Inspection on 29/06/06 for Wellesley Lodge

This inspection was carried out on 29th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 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 09/07/2008.

CARE HOMES FOR OLDER PEOPLE Wellesley Lodge 41 Worcester Road Sutton Surrey SM2 6PY Lead Inspector Peter Stanley Key Unannounced Inspection 29th June 2006 9:30am 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.V296444.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.V296444.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 wellesleylodge@tiscali.co.uk Larcombe Housing Association 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.V296444.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th December 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.V296444.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection of the home that took about six hours. The inspection involved discussion with the home’s new registered manager, Ms Sally Garbutt, who has had extensive previous experience in community care and residential care management for older people. The inspector also spoke to a wide range of service users, to one relative, and to staff on duty including the home’s long-serving deputy manager, Alice Brackley. The inspector examined a wide range of documentation which included staff and service user records, care plans, incident and accidents records. The inspector also case-tracked the records of six recently admitted service users. Comments cards were received from a number of service users and relatives. The inspector was very pleased with the progress that has been made since the last inspection, with 17 out of the previous 18 requirements having been met. The home’s new manager presented as knowledgeable and competent and has made good progress in the relatively short period that she has been in post. Throughout the inspection, she was able to demonstrate a commitment to maintaining and raising standards at the home and to promoting an open, enabling and inclusive philosophy of care. The feedback from this inspection evidenced that there is widespread satisfaction from service users with the quality of care and support provided, that there is choice and flexibility in daily routines, and that the home is regarded in a positive light. As a result of this inspection 6 requirements have been made, of which 1 remains to be met. There are also 6 recommendations, 3 of which are bought forward from the previous inspection. What the service does well: Prospective service users are being provided with the comprehensive and upto-date information required with which to make an informed choice regarding the suitability of the home. The health care needs of service users are being generally well met. Service users are being treated with respect in all aspects of their daily living, and are having their right to privacy upheld. The views and wishes of service users and their relatives, regarding the eventuality of the service user’s infirmity or death, are being respected. Staff training in bereavement and loss is being planned. Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 6 Service users are being encouraged to maintain contact with their family and friends, with visitors being made welcome at the home. Service users have opportunities for developing and maintaining links with the local community. Service users are enabled to exercise choice and control in their day-to-day activities and routines, with appropriate support from staff being provided to help to facilitate this. Service users receive a wholesome and appealing diet, with choice being offered, in pleasant surroundings, and at times convenient to them. The home has an appropriate complaints policy and procedure in place. Clear information for raising complaints is made available, and service users and their relatives/friends are encouraged to raise any concerns they may have. Service users are living in a safe, well-maintained environment, with access to safe and comfortable facilities. Service users have access to safe and comfortable communal facilities. Service users presented as settled and happy with their environment and with the communal facilities provided. Sufficient bathing, washing and toilet facilities are provided with which to meet the individual and collective needs of service users. Service users’ rooms were observed to be safe, comfortable and pleasantly decorated, reflecting service users’ personal identities, and being suited to their individual needs. Service users are being provided with the aids and specialist equipment they require to maximise their independence and ensure safety. Service users are living in a home that is being competently managed, and run in a way which creates an open, positive and inclusive atmosphere. Generally, the home’s record keeping, policies and procedures are safeguarding service users’ best interests; however, not all policies and procedures have been annually reviewed. What has improved since the last inspection? Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 7 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) has now been introduced. With the recent improvements in the home’s medication policy and procedures, service users are being more comprehensively protected. Accredited medication training has now been extended to all care staff. Service users are now being provided with a fuller and more varied range of opportunities for recreational and social activities. These are in accord with their social, cultural and religious interests and needs. 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 has now been extended to all staff. The home has the numbers and skill mix of staff sufficient to safely meet the needs presented by the home’s service users. The home has now achieved a minimum ratio of 50 trained members of care staff with NVQ Level 2 or equivalent. With the completion of all the necessary employment and criminal records checks for new staff, service users at the home are now being adequately protected by the recruitment policy and procedures. Three service users’ rooms have been redecorated and re-carpeted since the last inspection, and a first floor bathroom has been redecorated and upgraded. The home has been developing its quality assurance processes so as to evidence that it is meeting its aims and objectives, and is being run in the best interests of service users. A Development Plan has been put in place. Staff are now receiving supervision on a regular basis; this needs to be maintained over time if the welfare and best interests of staff and service users are to be met. What they could do better: Generally, the home is able to demonstrate that it is assessing and meeting the needs of service users admitted to the home. Review meetings should, however, be held after 6 months, following the initial review, and then on a 12 monthly basis. A lockable facility for the safe storage of personal valuables must be provided in the rooms of all service users. Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 8 The home presents as clean, pleasant and hygienic; training in infection control needs, however, to be extended to all staff that work in the home. 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. 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. Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 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.V296444.R01.S.doc Version 5.2 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): 1 to 5 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Prospective service users are being provided with the comprehensive and upto-date information required with which to make an informed choice regarding the suitability of the home. Generally, the home is able to demonstrate that it is assessing and meeting the needs of service users admitted to the home. Review meetings should, however, be held at least 12 monthly following the initial review. 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) has now been introduced. EVIDENCE: Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 11 The home has a Statement of Purpose and a Service User Guide in place. These have been recently reviewed and updated by the new registered manager and provides all the information required by the Regulations for existing and potential service users. 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 a recommendation from the previous inspection, the home has increased its four-week trial period to six weeks so as to ensure that the prospective resident has sufficient time in which to settle into their new environment, and to allow the person more time to decide if he/she will feel happy and comfortable living in the home and for their needs to be met. At the end of the trial period, a review meeting is held, to review the placement, and a decision is made regarding admission. This involves obtaining the views of the service user, and includes his/her closest relatives or friends, and where appropriate, a care manager from social services. The inspector discussed the need for all service users to express their views, and have their needs reassessed, within a review meeting. The home should aim to hold care review meetings at least once every 12 months, following the initial six weekly and six monthly review meetings. These should fully involve the service user, and include the nearest relative/friend and/or advocate, and, where appropriate, the care manager. A requirement applies. On admission, each service user is provided with a service user agreement, which outlines the terms, and conditions that apply to their placement. The manager confirmed that a new resident would not be admitted without having undergone a full assessment. 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 proforma is in place, this having been recently developed and expanded by the new manager into a very comprehensive document. This includes sections on communications, mobility, memory, mood, transfers, continence, eating and drinking, and personal care. The home provides care for 21 elderly residents, the number of places for service users who suffer from dementia having recently decreased from 10 to 8. There are currently 12 service users who require residential care because of their age and physical frailty. Care staff receive a comprehensive range of training tailored to meeting the care and support needs of older people. This includes training relating to the needs of older people with dementia. The manager confirmed that a new resident would not be admitted without having undergone a full assessment. Where a referral takes place, information Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 12 is sought from the care manager, hospital and GP, while the manager or her deputy will also go out and conduct their own assessment. A comprehensive in-house assessment proforma has been developed. This includes sections on communications, mobility, memory, mood, transfers, continence, eating and drinking, and personal care. Since the last inspection, the home has admitted six service users, all of which are privately self-funded. The inspector was informed that due to the fee levels that the home is now charging (£439 to £501 per week) the home is not presently receiving any referrals from social services. The inspector examined the recently admitted service users’ files and found that all necessary preadmission care assessments and risk assessments had been completed, and detailed care plans put in place. The inspector spoke to with three service users who have recently been admitted. This indicated that they had settled well, and that the home provides a pleasant and welcoming environment in which to live. Very favourable views were expressed regarding the quality of the care and support being provided at the home, with individuals feeling that their needs are being well met. The inspector also spoke to a number of other service users. This indicated a generally high level of satisfaction with the home and with the care and support received. Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 13 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): 7 to 11 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The individual plan of care has been developed so as to provide a clearer and more comprehensive record of service users’ health, personal and social care needs. The health care needs of service users are being well met. With the recent improvements in the home’s medication policy and procedures, service users are being more comprehensively protected. Accredited medication training has now been extended to all care staff. Service users are being treated with respect in all aspects of their daily living, and are having their right to privacy upheld. The views and wishes of service users and their relatives, regarding the eventuality of the service user’s infirmity or death, are being respected. Staff training in bereavement and loss is being planned. Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 14 EVIDENCE: The inspector examined service users’ care plans. These are now being presented in a new, more structured and typed format, and provide a clearer and more comprehensive breakdown of service users’ care and support needs and how these are being addressed. The inspector was advised that these plans are to be further developed so as to include a social profile of each resident. Linked to the introduction of new more person-centred care plans is the need for staff training in this area, so as to enable staff to develop relevant skills in person-centred care planning. The manager advised that there is a course organised by the London Borough of Sutton, which she is hopeful that staff will be able to attend. A recommendation applies. The inspector examined a number of service users’ files, including those of recently admitted service users. These evidenced up-to-date service user plans, with regular review taking place on a monthly basis. The health needs of service users are being generally well met. The home is served by a local GP group practice with which it enjoys a good relationship. Most service users are registered with this practice, though some service users exercise their wish to retain their own GP. There is a visiting district nurse and 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 for people with dementia). There is also contact with mental health services as and when required. An incontinence nurse is available on referral to provide advice and information to staff regarding the management of incontinence. No specific health concerns came to light during the inspection. The home has addressed a number of concerns relating to the storage and dispensing of medication. Following a change in pharmacy arrangements the home now uses the services of a major pharmacy, resulting in the introduction of the monitored dosage system for dispensing and recording. The inspector examined a sample of service users’ medication records, which are being appropriately maintained. 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, which details all aspects of medication procedures, and which all staff who administer medication are required to have worked through. A new medication audit sheet has also been put in place. Accredited medication training has recently been extended to all staff, thus meeting an outstanding requirement from previous inspections. Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 15 Service users are able to administer their own medication if they wish, though this is subject to a risk assessment. A number of changes have been made to the storage arrangements that have resulted in safer procedures, including the provision of a medication fridge and a separate metal safe for the secure storage of controlled drugs.. The home’s medication policy and procedures have been revised in the light of the changes that have been made, and the advice and consultation received. The inspector spoke to a large number of service users during the inspection. Feedback from these discussions, and from comments cards, indicated that staff are respectful of service users’ privacy and dignity, and that staff are sensitive to their needs and rights. Visiting relatives and professionals are able to see service users in the privacy of their own rooms. Staff and management were observed to interact with service users in a caring and respectful manner, and there was evidence of good, trusting relationships between staff and service users. There have been a number of 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 service users wishes in the event of their serious illness/death are recorded. While some staff have had access to training in coping with bereavement and loss, this needs to be extended to all care staff. The new manager confirmed that training in this area is being planned in line with a recommendation from the last inspection. Wellesley Lodge is seen as a ‘home for life’, and given that the needs of each service user can continue to be met, then a service user would be enabled to remain at the home in their final days. Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 16 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): 12 to 15 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are now being provided with a fuller and more varied range of opportunities for recreational and social activities. These are in accord with their social, cultural and religious interests and needs. Service users are being encouraged to maintain contact with their family and friends, with visitors being made welcome at the home. Service users have opportunities for developing and maintaining links with the local community. Service users are enabled to exercise choice and control in their day-to-day activities and routines, with appropriate support from staff being provided to help to facilitate this. Service users receive a wholesome and appealing diet, with choice being offered, in pleasant surroundings, and at times convenient to them. EVIDENCE: Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 17 This home has historically provided a good range of activities and outings. However, the evidence from the last inspection was of a falling-off in activities, and of a lack of stimulation amongst the residents. With the appointment of the new manager this has begun to turn around, and there was more evidence of activities, both formal and informal, taking place. A programme of activities is publicised on the notice board; this includes sing alongs, music and movement, discussion/reminiscence, and visiting entertainers, with an activity being scheduled for every afternoon. Recent events have included a Queen’s 80th birthday party, a St Patrick’s Day celebration and a Derby sweepstake. A Family and Friends Barbeque is being planned. Visiting musicians rotate in visiting the home once