CARE HOMES FOR OLDER PEOPLE
Wellesley Lodge 41 Worcester Road Sutton Surrey SM2 6PY Lead Inspector
Peter Stanley Unannounced Inspection 4 August 2005 9:30am 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 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 G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Wellesley Lodge Address 41 Worcester Road, Sutton, Surrey, SM2 6PY Telephone number Fax number Email 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 Mrs Christine Wicker Care Home 21 Category(ies) of Old Age (11) registration, with number Dementia - over 65 (10) of places Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: none Date of last inspection 2 March 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 G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection of the home took place over one day. The new registered manager, Mrs Christine Wicker, who has been in effective control since 1 April 2005, was present during the course of the inspection. Mrs Ann-Marie Costigan, the Personnel Director with Larcombe Housing Association (the Home’s registered providers) was present during the morning for two hours. The inspector toured the premises and spoke to a number of service users and staff. Care records and other documentation were examined. The inspector’s overall impression is that this is a well-run home, which provides a caring and homely environment for the home’s residents. Feedback from service users and staff was generally very positive. There are, however, a number of issues which will need to be addressed, detailed below. The home has addressed a number of requirements from the previous inspection, two requirements remaining outstanding. From this inspection a further eleven requirements and five recommendations are made. 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. Prospective service users, their friend and relatives are able to visit to assess the suitability of the home. Service users are having their health, personal and social care needs set out in an individual plan of care, with review taking place on a monthly basis. The range of needs presented by service users in the home is being appropriately met. Service users are being treated with respect and are having their right to privacy upheld. Service users are assured that at the time of their illness or death the home will treat them and their family with care, sensitivity and respect. Both service users and staff would, however, benefit from the extension of training in bereavement and loss to all staff who work in the home.
Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 6 Service users are being provided with a full and varied range of opportunities for recreational and social activity that is in accord with their social, cultural and religious 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. 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. The new manager needs, however, to obtain the necessary formal qualifications with which to achieve the necessary level of knowledge and skills required. Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 7 What has improved since the last inspection? What they could do better:
While the home is completing comprehensive initial assessments of service users prior to admission, there has been a failure to obtain full information regarding the health and care needs of a recently admitted service user. The range of needs presented by service users in the home is being appropriately met. While the home is completing comprehensive initial assessments of service users prior to admission, there has been a failure to obtain full information regarding the health and care needs of a recently admitted service user.
Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 8 While the health care needs of service users are generally being well met, the home has found it difficult to meet the high level of needs presented by a recently admitted service user with severe dementia. Service users are generally being protected by the home’s medication policy and procedures. Accredited medication training needs, however, to be extended to all care staff. The home has the numbers and skill mix of staff sufficient to safely meet the needs presented by the home’s service users. However, for safety to be assured, the home has to achieve a minimum ratio of 50 trained members of care staff with NVQ Level 2 or equivalent. While, generally, the home’s service users are being protected by appropriate recruitment policy and procedures, POVA checks for new staff members must be evidenced for all future staff appointments. While, generally, staff are being provided with the necessary induction and ongoing training with which to competently perform their work duties, there is a need for additional training in dementia awareness, adult protection, medication, and other areas. A training checklist to evidence the training completed by each staff member must be included on each staff file. The home needs to demonstrate, through developing its quality assurance processes, that it is meeting its aims and objectives and is being run in the best interests of the service users. While the home is providing regular supervision for staff, there is a need for the manager to undertake supervision and appraisal training and to participate more fully in the direct supervision of staff. A structured format for recording supervision, to provide greater clarity, needs to be developed. While generally satisfied that the health, safety and welfare of service users and staff are being appropriately protected, there is an outstanding requirement for service users safety to be ensured with the fitting of covers to all radiators in the home. Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 9 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 G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3, 4 and 5 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. While the home is completing comprehensive initial assessments of service users prior to admission, there has been a failure to obtain full information regarding the health and care needs of a recently admitted service user. The range of needs presented by service users in the home is being appropriately met. Prospective service users, their friend and relatives are able to visit to assess the suitability of the home. EVIDENCE: Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 12 The home has produced a Statement of Purpose and a Service User Guide. These have been recently updated by the new registered manager and provides all the information required by the Regulations for existing and potential service users. These documents have been revised to include contact details for the Commission For Social Inspection. 