Inspection on 22/05/08 for Wellesley Lodge

This inspection was carried out on 22nd May 2008.

CSCI found this care home to be providing an Good service.

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 05/06/07

Wellesley Lodge 29/06/06

Wellesley Lodge 13/12/05

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 28/09/2008.

CARE HOMES FOR OLDER PEOPLE Wellesley Lodge 41 Worcester Road Sutton Surrey SM2 6PY Lead Inspector Peter Stanley Unannounced Inspection 22nd May 2008 09:30 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.V363954.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 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 Larcombeha@yahoo.co.uk Larcombe Housing Association Sally Anne Rochester 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.V363954.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP (maximum number of places: 11) Dementia - Code DE(E) (of the following age range: over 65 years) (maximum number of places: 10 ) The maximum number of service users who can be accommodated is: 21 5th June 2007 2. Date of last inspection 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.V363954.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. Wellesley Lodge is registered with the Commission For Social Care Inspection (CSCI) as a care home providing care for up to 21 older persons, with 10 places for older persons who have dementia. Training in dementia awareness has been provided for all care staff, and is being extended to the home’s ancillary staff. This was a key inspection of the home that was completed over one day. The inspection involved discussion with the home’s registered manager, Ms Sally Rochester. The inspector spoke with a wide range of residents, including three residents who had been admitted to the home in recent months. He also spoke to two visiting relatives, to the recently appointed deputy manager, and to staff on duty. The inspector examined a wide range of documentation. This included staff and residents’ files, care plans, incident and accidents logs, and health and safety records. The inspector also case-tracked the records of four recently admitted service users. Completed questionnaires were received from 2 residents and 6 relatives. The views expressed were generally positive, the home being described as “welcoming” and “a friendly place to visit”, and the staff being described as “helpful” and “caring”. One relative said that the home “shows a very caring attitude” while another described the home as “always looking fresh and clean”. The inspector noted that the home offers a varied range of activities and entertainment, and the opportunity to participate in daily routines. One resident stated in her questionnaire that she derives considerable satisfaction from assisting with daily chores such as laying tables for lunch and doing a little light cleaning. The inspector also noted an enabling attitude towards encouraging residents to be as independent as possible, and to exercise choice, and for residents to be consulted regarding decisions that affect their day-to-day lives. There was, however, some comment which indicated that, due to staff turnover (9 new staff in the last 12 months), it could, at times, be difficult for residents and relatives to identify staff. One relative felt that the wearing of name badges would help in this regard. Another relative felt that there were “times when staff were not always available to supervise residents”, and that this was a problem which could, perhaps, be eased “by moving staff breaks around”. Another relative felt that the television in the main lounge was often too loud and that this “tended to kill conversation”. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 6 The feedback from this inspection, and the CSCI questionnaires, evidences generally widespread satisfaction from both residents and relatives with the quality of care and support being provided. The home is regarded as providing a very pleasant, supportive and caring environment. The positive and enabling culture within the home has been encouraged and promoted by the home’s registered manager, Sally Rochester. Since taking up her post in March 2006, she has demonstrated a commitment to maintaining and raising standards, and to promoting an open, enabling and inclusive philosophy of care. The home is in a good position to build on the excellent progress that has been made within the last two years, and to achieve sustained and continuing improvement in its operations. From this inspection there are 3 requirements and 2 recommendations, 3 out of 5 requirements from the previous inspection having been fully met. The inspector would like to extend his thanks to the manager, staff, residents and relatives for their assistance in helping to facilitate this inspection. What the service does well: The home is able to demonstrate that it is obtaining full information regarding the health and support needs of prospective residents prior to their admission. Prospective residents, their friends and relatives are able to visit to assess the suitability of the home. Residents are being provided with written information detailing the terms and conditions of their placement. The home is ensuring that residents’ health care needs are being fully met, and that their dependency levels are being closely monitored. Residents are being protected by the home’s medication policies, procedures and training. Residents are being treated with respect and their right to privacy is being maintained. Residents can be assured that, in the eventuality of their death, their wishes will be respected and that they and their family will be treated with care, sensitivity and respect. Residents are being provided with a full and varied range of opportunities for leisure and social activities. These are in accord with their social, cultural and religious interests and needs. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 7 Residents are being encouraged to maintain contact with their family and friends, with visitors being made welcome at the home. Residents have opportunities for developing and maintaining links with the local community. Residents are able to exercise choice and control in their day-to-day activities and routines. Residents receive a wholesome and appealing diet, with choice being offered, in pleasant surroundings, and at times convenient to them. Residents and their relatives can be assured that the home has an appropriate complaints policy and procedure in place, and that their complaints will be listened to, taken seriously and acted upon. The legal rights of residents within the home are being protected and promoted. The protection of residents is being safeguarded by the home’s adult protection, policies and training. Residents are living in a safe, well-maintained environment, with access to safe, sufficient and comfortable facilities. The home has sufficient aids and adaptations with which to safely meet the needs of residents. Residents’ rooms are safe, comfortable and pleasantly decorated, reflecting residents’ personal identities, and being suited to their individual needs. The home presents as being clean, pleasant and hygienic. The home has the numbers and skill mix of staff sufficient to meet the needs presented by the home’s residents, and to ensure their safety. Residents are being safeguarded by satisfactory recruitment policy and procedures, and the careful vetting of new staff. Staff are being provided with the necessary induction and training with which to perform their work duties competently, and to safely meet the needs of residents. Residents are living in a home that is being competently managed, and run in a way which creates an open, positive and inclusive atmosphere. The home is consulting widely with residents, relatives and other stakeholders, and is able to evidence the home’s ability to meet its aims and objectives. The financial interests of residents are being appropriately protected. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 8 Through the regular and appropriate supervision of staff, good practice is being promoted and the welfare and best interests of residents protected. A system of annual appraisal does, however, need to be put in place. The interests of residents are being safeguarded by the home’s record keeping, with records being kept secure, up to date and accurate. Generally, the health, safety and welfare of residents and staff are being appropriately promoted and protected. What has improved since the last inspection? What they could do better: Generally, prospective residents are being provided with comprehensive and up-to-date information required with which to make an informed choice regarding the suitability of the home. However, both the Service User Guide and Statement of Purpose are overdue for review and need to be updated. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 9 It is again recommended that two staff (one administering and one observing) be present for all administration of medication. This is in line with good practice, minimising the potential for any error to occur and thereby providing additional safeguarding for residents. All staff must be annually appraised as to their abilities, skills, training and development needs. A Development Plan needs to be put in place for 2007-08. 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. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 10 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.V363954.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 to 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally, prospective service users are being provided with comprehensive and up-to-date information required with which to make an informed choice regarding the suitability of the home. However, both the Service User Guide and Statement of Purpose are overdue for review and need to be updated. The home is able to demonstrate that it is obtaining full information regarding the health and support needs of prospective residents prior to their admission. Prospective residents, their friends and relatives are able to visit to assess the suitability of the home. Residents are being provided with written information detailing the terms and conditions of their placement. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 12 EVIDENCE: The home provides care for 21 elderly residents, which includes 10 places for older persons with dementia. The number of residents who suffer from dementia has increased to the maximum of 10 since the last inspection. There are currently 11 residents who require residential care because of their age and physical frailty. Care staff are being provided with a comprehensive range of training, this being tailored to meeting the care and support needs of older people. This includes training relating to the needs of older people with dementia. The home has a Statement of Purpose (SOP) and a Service User Guide (SUG) in place. These provide comprehensive information about the home and the services provided. They are, however, overdue for review, last having been updated in January 2007. A requirement applies. Following the initial referral, prospective residents are encouraged to visit the home with their families or friends, and to ask questions about the home and the care provided. The home’s AQAA (Annual Quality Assurance Assessment) states that information (brochure, SOP, SUG and a contract) about the home is being provided, with prospective residents and their relatives/friends being encouraged to read a copy of the home’s CSCI Inspection report. Should the application proceed, the prospective resident is then invited to visit and look round, to stay for lunch or tea, and to talk to staff, residents and any visiting relatives. A decision is then made regarding the person’s wishes and the offer of a place. The manager or assistant manager visit the person who has been referred and undertake a pre-admission assessment. This aims to gather information relating to the person’s history and background, his/her likes and dislikes, preferences, cultural and religious needs. The assessment format includes sections on communications, mobility, memory, mood, transfers, continence, eating and drinking, and personal care, and represents a very comprehensive document. The assessment is undertaken with the person, and his/her relatives/carers, at the person’s home, or at a place where the individual feels comfortable, such as a day centre. Risk assessments are also completed. For prospective residents who are referred from hospital or from a social services/health authority, the home obtains a copy of the care management assessment and care plan. From the information obtained from the assessments and risk assessments, a person-centred care plan is developed. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 13 Following admission, there is an initial six-week trial period. This is to ensure that the prospective resident has sufficient time in which to settle into their new environment, and to ensure that the home is able to fully meet their needs. Information regarding the steps taken to help settle the new resident into the home is provided in the home’s self-assessment (AQAA). It states that a named care worker is allocated to the resident, whose role it is to liaise with and befriend the individual, and help to settle him/her in. Also, it states that the resident is introduced to other residents who may share similar backgrounds, interests and abilities. And that relatives are introduced to other residents’ relatives to provide peer support. The inspector spoke with three residents who had been recently admitted and was assured that they had been made to feel welcome, and were being well supported by staff. One lady did, however, indicate that the experience of moving from independent living into residential care was not proving to be an easy one for her. This was not, she explained, so much a criticism of the home as of her feelings of loss at having to give up her independence and leave her own home. The inspector examined files for four residents who have been admitted within the last 12 months. All of these were privately self-funded referrals. The files evidenced that referral and assessment information had been obtained prior to admission, and that the home had undertaken an appropriate assessment for each resident. The home has also had two transfers from people living in residential homes in Somerset and Derbyshire, moving to be close to their families. Whilst the two residents have had their 6 weekly reviews and have been evidenced as having settled in well, the manager felt some concern that she had had to rely solely on the accuracy of information provided by the care professionals and families involved. According to the home’s AQAA, the home is planning to develop a feedback form to be given to the new resident, and the people involved in the placement, on completion of the six-week trial. This is designed to provide the opportunity to let the home know of any information that they feel would have been useful to know in advance or at the start of the placement. At the end of the trial period, a review meeting is held, with the resident, his/her relatives, the resident’s key worker, and the care manager (if social services are involved) being present. The person’s circumstances, wishes and the suitability of the placement in meeting their needs are discussed. A decision is then made regarding whether or not to proceed with a permanent admission. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 14 The home was evidenced to be holding 6 weekly care reviews following admission, with reviews following at 6 months and thereby on a 12 monthly basis. Following previous concerns, the home is now trying to ensure that care reviews are being held at least once a year for all residents. The reviews involve the resident, their key worker, relatives and any care professionals involved in their care. Sampling of residents’ files indicated that reviews are generally taking place on a timely basis. The inspector observed residents to be happy and settled in their environment, with good interaction taking place between staff and residents. From his discussion with a number of residents, the inspector gained the impression that the home is continuing to maintain good standards of care and support, and that the home provides a pleasant and welcoming environment in which to live. Comments from residents indicated that staff are perceived to be caring and respectful, and to be attentive to their individual needs. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 15 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 to 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home are developing person-centred care plans that detail the person’s health, personal and social care needs, and which reflect residents’ individual preferences and choices. These are being drawn up with the involvement of the individual concerned, and in consultation with their relatives or representatives. Care plans are being reviewed on a monthly basis. The home is ensuring that residents’ health care needs are being fully met, and that their dependency levels are being closely monitored. Residents are being protected by the home’s medication policies, procedures and training. Residents are being treated with respect and their right to privacy is being maintained. Residents can be assured that, in the eventuality of their death, their wishes will be respected and that they and their family will be treated with care, sensitivity and respect. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 16 EVIDENCE: Each resident has a personal information sheet which details emergency contacts, the circumstances and times of day which relatives wish to be kept informed and contacted. This also includes details of the person’s GP and social worker, and includes any essential medical information regarding any condition or disability. The home maintains a care plan for each resident, for which a photograph of the resident is attached to the front sheet. These are being presented in a structured and typed format, and provide a clear and comprehensive breakdown of residents’ care and support needs and how these are being addressed. The care plans have been developed so as to reflect a more person-centred approach, and indicate the involvement of residents in developing them. They include a personal profile of each resident, with details of the resident’s background, their likes and dislikes, preferences, interests/hobbies, and information as to their cultural, religious and spiritual needs. Also included are details regarding the resident’s medical history, their medication, personal care needs, nutritional and dietary needs, mobility and risk factors (including falls) together with details regarding their communication and understanding, and the resident’s, wishes regarding their end of life care. The resident and their family/advocate are involved in writing the care plan with both signing to say that they agree with the plan. The inspector examined a sample of care plans. Care plans and assessments maintained in separate files and provide considerable detail regarding residents’ assessed care and support needs. There was evidence of care plan reviews taking place with care plans being updated and amended when necessary. Care plans are generally being reviewed on a monthly basis. The manager advised that in supporting the development of a person-centred approach, staff have undertaken some in-house training. The inspector would, however, like to see this approach further developed and consolidated, and for the manager, deputy manager and senior care staff to attend the local authority’s (LB Sutton) PCP Facilitators course in Person-centred Care Planning. This training would assist in raising awareness of person-centred care processes, training which could then be rolled out to all staff who work in the home. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 17 Residents’ health needs are being generally being well met in this home, no specific concerns coming to light during the inspection. One resident has, however, exhibited specific behavioural difficulties, which involved an element of risk to other residents. These have, however, been appropriately addressed through social services safeguarding procedures, and through the receipt of the necessary psychiatric assessment and support. The home is served by a local GP group practice with which it enjoys a good relationship. Most residents are registered with this practice, though some residents exercise their wish to retain their own GP. There is a visiting district nurse who visits to monitor blood sugars for those residents (4) who are diabetic, and who administers treatment for one resident on a weekly basis. She attends as and when required for other residents. There is regular, periodic contact with visiting specialist health practitioners including physiotherapy, chiropody (both NHS and private), dental and optician services, and a specialist optical service visits 6 monthly for residents who have dementia. Residents are able to retain the services of their own dentist or optician if they so wish. There is also contact with mental health services as and when required. One resident is currently receiving visits from a CPN (Community Psychiatric Nurse), two others receiving CPN input as and when required. An incontinence nurse is available on referral to provide advice and information to staff regarding the management of incontinence. The home undertakes monthly checks of each resident’s mental and physical health, and assesses for any sign of pressure sores, behavioural and personal risks (including falls). Nutritional screening and weight monitoring are also undertaken on a monthly basis. These checks provide a score to identify the dependency level of each individual, this being used to ensure that the resident’s needs are being fully met. Anyone falling outside the average range for BMI (Body Mass Index) are closely monitored, with staff aiming to ensure that the individual is receiving sufficient dietary and nutritional intake. Staff develop their awareness in this area through attending the Level 2 certificate in Nutrition and Health. All staff receive occasional direct observation from the assistant manager or from a senior care worker. This focuses on the care that they are providing and includes personal hygiene and oral health. A record is kept of each direct observation session and includes what the care worker has done well and what areas could be improved. Staff are encouraged to promote each resident’s independence and to encourage the individual to undertake as much as they can for themselves. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 18 The home has an appropriate policy and procedure in place for the receipt, recording, storage, handling, administration and disposal of medication. The home has adequate arrangements in place for the storage of medication, which include the provision of a medication fridge and a separate metal safe for the secure storage of controlled drugs. There is an appropriate system in place for recording medications received, administered and returned. A medication information sheet is maintained for each resident, which includes a photo of the resident. The home uses the Monitored Dosage System to reduce any possibility of error. MAR sheets record all medications that are administered, these being signed for each entry by the staff member who administers each medication. The inspector has previously discussed administration of medication with the manager and recommended that two staff (one administering and one observing) be present for all administration. While this has not, as yet, been implemented, the manager did, however, provide an assurance that the present arrangements have, to date, proved satisfactory in preventing any errors from occurring. Staff who are responsible for administering medication are supervised by direct observation by the manager and assistant manager on all aspects of the drug system. There is also a medication training checklist, which details all aspects of medication procedures, and which all staff who administer medication are required to have worked through. The registered manager completes a monthly medication audit and completes occasional spot checks on staff that administer medication. The pharmacy also undertakes periodic inspections and provides accredited medication training for staff. All staff also undertake the Level 2 medication course which is provided by NESCOT (North-East Surrey College of Technology). While residents are able to administer their own medication if they wish, no residents are presently doing so. Should this eventuality arise, this would be subject to a risk assessment. The home is has a commitment to respecting the privacy, dignity and rights of residents, these being detailed in the home’s policies and procedures. Residents are given the opportunity to have their own room keys and all have access to room safes for their personal belongings. Residents can, if they wish, have a private telephone line installed in their rooms. All staff employed by the home receive training as part of their induction, about treating residents with dignity and respecting the individual’s right to privacy. The inspector spoke to a large number of residents during the inspection and received feedback from questionnaires. Views that have been expressed indicate that residents find staff to be kind, caring and respectful of their privacy, rights and dignity. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 19 There is an open door policy whereby relatives and friends are welcome to visit at any time. Visiting relatives and professionals are able to see residents in the privacy of their own rooms, or in the relative privacy of the smaller dining room. The inspector observed staff interacting with residents in a caring and respectful way, with evidence of staff having developed good, trusting relationships with residents. One care worker was sitting chatting to two elderly residents in the garden, both of whom presented as happily engaged in conversation and appreciative of the support that is being provided. The home meets the standard covering bereavement and loss. Wellesley Lodge is seen as a ‘home for life’, and given that the needs of each resident can continue to be met, then a resident would be enabled to remain at the home in their final days. Staff at the home have undertaken relevant training in palliative care. There have been six deaths at the home since the last inspection. The home has been evidenced to deal with these events in a sensitive way and to keep family and friends fully informed and involved in any arrangements that are made. Details of residents’ wishes in the event of their serious illness/death are recorded. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 20 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11 to 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are being provided with a full and varied range of opportunities for leisure and social activities. These are in accord with their social, cultural and religious interests and needs. Residents are being encouraged to maintain contact with their family and friends, with visitors being made welcome at the home. Residents have opportunities for developing and maintaining links with the local community. Residents are able to exercise choice and control in their day-to-day activities and routines. Residents receive a wholesome and appealing diet, with choice being offered, in pleasant surroundings, and at times convenient to them. EVIDENCE: Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 21 This home is evidenced to be providing a wide and varied range of activities and outings. A programme of activities is publicised on the notice board; this includes games and puzzles, sing-alongs, exercise sessions, reminiscence, and visiting entertainers, with an activity now being scheduled twice a day, for every morning and afternoon. Residents are being given the opportunity to be actively engaged during the day with a programme of activities and classes run by both care staff and visiting professionals. The home offers a range of daily activities, one every morning and one every afternoon. These are lead by care staff, visiting entertainers or by professionals visiting to undertake keep fit groups. There are also visits from a wildlife hospital with some small animals being bought into the home. There are two keep fit groups each week and there is secured funding for an eight week falls prevention exercise group. The inspector spoke with a number of residents and received positive feedback from residents regarding the range of activities and leisure opportunities available. There was evidence of both informal and organised activities being