every two weeks, and there is a once-weekly exercise session, which a visiting organiser undertakes with residents. Daily newspapers are delivered to the home and a mobile library visits once a month. The new manager has been encouraging 1 to 1 and less formal activities, with staff members being encouraged to initiate one-to-one or small group activity during the afternoon. During the inspection a staff member was involving a number of service users in an activity session within the main lounge. Board games are encouraged. The manager is hopeful that she will be able to extend daily activities further by appointing an activities organiser to develop and organise a range of activities. Service users are being consulted in service users’ meetings as to their interests and wishes. One tangible result has been the setting up of occasional visits from a young brownies group (aged 5 to 10) called Rainbows. This has proved very popular. The manager has also introduced a system for a staff member to escort two or three service users out for a short while before lunch, with priority being given to those service users who do not benefit from visits by relatives or friends. Small group outings, using a mini-bus provided by LB Sutton, are arranged to places such as Kew Gardens and Richmond Park, a programme of outings being publicised on the notice board. The inspector spoke with a number of service users regarding the activities provided. Feedback indicated that there has been a significant improvement in this area and that there is a greater emphasis being given to meeting individual preferences and interests. Visitors are welcome at the home and their active participation is encouraged. Their responses have generally been positive. The home has links with the local church and volunteers from the church visit and assist with organised events and activities. Service users’ beliefs and religious beliefs are respected, with arrangements being made for service users to attend services or receive visits where requested. Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 18 Feedback received from relatives and friends has been generally positive with comments cards and the home’s own surveys indicating that the home is very well regarded, with visitors being made to feel very welcome at the home. Friends and family are encouraged to participate in organised events and are able to accompany service users on organised group outings. Service users spoken to by the inspector indicated that they are able to exercise a fair degree of control and choice over their day-to-day lives. Staff were observed to be encouraging and enabling in their interactions with residents, and the philosophy of the home, in encouraging and helping to facilitate independence wherever possible, is a positive one. Service users are able to handle their financial affairs for as long as is practical or for as long as they wish. Many continue to do so. Service users can bring in their own possessions and furniture if they wish and this was observed in their rooms, which had been individualised. Service user meetings are being held on a regular two-monthly basis. There is a comment box in the hallway for any suggestions/complaints or compliments to be addressed to the management, anonymously if so wished. The inspector observed service users taking lunch in the very pleasant and homely dining areas. The food looked appetising and wholesome, with fresh vegetables, and service users indicated that they were very happy with the quality of food served. The inspector examined menus. This evidenced a good range of nutritious and appetising food with alternative options being offered to the main dish if required. The inspector spoke to one service user who is a vegetarian, who expressed her satisfaction with the food, and felt that her needs were being appropriately met. The inspector also spoke to a recently employed cook. She has recently completed her food hygiene training and demonstrated a good awareness of culinary good practice and the dietary needs of residents. The inspector inspected the kitchen and found this to be clean with good standards of food hygiene. Fridge and freezer temperatures are being maintained. However, a record of oven temperatures, when cooking meats, and other food products, needs to be maintained; a requirement applies. Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 19 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): 16 and 18 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home has an appropriate complaints policy and procedure in place. Clear information for raising complaints is made available, and service users and their relatives/friends are encouraged to raise any concerns they may have. 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 has now been extended to all staff. 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. No complaints were identified. The home has an appropriate policy and procedure in place for the protection of vulnerable adults. A requirement for all staff in the home to attend Sutton’s Vulnerable Adult protection training has now been met. The inspector spoke to Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 20 a number of service users. This indicated that service users feel safe and secure living in the home and that they have good and trusting relationships with staff. No adult protection issues or concerns were identified. Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 21 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): 19 to 26 Quality in this outcome area is generally good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users are living in a safe, well-maintained environment, with access to safe and comfortable facilities. Service users have access to safe and comfortable communal facilities. Service users presented as settled and happy with their environment and with the communal facilities provided. Sufficient bathing, washing and toilet facilities are provided with which to meet the individual and collective needs of service users. Service users’ rooms were observed to be safe, comfortable and pleasantly decorated, reflecting service users’ personal identities, and being suited to their individual needs. However, a lockable facility for the safe storage of personal valuables, must be provided in the rooms of all service users. Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 22 Service users are being provided with the aids and specialist equipment they require to maximise their independence and ensure safety. The home presents as clean, pleasant and hygienic; training in infection control needs, however, to be extended to all staff that work in the home. EVIDENCE: The inspector completed an inspection of the premises. No safety concerns were identified. The home was found to be generally well maintained, accessible and safe. While not purpose built, it presents as suitable for its stated purpose. The home provides safe and comfortable indoor and outdoor communal facilities. There is ample space available for sitting, recreational and dining space, with very pleasant areas to sit including a light and airy sun lounge. There are two dining areas, the smaller of which is set aside for those service users who require more assistance with eating. The kitchen was refurbished in 2005. There is a very pleasant, part-wooded, garden which service users are encouraged to access. Service users spoken to by the inspector were generally happy with their surroundings and the facilities provided. There are toilets on all floors and they are accessible to the current service users 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, and a shower. The upstairs first floor bathroom has been recently renovated and redecorated, and a bath hoist installed. Service users are evidenced to be provided with the specialist equipment they require to maximise their independence. The home was assessed in 2005 by an occupational therapist and received a positive report. A lift, ramps, grab rails, raised toilet seats, Zimmer frames, and other aids and adaptations, are observed to be present in the home. All service users have their own bedroom. The inspector looked at a number of bedrooms and found these to be safe and satisfactory. Since the last inspection three bedrooms (8, 11 and 12) have been redecorated, and new carpeting has been laid. While eight of the bedrooms fall below 10 m2, there is sufficient communal space to compensate. Service users spoken to by the inspector were generally happy with their rooms and no criticisms were expressed. The inspector was invited by one of one service user who has had distinguished military service, to visit his room. This reflected his military background and Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 23 close family ties, and presented as personalised and reflective of the gentleman’s identity. Each service user bedroom has been arranged according to individual taste, and some occupants have brought in personal items. The standard of furnishings and décor is generally good. The home generally presented as being clean, pleasant and hygienic. All cleaning fluids and agents are stored securely in a locked COSHH cupboard in the home’s cellar. The cellar is kept locked. The laxity in infection control procedures observed on the previous inspection, has been addressed, with clear procedures now being in place regarding the risk of cross-infection from the wearing of rubber gloves and aprons. There is an outstanding requirement, which remains to be met, for all staff to undertake infection control training. The manager advised that training is planned, with four staff set to do this on 4/7/06. Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 24 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): Quality in this outcome area is generally good. This judgement has been made from evidence gathered both during and before the visit to this service. The home has the numbers and skill mix of staff sufficient to safely meet the needs presented by the home’s service users. The home has now achieved a minimum ratio of 50 trained members of care staff with NVQ Level 2 or equivalent. With the completion of all the necessary employment and criminal records checks for new staff, service users at the home are now being adequately protected by the recruitment policy and procedures. 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: The home employs 16 care staff, 3 of whom are senior care staff, and 4 of whom are care bank staff. The home also employs 2 cooks, 3 kitchen assistants, two cleaners and a handyman. On the day of inspection appropriate Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 25 numbers of staff were found to be on duty; staff rotas indicated that on weekdays, a minimum of four care staff (including one senior care worker) on each shift, together with the deputy manager. At weekends 5 care staff (including one senior care worker) are on duty. 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 three new staff members since the last inspection. The inspector examined the staff files and found that all the necessary employment and criminal records checks have been completed. The inspector has agreed one staff appointment (an auxiliary worker) on the basis of the POVA First check having been completed, and an assurance that there will be no one-to-one contact with any service user until such time as the CRB certificate has been received. The inspector wishes to see staff files include a list of all the identity and recruitment checks that are required prior to appointment, with the dates being entered for when these have been completed; a recommendation applies. The home has a comprehensive and ongoing programme of induction and training in place. New staff members undertake a thorough induction and foundation courses. Ongoing staff training includes medication, adult protection, food hygiene, first aid, health and safety and infection control. 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 home is acting on a previous requirement to prioritise dementia awareness training. Seven staff have undertaken distance learning through NESCOT (North-East Surrey College of Technology), with places having been booked for a training course in dementia with the Alzheimer’s Society. An extension of the time-scale for meeting this requirement, to 30/9/06, was agreed. The inspector identified a need for training in person-centred care planning, for which a recommendation applies. As previously recommended, training in Bereavement and Loss should also be extended to all care staff. Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 26 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): 31, 32, 33, 36, 37 and 38. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Service users 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 has been developing its quality assurance processes so as to evidence that it is meeting its aims and objectives, and is being run in the best interests of service users. A Development Plan has been put in place. Staff are now receiving supervision on a regular basis; this needs to be maintained over time if the welfare and best interests of staff and service users are to be met. Generally, the home’s record keeping, policies and procedures are safeguarding service users’ best interests; however, not all policies and procedures have been annually reviewed. Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 27 EVIDENCE: The home’s new registered manager, Ms Sally Garbutt, 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. Throughout the inspection, the manager presented as very knowledgeable and competent and has made good progress in the relatively short period she has been in post. Throughout the inspection, she was able to demonstrate a commitment to maintaining and raising standards at the home and to promoting an open and inclusive philosophy of care. Both service users and staff spoke in positive terms about the manager, who was perceived to be caring, supportive and enabling in her approach. A requirement, for the proprietors to evidence Regulation 26 monthly visits, has been met with a written report for each visit being provided. 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 also been developed for obtaining the views of relatives/friends, relevant professionals and other visitors. The home has now produced an annual quality assurance Development Plan, which includes feedback from service users and other parties, regarding the extent to which the Home is meeting its aims and objectives. The inspector examined a sample of staff supervision notes and evidenced that all staff, including the Deputy Manager, are now receiving regular two-monthly supervision. Supervision is now being divided between the manager and deputy manager. The manager advised that she is planning to develop a new appraisal system for appraising the development and performance of staff. A new supervision format has been developed. This provides separate headings for professional/practice issues, training/development, personal issues (sickness, leave etc). The format needs, however, to be further revised so as to provide sufficient space for the recording of main discussion points discussed, and the actions/decisions agreed. The home is acting on a previous requirement for supervision and appraisal training, with both the home’s manager and deputy manager booked to attend training with the London Borough of Sutton on 30/6/06. Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 28 Generally, the home’s record keeping, policies and procedures are safeguarding service users’ 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. However, while policies and procedures are reviewed on a rolling basis, a number (detailed in the Pre-Inspection Questionnaire) have not been reviewed within the last 12 months. This includes health and safety, which has not been reviewed since November 2004. The home must aim to ensure that all policies and procedures are reviewed on an annual basis, and a checklist maintained detailing when these were last reviewed. A requirement applies. The home has evidenced that it has completed all health and safety checks within the required time-scales. Fridge/freezer temperatures are being checked on a daily basis. A record of oven temperature checks needs, however, to be maintained, for which a requirement applies. Radiator covers have now been fitted to all radiators in the home. Risk assessments for the home are in place. Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 29 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 3 3 3 2 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 2 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X X 3 2 2 Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 30 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 OP4 Regulation 12(1), 14(2), 15(2) Requirement The home should hold care review meetings at least once every 12 months, following the initial six weekly and six monthly review meetings. These should fully involve the service user, and include the nearest relative/friend and/or advocate, and, where appropriate, the care manager. All service users must be provided with a lockable drawer or facility in their own room. The registered manager must ensure that all staff undertake Infection Control training. Time-scale extended. Previous time-scale not met. 4 OP30 18(1)(a) & (c) 12(1)(a), 13(4)(c) Dementia awareness training must be extended to all care staff. The home must aim to ensure that all policies and procedures are reviewed and updated on an annual basis. DS0000007169.V296444.R01.S.doc Timescale for action 30/09/06 2 3 OP24 OP26 !2(4)(a), 23(2)(m) 12(1)(a) 13(4)(a,c) 30/09/06 30/09/06 30/09/06 5 OP37 31/12/06 Wellesley Lodge Version 5.2 Page 31 6 OP38 13(4)(c) A record of oven temperatures, when cooking meats, and other food products, must be maintained. 31/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP29 Good Practice Recommendations All care staff should undertake training in person-centred care planning. For staff recruitment, each staff file should include a checklist. This should detail all the recruitment and identity checks required, and indicate the date when each check has been completed. Bereavement training should be extended to all staff. The new supervision format needs to be further developed. This needs to provide sufficient space for the recording of main discussion points arising from each issue discussed, and the 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. The registered manager and deputy manager should aim to undertake supervision and appraisal training. 3 4 OP30 OP36 5 OP36 6 OP36 Wellesley Lodge DS0000007169.V296444.R01.S.doc Version 5.2 Page 32 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. 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