Inspection on 13/12/05 for Wellesley Lodge

This inspection was carried out on 13th December 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

Wellesley Lodge 22/05/08

Wellesley Lodge 05/06/07

Wellesley Lodge 29/06/06

Wellesley Lodge 04/08/05

Wellesley Lodge 02/03/05

Wellesley Lodge 02/12/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Wellesley Lodge 41 Worcester Road Sutton Surrey SM2 6PY Lead Inspector Peter Stanley Unannounced Inspection 13th December 2005 9:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Wellesley Lodge Address 41 Worcester Road Sutton Surrey SM2 6PY Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8643 8860 020 8643 9086 Larcombe Housing Association Mrs Christine Marie Wicker Care Home 21 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (11) of places Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th August 2005 Brief Description of the Service: Wellesley Lodge is situated to the south west of Sutton, between Cheam and Sutton town centres. The home is owned by Larcombe Housing Association and is registered to provide care for 21 elderly persons, including places for 10 elderly persons with dementia and related illnesses. The property is a large detached house, with accommodation for residents on the ground and first floors. There are 21 single bedrooms. Access to the first floor is by way of either a staircase or a shaft lift. Communal facilities include a spacious lounge and a smaller secondary lounge and a conservatory. There are also 2 separate dining rooms. The home has a cellar used for storage and there is a garden at the rear of the property with many fruit trees, a grassed area, patio and a covered area. There is some off street parking to the front and side of the premises. Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home that took about six hours. The home’s registered manager and provider, left in November, and the Home is being temporarily managed by an acting manager, Marion Drake (coopted from another home) with whom the inspection was conducted. The inspector spoke to a large number of service users, and to staff on duty. Care records and other documentation were examined. Many positive comments were received from service users regarding the home and the care provided by staff, with service users presenting as generally settled in their environment. There was, however, some evidence of a lack of stimulation, and a wish for more regular activities to be offered. Staff members on duty expressed positive views about the home, and were observed to be interacting well with service users. There are, however, a number of concerns that need to be addressed, with a large number of requirements (18). 5 of these remain to be met from the previous inspection, and require action to be taken within the extended timescales that have been set (shown in bold italics). 7 recommendations are also made from this inspection. Of particular concern is the failure of the Home to ensure that all care staff are being provided with regular, one-to-one supervision. This impacts on the support of staff, and care of service users, and must be addressed as a high priority. The inspector understands that the home’s deputy manager is currently responsible for supervising all of the Home’s care staff. The division of supervisory responsibilities with the new registered manager, and some delegation (with training) to senior care workers, would assist in lightening the heavy supervisory workload currently being shouldered by the deputy manager. The inspector is also very concerned regarding the apparent failure of the registered providers to comply with their responsibility for monitoring the home. Regulation 26 requires that the responsible individual (representing the registered providers) complete an unannounced inspection of the home at least once a month, and prepare a written report (a copy of which must be forwarded to the CSCI). None was evidenced since September 2005. Concerns relating to medication are also raised in this report, for which urgent action must be taken. In this regard, training and consultancy, regarding the Home’s procedures and practice, from a major accredited pharmacist, is strongly advisable. The appointment of a new registered manager should hopefully provide the opportunity for the home to review the shortcomings identified in this report, Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 Page 6 and to build on its previously good record. The inspector would like to extend his thanks to the acting manager, the administrator, staff and service users for their assistance throughout the inspection. What the service does well: What has improved since the last inspection? Since the last inspection 8 staff have undertaken Sutton’s one-day Vulnerable Adult training; this must, however, be extended to all staff. 9 staff are currently undertaking dementia awareness training; this must, however, be extended to all care staff. Questionnaires have been extended from service users to include relatives/friends and visiting professionals and other visitors. Quality assurance processes need, however, to be consolidated and a Development Plan produced. Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 Page 7 What they could do better: Generally, service users are evidenced as having their health, personal and social care needs set out in an individual plan of care; however, a service user plan had not been put in place for one recent admission. For service users to be sufficiently protected, there are a number of issues relating to the safe storage of medication, which need to be addressed. Accredited medication training, provided by a major pharmacist, needs to be extended to all care staff. While service users are being provided with opportunities for leisure and social activity, these should be consistently made available, on a daily basis, in order to sufficiently meet the social needs of service users. The home has the numbers and skill mix of staff sufficient to safely meet the needs presented by the home’s service users. However, for safety to be assured, the home has to achieve a minimum ratio of 50 trained members of care staff with NVQ Level 2 or equivalent. While, generally, the home’s service users are being