined (3). The documents were detailed and the plans were based on the assessments the home carried out in order to identify what help individuals needed (see pages 9 and 10). The plans set out clearly the actions staff had to take and what specialist equipment was needed to provide the support and assistance each person required. Waverley Lodge Nursing Home DS0000011423.V269555.R01.S.doc Version 5.0 Page 11 Observation and discussion with residents confirmed that individuals received the help they needed and that the equipment was in place as set out in their plans of care. There was evidence from both the documentation and discussion with residents that individuals had been involved in developing the plans and agreed with the contents. All nursing and care staff spoken to were fully aware of the contents of the care plans that were sampled and the assistance that the individuals concerned required. The care plans documents included assessments of the potential risks to residents of among other things, pressure sores, malnutrition, falls, and wandering. Strategies for eliminating or reducing the risk of harm had been identified and implemented e.g. pressure-relieving aids were in place. There was documentary evidence that care plans were evaluated and reviewed regularly. The home had written policies and procedures concerned with the management and administration of medication. A range of reference material about medication was readily available including a recent copy of the British National Formulary (BNF). Medication was kept in locked and secured medicine trolleys, cupboards and where required in a medical refrigerator. Controlled drugs were stored securely and in an appropriate metal locked cabinet. Medicines were dispensed from their original containers and registered nurses were responsible for the management and administration of medication. Records were kept of the ordering, receipt, administration and the disposal of medicines and these were accurate and up to date. The home had implemented new methods for the disposal of unwanted and unused medicines. The home’s written medication procedures referred to above did not reflect this changed practice. This had arisen as a result of recent changes in the National Health Service contract for community pharmacists and to ensure compliance with legislation about the disposal of industrial waste. The operations manager for Sentinel Health care Ltd, said that before producing a new written procedure they were waiting for clarification about the use of the bins for the disposal of medicines and also for used needles (“sharps”) that a contractor had provided as they had been given conflicting about their use. Waverley Lodge Nursing Home DS0000011423.V269555.R01.S.doc Version 5.0 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 The home had good procedures in place for ensuring residents could exercise self-determination. EVIDENCE: The home supported residents to manage their own finances if they wished to do so by for example helping them to use local banking services. Some residents spoken to indicated that they were pleased to give the responsibility for looking after their financial affairs to their families or other representatives. The home had details of an advocacy and information services on display in it’s entrance hall, should a resident or relatives wish to obtain independent advice Waverley Lodge Nursing Home DS0000011423.V269555.R01.S.doc Version 5.0 Page 13 about any matters that may cause them concern. It was suggested that such information could be displayed more prominently. The home permitted residents to furnish their own bedroom accommodation if they wanted to do so and several residents spoken to said that they had items of their own furniture in their bedrooms rooms. The home had written policies and procedures about “Confidentiality” and “Access to Records”. The latter stated among other things that residents had the right to access their own records. Residents spoken to were aware that they could see records that the home kept concerning them if they wanted to. The home kept records secure in the office used by the manager. Residents spoken to expressed a general view that the home’s routines were relaxed and that they were “free to do as they wanted within reason”. Waverley Lodge Nursing Home DS0000011423.V269555.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 The home had good procedures in place to ensure that residents could exercise their civic rights. EVIDENCE: The operations director for Sentinel Healthcare Ltd, said that the home was sent documents by the local council to enable the details of residents to be entered and registered on the electoral roll. She also said that at election time individuals had the choice of either getting transport to the local polling station or exercising a postal vote. Residents spoken to said that they could vote in elections and participate in the electoral process. • “I have been able to vote”. • “Politicians come up and see us. I told the local Member of Parliament that I voted Liberal Democrat but I don’t”. Waverley Lodge Nursing Home DS0000011423.V269555.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 25 The home’s bedrooms accommodation was well maintained, furnished and equipped for service users safety and specific needs. EVIDENCE: All residents spoken to expressed contentment with the condition of their bedrooms and indicated that the accommodation was well maintained and looked after. Bedrooms viewed were furnished and equipped as expected by Standard 24 of the National Minimum Standards for care Homes for Older People. They were fitted with carpets and doors had suitable locks. They were naturally ventilated Waverley Lodge Nursing Home DS0000011423.V269555.R01.S.doc Version 5.0 Page 16 and heated by radiators that were covered with guards to prevent residents from the risk of burns. Nursing beds i.e. either height adjustable or “profile”, had been provided where these were required for the person accommodated. The temperature of the hot water was tested in wash hand-basins in 2 en-suite facilities in bedrooms and it was “comfortable”. Records were seen of regular testing of the temperature of water at hot outlets throughout the home and it being delivered at around 43°C. Waverley Lodge Nursing Home DS0000011423.V269555.R01.S.doc Version 5.0 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28 and 30 The home’s staff training and development procedures were good ensuring that staff acquired the necessary competence and could be deployed with an appropriate skill mix in order to meet the needs of the residents. EVIDENCE: At the time of the inspection the home was employing 4 registered nurses and 9 health care assistants and of the latter 5 (55 ) had obtained qualifications to at least National Vocational Qualification (NVQ) level 2 in care or its equivalent. The operations director for Sentinel Healthcare Ltd, said that another new healthcare assistant was also due to begin working in the home in the near future and that they had already obtained an appropriate formal qualification. At the last inspection of the home on 3rd August 2005, there were 10 health care assistants working in the home and of those 4 (i.e.40 ) were qualified to at least NVQ level 2 in care or its equivalent. There was evidence of the home’s commitment to staff training and development from discussion with staff. All staff spoken to confirmed that they Waverley Lodge Nursing Home DS0000011423.V269555.R01.S.doc Version 5.0 Page 18 had opportunities