facilitated by staff, and of attention being given to developing individual interests and hobbies, such as knitting, reading and gardening. The home’s manager has been keen to encourage one-to-one and less formal activities, with staff members being encouraged to initiate individual and small group activity during the afternoon. During the inspection a visiting activities organiser was observed engaging some residents on an individual basis. Activity sessions are regularly held within the main lounge. Board games are encouraged. Staff were, once again, observed to be interacting in a positive way with residents, with residents being encouraged to engage and participate in conversation and activities. All residents are given the opportunity to join in activities whether it is a group activity, a specialist activity they enjoy or an activity that they previously enjoyed such as domestic type work, helping lay tables or assisting with gardening. Residents are being consulted in resident meetings as to their interests and wishes. Residents who have dementia are encouraged to use the skills that they remember and to assist, if they wish, with daily tasks such as light cleaning or laying tables in the dining room. There is also a system whereby two or three residents at a time are escorted out for a short walk before lunch, with priority being given to those residents who do not benefit from visits by relatives or friends. There is a positive attitude within the home to developing links with the wider community. Social contacts are encouraged and contacts in the community with social clubs and churches are supported. Visits by children from a local school and from a local brownie group are also encouraged. The home has links with the local church and volunteers from the church visit and assist with organised events and activities. Residents’ beliefs and religious Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 22 beliefs are respected, with arrangements being made for individuals to attend services or receive visits where requested. Residents attend three different churches in the community and the local priest visits monthly to offer communion to those of the Catholic faith. There is also a monthly interdenominational service and communion for those residents who wish to attend. The home aims to encourage resident involvement in planning activities and outings, with residents being consulted as to their preferred choices in residents’ meetings. The home are members of Sutton Community Transport and organise monthly outings by minibus to places of interest, the seaside, or meals out to local pubs. The home is aiming to increase outings to twomonthly with the recruitment of a second volunteer driver. Relatives are encouraged to join with the residents on outings if they wish. Residents are consulted as to where they would like to go and are able to make suggestions at residents’ meetings. These have included visits to a local wildlife hospital, and to various gardens and beauty spots. Daily newspapers are delivered to the home and a mobile library visits once a month. There is also a talking books service, provided by Surrey Association for the Blind, which visits the home on a regular basis. A hairdresser visits the home weekly and residents are able to enjoy a visit to her saloon. From the views expressed by residents and relatives, residents are able to exercise considerable choice and control in their daily routines and activities. Staff are observed to be encouraging and facilitative in their interactions with residents. The ethos of the home in this regard is evidenced as being a very enabling one. Residents are able to handle their financial affairs for as long as is practical or for as long as they wish. Three residents are presently managing their own monies. There are regular monthly residents’ meetings and there is evidence of resident involvement and consultation regarding residents’ preferences and their daily activities. One resident sits as a residents’ representative on the home’s interviewing panel. Overall, the inspector is impressed with the level and range of activity and user-involvement being promoted within this home. Views expressed by residents indicate that the food that is served is very good. Fresh vegetables and fresh ingredients are used, the quality of food served being well vetted. Menus evidence that the home is providing a good range of nutritious and appetising food with alternative options being offered to the main dish if required. A menu-planning group, involving residents, has led to the introduction of an increased variety of foods including pasta dishes and other types of cuisine to complement the more traditional range of foods. There is a monthly barbecued lunch, and all residents are being given the choice of a cooked Sunday breakfast. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 23 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 to 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives can be assured that the home has an appropriate complaints policy and procedure in place, and that their complaints will be listened to, taken seriously and acted upon. The legal rights of residents within the home are being protected and promoted. The protection of residents is being safeguarded by the home’s adult protection, policies and training. EVIDENCE: The home has an appropriate complaints policy and procedure, a summary of which appears in the Statement of Purpose and Service User Guide. A written complaints record is maintained, which details the nature of the complaint, the subsequent investigation and actions taken. The home logs both concerns and compliments and aims to be pro-active in resolving any concerns that arise. The home has received no complaints within the last 12 months. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 24 The home promotes an open culture with residents and relatives encouraged to raise any issues or their concerns. In this regard, the home is planning to introduce a “comments, compliments and complaints box” for use by everyone connected to the home. To provide additional protection to residents regarding their rights, the home will assist any resident, who wishes to do so, to have contact with an advocate through a local advocacy service (Sutton Advocacy Partners). The home aims to protect residents’ legal rights by involving family and friends in respect of their contracts, benefits and monies, and in discussing any issues that may arise. All residents are registered to vote, and are supported where necessary to exercise this right. Postal votes are promoted and residents are given privacy to complete these. The home has a policy regarding residents’ money and financial affairs. Each resident is provided with a monthly statement of their personal allowance, with residents’ monies being kept in individual account wallets and accessible at any time. Some residents manage their own money and are provided with room safes for them to keep their money and valuables safe and secure. The home has an appropriate policy and procedure in place for the protection of vulnerable adults. The home has a Whistle Blowing Policy in place for staff to reference should the need arise. All staff