protected by appropriate recruitment policy and procedures, the home has failed to obtain a criminal records check for a recent staff appointment. Generally, staff are being provided with the necessary induction and ongoing training with which to competently perform their work duties. However, for the needs of service users with dementia to be fully addressed, training in dementia awareness must be extended to all staff. The home does not currently have a registered manager, and is being managed in a generally competent way by an acting manager. The early appointment of a new registered manager is, however, essential, if service users are to receive the assurance they require regarding the running of the home, and the services provided. Staff at the home are not being appropriately supervised; this is nonsupportive of staff and is potentially placing service users at risk. The registered providers) are failing to comply with their responsibility under Regulation 26, for a report (based on an unannounced inspection of the home) to be completed at least once a month. Please contact the provider for advice of actions taken in response to this Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 Page 8 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home is able to demonstrate that it is assessing and meeting the needs of service users admitted to the home. Prospective service users, their friend and relatives are able to visit to assess the suitability of the home; a longer trial period (to six weeks) would, however, assist the service user to feel assured that he/she is making the right decision. EVIDENCE: Standards 3, 4 and 5 assessed. Information is sought from care managers, hospitals and GP’s, while the manager or her deputy will also go out and conduct their own assessment. An in-house assessment pro forma is in place, this having been developed into a very comprehensive document. This includes sections on communications, mobility, memory, mood, transfers, continence, eating and drinking, and personal care. Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 Page 11 The Acting Manager advised, that following a requirement from the last inspection, the home is maintaining a close check on all admissions. The home has admitted four service users since the last inspection. Preadmission care assessments had been completed by the home and relevant information obtained from statutory agencies regarding assessed needs. As required in the Regulations (Schedule 3), a photograph of the service user is required; this was not included on these files, for which a requirement applies. The home has the capacity to meet the individual needs of service users admitted to the home. This home provides care for 21 elderly residents, the number of places for service users who suffer from dementia having increased from 8 to 10. The remainder of the places are for persons who require residential care because of their age/frailty. Staff are receiving specific training in caring for clients with dementia. Care staff receive a comprehensive range of training tailored to meeting the care and support needs of older people. The inspector spoke to a number of service users, who expressed their satisfaction with the care and support being provided at the home, and who felt that their needs are being met. The acting manager confirmed that prospective service users are always invited to visit the home prior to agreeing to accept an offer of a place. If they are unable to visit, then the manager would expect a family member to visit on their behalf. Potential residents are invited to stay for a day, have lunch and talk to residents and any visiting relatives. Following admission, there is a fourweek trial period, to enable the home to determine if it will be able to meet the service users needs, and for the service user to decide if he/she will feel happy and comfortable living in the home. The inspector discussed the length of the trial period with the acting manager; it was agreed that the length of the trial period is on the short side and that consideration should be given to extending this to at least six weeks. A recommendation applies. Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Generally, service users are evidenced as having their health, personal and social care needs set out in an individual plan of care; however, a service user plan had not been put in place for one recent admission. The health care needs of service users are being generally well met. For service users to be sufficiently protected, there are a number of issues relating to the safe storage of medication which need to be addressed. Accredited medication training, from a major pharmacist, also needs to be extended to all care staff. EVIDENCE: Standards 7, 8 and 9 assessed. The inspector examined service users’ care plans. These are hand written and are not always clearly legible. The inspector recommends that all care plans are typed out to ensure that they are readily understood by staff. Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 Page 13 Following a previous requirement, an additional form has been introduced for staff to record each identified need under a predetermined heading (i.e. sensory, dietary, continence), and to record how that need is to be met. This is then reviewed monthly. The inspector sampled service users files and found that service users’ needs are being appropiately recorded in their service user plan, with daily notes evidencing how these needs are being met. The inspector examined the files for four recently admitted service users and found one file which did not include a service user plan. This was a concerning omission and one which must not be allowed to reoccur; a requirement applies. Since the last inspection, when there were concerns regarding a service user with dementia, dementia awareness training is gradually being rolled out to all staff. As evidenced at the last inspection, the home is generally meeting the health care needs of its’ service users and there are good relationships in place with a visiting district nurse and other health care professionals. The home has regular, periodic contact with visiting specialist health practitioners including physiotherapy, chiropody, dental