to obtain formal qualifications and also enhance their skills and knowledge by attending courses and training events in subjects appropriate to the type of work they were involved in e.g. palliative care, as well as general nursing and personal care. They also said that they attended regular training sessions in core/statutory health and safety subjects. New staff confirmed that they had received induction training to a level expected by “Skills for Care” the social care sector’s training organisation that replaced the Training Organisation for Personal Social Services (TOPSS) in April 2005. Comments from staff about their training and career development included the following: • “I am doing mentorship at Bournemouth University and we have monthly sessions. I have attended courses on wound care and I have also applied to do a course in palliative care at a local hospice”. • “My induction training included looking giving residents rights, choice, privacy and respect. I have done manual handling, food hygiene, infection control and fire safety. I hope to do NVQ 2 soon.” Residents spoken to said that they thought that the staff group had the ability and competence necessary to look after them properly. At the time of the inspection there were 2 registered nurses on duty and 4 health care assistants and of the latter 3 had qualifications equivalent to at least NVQ level 2 in care. Waverley Lodge Nursing Home DS0000011423.V269555.R01.S.doc Version 5.0 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 37 and 38 The home’s manager had the experience and skills necessary to run the home effectively. Systems for monitoring quality, keeping records and managing health and safety in the home were generally good ensuring that residents’ welfare and interests were safeguarded. EVIDENCE: Waverley Lodge Nursing Home DS0000011423.V269555.R01.S.doc Version 5.0 Page 20 The home’s acting manager had been in post 3 weeks at the time of the inspection. She was a registered nurse and had been qualified for 7 years. Her experience included posts where she worked in intensive care in hospital and as a nursing officer on cruise ships. In the latter role she dealt with a wide range of problems and clinical matters and she compared that work to a practice nurse in a surgery. Staff views about the appointment of the new manager were positive as all of those spoken to perceived the period of time between the resignation of the last manager and the appointment of the new manager as “difficult”. They said that since she had started work some 3 weeks before the inspection visit she had met with staff individually and organised staff meetings and that “already things have improved”. The home had a system in place for monitoring quality. There was documentary evidence that aspects of the home’s service were audited throughout the year (e.g. Care Plans; medication administration charts, accident analysis). Residents said that they were consulted informally about the care they received and related matters and that formal meetings were organised at which they could voice their opinions. Relatives were sent questionnaires by the Sentinel Healthcare Ltd, seeking their views about the quality of the service the home provided. Sentinel Health Care Ltd had also employed external consultants to conduct a staff satisfaction survey and had published the results. Representatives from Sentinel Healthcare Ltd, undertook statutory monthly visits to the home and assessed aspects of the service and subsequently produced reports of the visits for the home’s manager and copies for the Commission for Social Care Inspection (CSCI). There was a comprehensive range of policies and procedures readily available for staff to refer to that informed care and working practices in the home. There was also evidence that they were reviewed updated and developed as legislation and practice determined. Staff comments about these policies and procedures included: • “ I have read many of the policies and procedures. Quite a few were included in my induction pack. They are guidelines for the things that we do every day like administering drugs”. • “They give us measures and rules to follow ….”. • “I have read some of them and they are very important, they make sure that we all do the same thing”. Sentinel Healthcare Ltd, acted as agent or appointee for some residents who because of their frailty or disability could not manage their own financial affairs. A central account was managed at the head office of Sentinel healthcare Ltd and it complied with the guidance issued by the CSCI, (i.e. the account earned interest that was apportioned between individuals based on the amount each had in the account). Accurate records were maintained of each persons transactions and the balance they held. Waverley Lodge Nursing Home DS0000011423.V269555.R01.S.doc Version 5.0 Page 21 The home also held small amounts of monies for some residents to enable them to have cash for themselves. Accurate records were kept of such sums and the balance being held on their behalf. A number of statutorily required records were examined during the inspection and they included the following: • • • • • • • • • Assessments and care plans for residents and related records. Statement of Purpose Service Users Guide Medication Fire safety including tests of equipment and drills and staff training Monies held on behalf of residents Visitors to the home Accidents Complaints All of the records examined were accurate and up to date but there was no record available of furniture brought by a resident into accommodation occupied by them. Such records must be kept to ensure that individuals’ interests are safeguarded. There was evidence from both discussions and records that all staff working in the home had received regular training in health and safety subjects that were relevant to their role in the home. These included first aid, fire safety, food hygiene, moving and handling, infection control and control of substances hazardous to health. Records also indicated that systems and equipment in the home were tested and serviced at intervals and with the frequencies either required according to relevant regulations or good practice. These included: • Fire safety equipment • Electrical wiring • Boilers and central heating • Portable electrical appliances • Hoists and slings • Lifts • Hot water systems –(tested for temperature and the presence of legionella). Waverley Lodge Nursing Home DS0000011423.V269555.R01.S.doc Version 5.0 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 Standard No Score 1 X 2 X 3 3 4 X 5 X 6 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 3 18 X ENVIRONMENT Standard No Score 19 X 20 X 21 X 22 X 23 X 24 3 25 3 26 X STAFFING Standard No Score 27 X 28 3 29 X 30 3 MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 2 38 3 Waverley Lodge Nursing Home DS0000011423.V269555.R01.S.doc Version 5.0 Page 23 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 OP37 Regulation 17 Requirement The registered person must ensure that all statutorily required records are up to date at all times and specifically that records are kept of furniture that residents bring into accommodation used by them. Timescale for action 31/12/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Waverley Lodge Nursing Home DS0000011423.V269555.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Nursing Home DS0000011423.V269555.R01.S.doc Version 5.0 Page 25 - 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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