in the home have attended Sutton’s Vulnerable Adult protection training, and have been vetted under the necessary CRB check and POVA checks prior to commencing work at Wellesley Lodge. The home is now able to access the London Borough of Sutton’s website for staff to take the safeguarding adults training on line. This enables staff to work on the course at their own pace. There has been one concern involving an allegation of abuse against a resident, regarding the individual’s behaviour towards other residents. This was referred through the statutory safeguarding processes, with appropriate actions being taken to seek the necessary professional advice, review the person’s risk assessment and safeguard the situation. Following a strategy meeting, no further investigation was felt to be necessary. At the meeting the home was praised by the chair for the timely, appropriate and sensitive way in which the situation was handled to safeguard their residents. The inspector spoke widely with residents, and did not find any indication of anxieties regarding their safety. He also spoke with two relatives of a recently admitted resident who both spoke warmly of the staff and the concern shown in helping her to settle and feel comfortable. Generally, residents presented as being content and secure living in the home, and as having good, trusting relationships with staff. This was also the impression gained from the views expressed by relatives and residents in the returned questionnaires. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 25 Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 26 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 to 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are living in a safe, well-maintained environment, with access to safe, sufficient and comfortable facilities. The home has sufficient aids and adaptations with which to safely meet the needs of residents. Residents’ rooms are safe, comfortable and pleasantly decorated, reflecting residents’ personal identities, and being suited to their individual needs. The home presents as being clean, pleasant and hygienic. EVIDENCE: Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 27 The inspector completed an inspection of the premises. The home presents as being well maintained and decorated, and as providing a pleasant, safe and comfortable environment. A maintenance and development programme is in place, regarding the renewal of the fabric and decoration of the home. This includes ongoing redecoration and re-carpeting of residents’ bedrooms, and of the home’s communal areas. There has been re-decoration of the office and communal areas, and re-carpeting of the main entrance hall, staircase and first floor corridors. The home provides safe and comfortable indoor and outdoor communal facilities. Radiator covers have been fitted to all radiators in the home. There is ample space available for sitting, recreational and dining space. The conservatory area has been re-furnished with soft, comfortable furniture, providing a pleasant place for residents to sit and look out across the garden. Reorganisation of the main lounge area is planned so as to provide a more varied and improved environment. There is a large and a smaller dining room. The kitchen was refurbished in 2005. A sensory courtyard garden has been developed, providing seating for residents with suitable planting and a water feature, with space having been left for residents who are interested in carrying out their own planting. There is a very pleasant, part-wooded, rear garden which residents are encouraged to access. The home has acquired new, improved garden furniture with attractively laid out tables, chairs and parasols. The inspector spoke with two residents who were sitting outside and was given a very full appreciation of the enjoyment that they derive from being in the garden, and how happy they have been living at the home. Residents are encouraged to assist with gardening if they so wish. All residents have their own bedroom. Two residents, a married couple, share a room in accordance with their expressed wishes. The inspector looked at a number of bedrooms and found these to be generally safe, comfortable and suitable in meeting residents’ needs. The rooms tend to reflect residents’ individual tastes and identities, and include personal photos and mementoes. Individuals are able to bring personal possessions and items of furniture with them to the home. While eight of the bedrooms fall below 10 m2, there is sufficient communal space to compensate. Views expressed by a number of residents indicated that they were happy with their rooms and with the facilities provided. All rooms have appropriate door locks, which can be opened from the outside if necessary. Magnetic door guards (to enable self-closing) have been fitted to all bedroom doors. There are toilets on all floors, which are accessible for residents and close to their bedrooms. These are functioning, regularly cleaned and contain supplies of paper towels and liquid soap. The home has two accessible ‘Parker’ baths, Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 28 and a shower. The upstairs first floor bathroom has been renovated and includes a bath hoist. The home presents as safe, with sufficient aids and adaptations in place. A new Aid-Call system (Telecare) has been installed, initially in half the rooms working alongside the existing system, and then being extended to all of the remaining rooms. A lift, ramps, grab rails, raised toilet seats, zimmer frames, and other aids and adaptations, are observed to be present in the home. An emergency lifting cushion and a set of mechanical weighing scales are also available. An occupational therapy assessment was last carried out on 24 August 2007 by a freelance occupational therapist. No recommendations were made. The home generally presents as being very clean, pleasant and hygienic. All cleaning fluids and agents are securely kept in a separate shed outside of the home. This is kept locked. The home has a clinical waste contract for weekly collections of infections and offensive waste. Clear procedures are in place regarding the risk of cross-infection. The home has reviewed and improved its’ infection control and MRSA policies, with all domestic and kitchen staff having undertaken recent training in this area. The home has a separate sluice room which is kept locked when not in use. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 29 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 to 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has the numbers and skill mix of staff sufficient to meet the needs presented by the home’s residents, and to ensure their safety. Residents are being safeguarded by satisfactory recruitment policy and procedures, and the careful vetting of new staff. Staff are being provided with the necessary induction and training with which to perform their work duties competently, and to safely meet the needs of residents. EVIDENCE: The home is evidenced to have sufficient numbers and skill mix of staff. The home employs 17 care staff, 6 of whom are senior care staff. The home also employs 10 auxiliary staff, including catering staff, a laundress, administrative staff, cleaning staff and a recently recruited handyman. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 30 Inspection of files evidences that staff have obtained relevant qualifications. The home is now making efforts to increase the proportion of staff who have NVQ qualifications. 12 care staff have obtained an NVQ Level 2 social care qualification, while 5 others are currently studying for this qualification. While just 2 staff have achieved an NVQ Level 3, a further 7 staff are currently studying for this qualification. This represents a considerable improvement on the previous inspection. All non-care staff are encouraged to do an NVQ. Three staff have completed an NVQ level 2 in housekeeping, two are undertaking NVQ level 2 in catering, while one has completed an NVQ level 2 in Customer services. The home maintains 4 staff on duty throughout the day (together with the person in charge), both on weekdays and at weekends, with 2 waking staff being on duty overnight. One senior care worker and one care worker work overnight with a back-up sleep-in carer. The manager or deputy manager is on-call if required. The inspector checked the staff rota and evidenced that appropriate numbers of staff are being rotared for duty. The home has had a significant number new staff within the last year, with 9 new staff having been recruited since the last inspection. The home has reduced the number of hours that care workers are employed to a maximum of 42 hours per week, and has increased the number of care workers. This has reduced the number of agency staff used. The home has been concerned to identify skills and training needs within the staff group with the aim of enabling staff to develop and progress. There are monthly staff meetings in which staff development and issues relating to the care and support of the residents are discussed. Staff meet occasionally without the manager being present so as to encourage open feedback. The inspector examined staff files and found that all the necessary employment and criminal records checks have been completed. All staff are being thoroughly vetted prior to taking up their posts, with the take-up of references and other checks being evidenced. Following a requirement from the last inspection, the home is now ensuring that a signed health declaration is being included. The health declaration form has now been reviewed and updated, and a more comprehensive health declaration put in place. The home has a comprehensive and ongoing programme of induction and training in place. The home is currently reviewing its’ induction process and is aiming to adopt the Skills for Care induction training standards so as to improve the quality of training for newly appointed care workers. All staff are required to spend their first week shadowing an experienced member of staff and complete induction training. All staff are encouraged to develop their knowledge through training and development programmes, with a high number undertaking NVQ courses at Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 31 local colleges. New staff members undertake a thorough induction and foundation courses. Ongoing staff training includes medication, safeguarding adults, food hygiene, first aid, manual handling, health and safety, fire safety training and infection control. There has also been ongoing training in dementia awareness and in bereavement and loss. Other training made available includes nutrition and health, palliative care and equality and diversity. Staff are now able to undertake training on-line (LB Sutton) in the areas of safeguarding and mental capacity, which enables them to work through the course units at their own learning pace. The manager advised that there has been some in-house training in personcentred care, in line with the move towards making this more of a reality for the home’s residents. The inspector recommends, however, that the home endeavour to arrange for the manager, deputy manager and senior care staff to attend London Borough of Sutton’s PCP Facilitators course in Person-centred Care Planning. This training would provide useful information, tools and resources for helping to further personalise care and promote residents’ involvement, and for involving residents fully in this process. The training should then be rolled out to all care staff. A computerised record is kept of all staff and the courses that they have attended. A copy of the training programme for 2008 was made available, this evidencing the training that has been completed and scheduled for all members of staff. A staff training record is also being included on each staff file. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 32 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 to 33, 35 to 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are living in a home that is being competently managed, and run in a way which creates an open, positive and inclusive atmosphere. The home is consulting widely with residents, relatives and other stakeholders, and is able to evidence the home’s ability to meet its aims and objectives. The financial interests of residents are being appropriately protected. Through the regular and appropriate supervision of staff, good practice is being promoted and the welfare and best interests of residents protected. A system of annual appraisal does, however, need to be put in place. The interests of residents are being safeguarded by the home’s record keeping, with records being kept secure, up to date and accurate. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 33 Generally, the health, safety and welfare of residents and staff are being appropriately promoted and protected. EVIDENCE: The home’s registered manager, Ms Sally Rochester, has relevant management qualifications (Registered Managers Award and NVQ4), and has had extensive previous experience in both community care and residential care management for older people. Since taking over as the home’s manager in March 2006, Ms Rochester has demonstrated a commitment to maintaining and raising standards at the home and to promoting an open and inclusive philosophy of care. In the last year she has attended training in NVQ Level 3 food management systems, appraisal and supervision training, and manual handing risk assessment training for managers. She has also developed links with another voluntary organisation, who manage residential homes, to share ideas and good practice, and to provide peer support. The inspector spoke individually with a number of residents and staff. Some very positive views were expressed about the manager, with her being perceived to be caring, supportive and enabling in her approach. One resident described her as “a human being, who takes a genuine interest in the residents”. Another described her as being “very caring” and “approachable”. From the comments made, the general impression gained was that the home provides a homely and pleasant environment in which to live and that residents feel they are being well supported by the manager and staff. No critical comments were received. Throughout the inspection, the manager presented as being very knowledgeable and competent, and demonstrated an awareness and understanding of the needs of older people, including those who have dementia. Ms Rochester has built on earlier progress in addressing shortcomings and has developed a positive ethos in the home. This has involved consulting with and working closely with both residents and staff to raise standards. With the support of the Board of Directors, she has managed to develop services that are flexible and responsive to residents’ needs and wishes, and which involve residents more fully in the consultation and decision-making processes. There is an ongoing programme of restructuring and development to assist in taking the home forward and build on previous progress. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 34 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 to residents asking for their views of the home. Questionnaires have been developed for obtaining the views of relatives/friends, relevant professionals and other visitors. There has been a high rate of returns, which generally indicate a high level of satisfaction with the home. Whilst the home has produced a basic improvement plan, it has yet to develop a Development Plan for 2007-08. This must be prioritised as a key task. Staff are encouraged to make suggestions at regular monthly staff meetings and are actively involved in contributing towards the home’s annual quality assurance assessment (AQAA) through discussing what the home does well, and what it could do better, and in contributing suggestions towards the development of plans for improvement. Staff meetings include occasional meetings, without the manager being present, which are designed to encourage open feedback. There are also regular two-monthly residents’ meetings, which provide the opportunity for residents to express their views on issues such as the care and support that residents receive, the quality, range and choice of food available, standards of cleanliness in the home, social activities and outings, staff attitudes, and the experience of living at Wellesley Lodge. A representative, delegated by the Board of Directors, has been carrying out section 26 inspections on a monthly basis. The manager advised that the home now has a reciprocal arrangement with another voluntary home whereby the two managers complete a monthly inspection on each other’s home. Feedback from residents and staff are discussed with the manager following these inspections. Inspection of staff supervision records indicates that staff have been receiving regular two-monthly supervision. Supervision of care and auxiliary is divided between the manager and deputy manager, with the administrator supervising the recently recruited handyman. A supervision format has been developed which provides separate headings for professional/practice issues, training and development, and personal issues such as sickness, leave etc. The format provides sufficient space for the recording of main discussion points discussed, and the actions/decisions agreed. A recommendation for supervision and appraisal training has now been implemented, the manager, deputy manager and the administrator having undertaken this training. Following a requirement from the last inspection, the manager has been working towards the development of an appraisal system for appraising the development and performance of staff. Formats for both the appraisal and the Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 35 pre-appraisal self-evaluation have both been developed. The requirement is, however, only partly met, as the process of appraising staff has not, as yet, been implemented. This needs to be prioritised for 2008. Generally, the home’s record keeping, policies and procedures are safeguarding residents’ best interests. The inspector examined a wide range of records including staff and service users files, incident and accident forms, and other documentation. These were generally well maintained, kept up-to-date, and are stored securely in the office’s lockable filing cabinets. The manager is ensuring that all the home’s policies and procedures are being reviewed on an annual basis. A checklist is also being maintained detailing when these were last reviewed. The home has evidenced that it has completed all health and safety checks within the required time-scales. Fridge/freezer temperatures are checked on a daily basis, and a record of oven temperature is maintained. Fire inspection reports and risk assessments for the home are in place. The Building Manager is allocated the role of health and safety manager for the home and undertakes risk assessments and weekly audits to ensure that the home providers a safe environment for all residents, staff and visitors. The home’s manager, who has completed a course for managers, in risk assessment and manual handling, within the past year, undertakes manual handling risk assessments. A fire risk assessment has been completed, this having been approved by the Fire Safety Officer for Surrey Fire Services. All staff participate in first aid training and a first-aider is on duty at all times. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 36 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 2 3 3 3 4 X HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 2 X 3 2 3 3 Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 37 Are there any outstanding requirements from the last inspection? Yes No. 1 Standard OP1 Regulation 6(a) & (b) Requirement Information. The Statement of Purpose and Service User Guide were last reviewed in January 2007, and must be reviewed and updated as a priority. Timescale for action 31/07/08 2 OP33 24(2) Quality assurance. An annual quality assurance Development Plan must be completed for 2007-08, and a copy forwarded to the CSCI. 30/09/08 3 OP36 18(1)(a) & (c) Staff appraisal. A system of staff appraisal, which assesses competency, and includes a pre-appraisal selfevaluation, must be developed. Partly met. Time-scale extended. While the necessary appraisal formats and processes have been put in place, annual staff appraisals have yet to be completed. 30/09/08 Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 38 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 OP7 Good Practice Recommendations Person-centred care planning. The home should endeavour to arrange for the manager, deputy manager and senior care staff to attend London Borough of Sutton’s PCP Facilitators course in Personcentred Care Planning. This training should then be rolled out to all care staff. 2 OP9 Administration of Medication procedures It is recommended that two staff (one administering and one observing) be present for all administration of medication. This is in line with good practice, minimising the potential for any error to occur and thereby providing additional safeguarding for residents. A duplicate copy of each MAR sheet would be required for the second staff member (the observer) to sign. This recommendation has not, as yet, been acted upon, having been recommended in the last inspection report. Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 39 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Wellesley Lodge DS0000007169.V363954.R01.S.doc Version 5.2 Page 40 - 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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