and optician services. There is also contact with mental health services as and when required. The home has complied with a requirement for the secure storage of controlled drugs. On inspection, however, it was felt that it would be preferable for all controlled drugs to be removed from the medication trolley altogether, and for these to be located within a safe within the locked cupboard attached to the wall; a further requirement therefore applies. There are a number of other concerns in respect of medication which need to be addressed, for which the inspector is making the following requirements: For all creams and ointments to be kept separately from any internal (oral or ingested) medications. These could be placed within a separate container within the medication trolley, but not side by side. For a new medication fridge to be put in place for the storage of antibiotics, eye drops and any other medication requiring to be kept at a controlled temperature. It is not acceptable for any of these items to be placed within the main food fridge as was evidenced on this inspection. In order that staff awareness of safe procedures for the storage and administration of medication is raised, the inspector is making it a requirement for staff to receive accredited medication training from a major pharmacist with extensive experience of providing accredited training. From his discussion with the acting manager, the inspector is of the view that the training so far provided by a local pharmacy is not sufficiently rigorous or comprehensive. Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 Page 14 The inspector also recommends that the home reviews its medication policy and procedures in the light of any training and consultation received from a major accredited pharmacist. The acting manager advised that a new medication information sheet has been introduced for each service user, which includes a photo of the service user. There is also a medication training checklist, detailing all aspects of medication procedures, which all staff who administer medication are required to have worked through. A new medication audit sheet has also been put in place. The inspector examined some medication records which are being closely monitored by the acting manager, and found these to be satisfactorily maintained. Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 Page 15 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): While service users are being provided with opportunities for leisure and social activity, these should be consistently made available, on a daily basis, in order to sufficiently meet the social needs of service users. EVIDENCE: All standards met at the last inspection. The inspector spoke to a number of service users and found some evidence of a falling-off in activities, and of a lack of stimulation. This has been identified as a concern from a previous inspection, but had appeared to improve on the last inspection. The acting manager advised that there is an activity scheduled for an hour each afternoon, but acknowledged that this may have fallen off of late. Activities are, it seems, being planned over the Christmas period. While no requirement is being applied on this occasion, the inspector wishes to see a marked and sustained improvement in this area, and this will be focussed on in more depth at the next inspection. Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home’s adult protection policies and procedures have been revised so as to ensure that there are clear guidelines for reporting abuse. Statutory vulnerable adult training is gradually being extended to all staff. EVIDENCE: Standard 18 assessed. No complaints or adult protection concerns were identified. A requirement from the last inspection, for all staff to attend Sutton’s Vulnerable Adult training has been partially met. The acting manager advised that 8 of the 16 care staff have so far completed this training and that further training is planned for the other staff in January, subject to confirmation from Sutton. The inspector spoke to a number of service users. This indicated that service users feel safe and protected within the home, with staff being perceived as caring and supportive. Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home presents as clean, pleasant and hygienic; training in infection control is, however, required following some laxity in procedures which presented a risk of cross infection. EVIDENCE: Standard 26 assessed. Standards 19 to 24 met at the last inspection. The home generally presented as being clean, pleasant and hygienic. The inspector understands, however, that there has been some laxity in infection control procedures, with staff having been observed wearing rubber gloves and aprons inappropriately around the home. The acting manager has placed a notice on the staff notice board, which makes clear that this is not acceptable given the risk of cross-infection. The inspector discussed the need for all staff to undertake Infection Control training and is making this a requirement. Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home has the numbers and skill mix of staff sufficient to safely meet the needs presented by the home’s service users. However, for safety to be assured, the home has to achieve a minimum ratio of 50 trained members of care staff with NVQ Level 2 or equivalent. While, generally, the home’s service users are being protected by appropriate recruitment policy and procedures, the home has failed to obtain a criminal records check for a recent staff appointment. Generally, staff are being provided with the necessary induction and ongoing training with which to competently perform their work duties. However, for the needs of service users with dementia to be fully addressed, training in dementia awareness must be extended to all staff. EVIDENCE: Standards 27, 29 and 30 assessed. On the day of inspection appropriate numbers of staff were found to be on duty; staff rotas indicated a minimum of four care staff (including two senior care staff). One senior and one care worker work overnight with a back-up sleep-in carer. The manager or deputy manager are on-call if required. The home has recruited one new staff member since the last inspection. On inspection of the staff file it was found that only one reference has been Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 Page 19 obtained (a requirement applies), and no CRB (Criminal Records Bureau) certificate received. This lapse in recruitment procedures is potentially placing service users at risk and must not re-occur. It was agreed that the home immediately apply for a POVA First check, and that there would be no one-toone contact with any service user until such time as the CRB certificate has been received. A requirement applies. The inspector received an assurance that four Care Bank staff applications, for whom CRB certificates have not yet been received, will not be allowed to work at the home until their CRB certificates have been received. A computerised record is kept of all staff and the courses that they have attended. As previously recommended by the inspector, a staff training record is now being included on each staff file. This details the training completed and scheduled (with dates) for each member of staff. The inspector spoke to two care staff and ascertained that they were undertaking relevant training, and receiving ongoing support. Both spoke positively about the home and their work with service users. A requirement from the last inspection, for all staff to undertake dementia awareness training has not yet been fully met. The acting manager advised that 9 staff are currently undertaking this through distance learning training with NESCOT (North East Surrey College Of Technology). This training needs to be extended to all the Home’s staff. As previously recommended, training in Bereavement and Loss should also be extended to all care staff. Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The home does not currently have a registered manager, and is being managed in a generally competent way by an acting manager. The early appointment of a new registered manager is, however, essential, if service users are to receive the assurance they require regarding the running of the home, and the services provided. The home is developing its quality assurance processes, with view to evidencing that it is meeting its aims and objectives, and is being run in the best interests of service users. This needs to be consolidated, and a Development Plan put in place. Staff at the home are not being appropriately supervised; this is nonsupportive of staff and is potentially placing service users at risk. EVIDENCE: Standards 31, 33, 36 and 38 assessed. Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 Page 21 Since the last inspection, the registered manager has left, and the home has, since 21/11/05 been managed by an acting manager, Marion Drake; she is normally a deputy manager at another care home, and has extensive experience of management in another home. She was observed to be managing the home in a competent way. The inspector was advised that a new registered manager is due to be appointed early in the New Year; in the interests of service users, an early appointment is essential. The inspector is very concerned regarding the failure of the registered providers to comply with a requirement in respect of Regulation 26. This requires that the responsible individual (representing the providers) carries out an unannounced visit to the home at least once a month, and prepares a written report, a copy of which must be forwarded to the CSCI. The inspector examined the relevant reports and found no evidence of any visit having taken place since September 2005. Given that the home does not currently have a registered manager, this is particularly concerning and must be rectified forthwith. Following a recent requirement (2-3 December 2004) the home has introduced quality assurance systems to assist in measuring the success of the home in meeting the aims and objectives set out in the Statement of Purpose. A monthly audit pro forma has been developed, with which to monitor the quality of the service, and questionnaires have been given residents asking for their views of the home. Questionnaires have now also been developed for obtaining the views of relatives/friends, relevant professionals and other visitors. The home needs to produce an annual quality assurance Development Plan, to include feedback from service users and other parties, regarding the extent to which the Home is meeting its aims and objectives; a requirement applies. The inspector examined staff supervision files and was very concerned to note that there was no evidence of staff having received any proper one-to-one supervision since May 2005. The inspector understands that the deputy manager is currently undertaking all supervision: she was not present on the day of inspection to discuss this. The inspector feels that the level of supervision required for a home with 16 care staff and 6 ancillary staff is far too great a burden for one person and should be divided between the manager, deputy manager and senior care workers. To assist this process of delegation of supervisory duties, two things need to happen. Firstly, the home should, as a priority, review the job descriptions of senior care workers with view to including supervisory responsibilities. This change would be consistent with practice in other large care homes. Secondly, all staff who are given supervisory responsibilities should attend supervision and appraisal trainingthis is a high priority and should be actioned forthwith. In the meantime regular, one-to-one, recorded supervision (on at least a 2 monthly basis) must be held with all care staff who work in the home. This Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 Page 22 must include the regular supervision of the Deputy Manager by the Manager, for whom no supervision has been evident. The inspector takes a very serious view of the present situation as the lack of proper supervision is nonsupportive of staff and is potentially placing service users at risk. The home’s registered providers have the responsibility to ensure that this situation is not allowed to continue and to ensure that immediate steps are taken to address these shortcomings. A number of requirements apply. A new supervision format should also be developed, the present format providing insufficient detail or clarity regarding the issues discussed in supervision. This needs to provide separate headings for professional and practice issues, training/development issues, personal issues (sickness, leave etc) and actions/decisions agreed. This should be signed by both the supervisor and supervisee, and dated. All health and safety checks were completed at the last inspection. A requirement in respect of radiator covers being fitted on all remaining radiators in the home is still outstanding. The acting manager advised the inspector that the work required has been booked with a contractor and that this is due to be completed early in the New Year. No other concerns were identified. Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 x 14 x 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 2 x x x x x x x 2 STAFFING Standard No Score 27 3 28 x 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 2 x x 1 x 2 Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15(1) & (2) Requirement The registered manager must ensure that a service user plan is put in place for all service users, and that this is reviewed on a regular monthly basis. The registered manager must ensure that all controlled drugs are securely stored in a locked metal container or safe. This must be kept in a locked cupboard and affixed to the wall, and not kept with any other drugs or within the medication trolley. The registered manager must ensure that all creams and ointments are be kept separately from any internal (oral or ingested) medications. These could be placed within a separate container within the medication trolley, but not side-by-side. A new medication fridge must be put in place for the storage of antibiotics, eye drops and any other medication requiring to be kept at a controlled temperature. The registered manager must ensure that accredited DS0000007169.V270986.R01.S.doc Timescale for action 31/12/05 2 OP9 13(2), (4)(a) & (c) 31/01/06 3 OP9 13(2), (4)(c) 31/12/05 4 OP9 13(2), (4)(c) 31/01/06 5 OP9 13(2) 31/05/06 Wellesley Lodge Version 5.0 Page 25 6 OP18 13 (6) 7 8 9 OP26 OP28 OP29 12(1)(a) 13(4)(a,c) 18 (1)(a) 19(1)(b) Schedule 2 10 OP29 19(1)(b), Schedule 2 11 12 OP30 OP33 18(1)(a) & (c) 24(2) medication training is extended to all care staff. This training must be provided by a major accredited pharmacist with extensive experience of training in this area. (Training from a small local pharmacy will not suffice). The registered manager must ensure that all staff attend Suttons one-day Vulnerable Adult protection training. The registered manager must ensure that all staff undertake Infection Control training The registered manager must ensure that at least 50 of the care staff obtain an NVQ Level 2. The registered manager must ensure that new CRB checks are in place for all applicants prior to their being employed in the home. A CRB certificate must be obtained for one recent staff appointment, and a copy of this forwarded to the CSCI, Croydon office. The registered manager must ensure that all recruitment and identity checks (including the need for 2 references) are completed prior to the confirmation of any new staff appointment. Dementia awareness training must be extended to all care staff. The registered provider/manager must compile an annual (Quality Assurance) Development Plan. This should provide feedback (including questionnaires), from service users, their relatives and representatives, visiting professionals and other visitors, in assessing the homes performance in meeting the aims DS0000007169.V270986.R01.S.doc 28/02/06 31/05/06 31/05/06 31/12/05 31/12/05 31/05/06 31/05/06 Wellesley Lodge Version 5.0 Page 26 13 OP33 26 14 OP36 18(2) 15 OP36 18(2) 16 OP36 18(2) 18(1)(a.c) 17 OP37 17(1)a Sch3,No2 13 18 OP38 and objectives outlined in the Homes Statement of Purpose. A copy of the Plan should be supplied to the CSCI. The registered provider must ensure that the home is visited on a monthly basis and a report of each visit produced. A copy should be available in the home, and a copy sent to the local CSCI office. The Registered Manager and Deputy Manager must ensure that all staff receive regular, one-to-one, recorded supervision (on at least a two monthly basis). The Registered Manager must provide regular, one-to-one, recorded supervision for the Deputy Manager (on at least a two monthly basis). All staff with supervisory responsibilities must undertake supervision and appraisal training. (This should include senior care staff for whom supervisory responsibilities could be delegated). The registered manager must ensure that a photograph of the service user is included on all service users’ files. Radiator covers must be fitted on all remaining radiators in the home, and risk assessments for service users reviewed where appropriate. 31/01/06 31/12/05 31/03/06 31/05/06 31/12/05 31/03/06 Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP5 Good Practice Recommendations The registered providers and manager should consider extending the trial period for newly admitted service users from four to six weeks. The inspector recommends that all care plans are typed out to ensure that they are readily understood by staff. The home should aim to review its medication policy and procedures in the light of any training and consultation received from a major accredited pharmacist, and/or a CSCI pharmaceutical inspector. Bereavement training should be extended to all staff. There needs to be further First Aider training, to include night staff. A new supervision format should be developed. This needs to provide separate headings for professional and practice issues, training/development issues, personal issues (sickness, leave etc) and actions/decisions agreed. This should be signed by both the supervisor and supervisee, and dated. The registered providers and manager should aim to widen the job description of senior care staff so as to enable some delegation of supervision and other key tasks. 2 3 OP7 OP9 4 5 6 OP30 OP30 OP36 7 OP36 Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 Page 28 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Wellesley Lodge DS0000007169.V270986.R01.S.doc Version 5.0 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. 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