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 has admitted two service users since the last inspection. While inhouse assessments had been completed, there was only very limited information provided by the hospital regarding the referral of one service user, who was self-funding. The placement of this service user has subsequently been found difficult to manage given the high level of behavioural problems associated with the service user’s mental state. The information initially provided by the hospital was very brief and did not provide any indication of these problems. The inspector is concerned that the home was not provided with the information with which to fully assess the service user’s mental state and care needs prior to admission. As it is the Home’s primary responsibility to assess self-funders (not being subject to a Care Management assessment), the home must obtain full information from the referrer regarding the type and level of need being presented, and the type and level of care required. A requirement applies. This home provides care for 21 elderly residents, the number of places for service users who suffer from dementia having recently increased from 8 to 10. The remainder of the places are for persons who require residential care because of their age/frailty. Staff receive specific training in caring for clients with dementia. Care staff receive a comprehensive range of training tailored to meeting the care and support needs of older people. The manager confirmed that prospective service users are always invited to visit the home prior to agreeing to accept an offer of a place. If they are unable to visit, then the manager would expect a family member to visit on their behalf. Potential residents are invited to stay for a day, have lunch and talk to residents and any visiting relatives. Following admission, there is a four-week trial period, to enable the home to determine if it will be able to meet the service users needs, and for the service user to decide if he/she will feel happy and comfortable living in the home. Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 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 standard(s) 7, 8, 9, 10 and 11 Service users are evidenced as having their health, personal and social care needs set out in an individual plan of care, with review taking place on a monthly basis. While the health care needs of service users are generally being well met, the home has found it difficult to meet the high level of needs presented by a recently admitted service user with severe dementia. Service users are generally being protected by the home’s medication policy and procedures. Accredited medication training needs, however, to be extended to all care staff. Service users are being treated with respect and are having their right to privacy upheld. Service users are assured that at the time of their illness or death the home will treat them and their family with care, sensitivity and respect. Both service users and staff would, however, benefit from the extension of training in bereavement and loss to all staff who work in the home. EVIDENCE:
Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 14 The inspector sampled service users files and found that service users’ needs are being appropiately recorded in their service user plan, with daily notes evidencing how these needs are being met. Following a previous requirement, an additional form has been introduced for staff to record each identified need under a predetermined heading (i.e. sensory, dietary, continence), and to record how that need is to be met. This is then reviewed monthly. The manager has been previously advised by the inspector to monitor the forms to ensure that the care staff do not use inappropriate terminology in describing service users. The manager advised that the home is visited by the GP on a weekly basis, and that there is a good and positive relationship with both the GP and the District Nurses attached to the GP surgery. At the time of this visit there was one service user who had been admitted from hospital with a pressure sore, for whom the district nurse is visiting on a regular basis. The manager also advised that the home has regular, periodic contact with visiting specialist health practitioners including physiotherapy, chiropody, dental and optician services. There is also contact with mental health services as and when required. Following a requirement from the previous inspection the home is now recording the actions it is taking to address any concerning pattern of weight loss. While the home is evidenced to be meeting the range of care needs presented by the home’s service users, there has been difficulty in meeting the level of needs presented by a recently admitted service user, who is presenting aggressive and challenging behaviour. The inspector discussed this with the manager and was informed that the G.P has assessed the service user and is referring to a psycho-geriatrician with view to transferring the user to a more appropriate placement. The home has an appropriate medication administration policy and procedure in place for staff. Medication administration records for a number of service users were examined and found to have been completed satisfactorily. The manager advised that all medication records are monitored by the deputy manager on a regular basis. As gaps in recording have been noted on previous inspections, this will need to be closely monitored on future inspections. The inspector was, however, concerned to observe that a controlled drug (morpine) was being kept in the medications cabinet together with the other prescribed drugs. Any controlled drug must be securely stored within a separate lockable metal box or container; one of which is already in place and available for use within the medications cabinet. A requirement applies.
Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 15 Blister packages are used for tablets instead of bottles for easy identification and monitoring. The manager advised that only senior carers who have had accredited medication training are permitted to dispense medication. 9 of the 16 care staff have completed this training, but this needs to be extended to all care staff. A requirement applies. It is recommended that if the home keeps/uses any ‘household remedies’, then the aforementioned medication procedure must reflect this. Service users can self medicate, subject to a risk assessment. Service users spoken to by the inspector indicated that their privacy is respected and that staff are caring and sensitive to their needs. Staff and management were observed to interact with service users with respect and dignity and demonstrated a close and caring relationship towards them. A service user’s preferred term of address is used. Although there is no visitors’ room, relatives and visiting professionals can meet service users privately in their own rooms if needed or the small dining room if not in use. There have been two bereavements in recent months both of which were sensitively dealt with by the Home, both service users being able to die peacefully at the home, and with the full involvement of close family and friends. 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 manager confirmed that she saw Wellesley Lodge as a ‘home for life’. Given that the needs of each service user can continue to be met, internally or with external support, then a service user would be enabled to remain at the home in their final days. Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 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 standard(s) 12, 13, 14 and 15 Service users are being provided with a full and varied range of opportunities for recreational and social activity that is in accord with their social, cultural and religious 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: It was previously required that the home increase the activities available to service users. This was discussed with the new manager who indicated that the programme of activities has been extended with an activity scheduled for every afternoon. These include board games, sing-alongs, music and
Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 17 movement, discussion/reminiscence, and visiting entertainers. Service users spoken to by the inspector indicated that there was sufficient activities to occupy them and that they were enabled to participate with the assistance of staff. Visitors are welcome at the home and their active participation is encouraged. Their responses have generally been positive. The home is developing links with the local church and a list of activities that church volunteers could participate in with service users has been drawn up. The manager advised that the home has recently organised a fete in the Home’s garden, which was well attended by people from the local community, and which the Home’s service users greatly enjoyed. The home is run in a manner that promotes choice and independence and this was evidenced through service users’ comments, staff interviews and observation. Service users spoken to by the inspector indicated that they felt 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. 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. There is a comment box in the hallway for any suggestions/complaints or compliments to be addressed to the management, anonymously if so wished. Service users are able to take meals, and particularly snacks, at times and places to suit them and have a choice of meals and alternatives. The inspector spoke to the cook and examined menus. This evidenced a good range of nutritious and appetising food with alternative options being offered to the main dish if required. The meals mostly contain meat but the inspector understands that this has not been a problem as there are no vegetarians amongst the present service user group. Three service users are diabetic and their diets are closely monitored to provide suitable food. The feedback from service users was very positive with service users indicating that the food is very good and sustaining. Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 18 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 standard(s) 16 and 18 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. However, in order that service users are sufficiently protected, staff must attend statutory vulnerable adult 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. Since the last inspection there has been one complaint. This was discussed with the manager, the inspector being satisfied that this had been dealt with in an appropriate and satisfactory way. A written complaints record is maintained, a new format having recently been put in place. This 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 a policy and procedure in place with regard to the protection of vulnerable adults. Following a requirement from a previous inspection this has been developed and updated The inspector is making it a requirement for all staff in the home to attend Sutton’s Vulnerable Adult protection training, this
Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 19 having been previously discussed with the former manager on an earlier inspection. An adequate whistle-blowing procedure is in place. Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 20 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 standard(s) 19, 20, 21, 22, 23, and 24. 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. EVIDENCE:
Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 21 The home was generally well maintained, accessible and safe, and, while not purpose built, suitable for its stated purpose. The inspector completed an inspection of the premises and did not identify any safety concerns. The kitchen was refurbished in 2005. 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 rooms, the smaller of which is set aside for those service users who require more assistance with eating. There is a very pleasant, partwooded, 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, a shower and a traditional bath. Hoists are available for use where required. Service users are evidenced to be provided with the specialist equipment they require to maximise their independence. The home has been recently assessed by an occupational therapist and have received a positive report. A lift, ramps, grab rails, raised toilet seats, zimmer frames, and other aids and adaptations, were observed to be present in the home. The inspector looked at a number of bedrooms and found these to be safe and satisfactory. While eight of the bedrooms fall below 10 m2, there is sufficient communal space to compensate. All service users have their own bedroom. 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. Service users spoken to by the inspector were generally happy with their rooms and no criticisms were expressed. Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 22 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 The home has the numbers and skill mix of staff sufficient to safely meet the needs presented by the home’s service users. However, for safety to be assured, the home has to achieve a minimum ratio of 50 trained members of care staff with NVQ Level 2 or equivalent. While, generally, the home’s service users are being protected by appropriate recruitment policy and procedures, POVA checks for new staff members must be evidenced for all future staff appointments. While, generally, staff are being provided with the necessary induction and ongoing training with which to competently perform their work duties, there is a need for additional training in dementia awareness, adult protection, medication, and other areas. A training checklist to evidence the training completed by each staff member must be included on each staff file. EVIDENCE: Service users spoken to by the inspector feel that they are being well supported by staff and that their needs are being met. The inspector observed good interaction between staff and service users. Staff rotas were examined. The rotas state the full name of each staff member, and indicate whether the staff member is a senior care worker, care worker or ancillary staff member. The rotas evidence that the home is providing in excess of the minimum
Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 23 staffing levels required in a home of this size and nature, with a good mix of both senior care and care staff. Five care staff are on during the day (including one senior carer), and one senior and one care worker overnight with a back-up sleep-in carer. The manager or deputy manager are on-call if required. The manager advised that four staff have completed the NVQ Level 2 (one of whom has an NVQ Level 3), and that a further four staff will be undertaking study for the NVQ 2. The home is presently well below the 50 target figure, though it should be on track for meeting this once further training of staff has been completed. A requirement applies. There was a requirement from the December inspection relating to a new staff member for whom a POVA check had not been received. No new staff members have been recruited since the last inspection. The need for a POVA check has been written into the recruitment procedure and an assurance obtained from the new manager that no further staff appointment will be completed until this has been evidenced. The inspector spoke to a number of staff on duty. This indicated that staff feel that their training and development needs are being addressed, several positive comments being received. Staff undertake training in the ‘basic’ courses – first aid, manual handling, food hygiene and fire safety. Some staff have undertaken dementia awareness training; this needs to be extended to all care staff. A requirement applies. Accredited medication training has been undertaken by nine staff; this needs to be extended to all staff. A requirement applies (Standard 9). Other training which needs to be prioritised includes managing continence and bereavement training. Recommendations apply. A computerised record is kept of all staff and the courses that they have attended. A staff training record needs to be included on each staff file.This must detail the training completed and scheduled (with dates) for each member of staff. A recommendation applies. Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 24 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 36 and 38 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 new manager needs, however, to obtain the necessary formal qualifications with which to achieve the necessary level of knowledge and skills required. The home needs to demonstrate, through developing its quality assurance processes, that it is meeting its aims and objectives and is being run in the best interests of the service users. The home has been able to demonstrate that it is financially viable. While the home is providing regular supervision for staff, there is a need for the manager to undertake supervision and appraisal training and to participate more fully in the direct supervision of staff. A structured format for recording supervision, to provide greater clarity, needs to be developed. While generally satisfied that the health, safety and welfare of service users and staff are being appropriately protected, there is an outstanding
Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 25 requirement for service users safety to be ensured with the fitting of covers to all radiators in the home. EVIDENCE: Since 1 April 2005 the Home has been managed by Mrs Christine Wicker. She has previously worked for three years as an administrator within this home. There was a handover period (from 1 January 2005) during which she was inducted by the Home’s previous manager. While this is Mrs Wicker’s first managerial position in a residential care home, she has had previous managerial experience within a sheltered housing scheme. She is currently studying for the NVQ Level 4, and is then intending to register for study leading to the Registered Manager’s Award. During the inspection, Mrs Wicker displayed a good grasp of the care and management issues discussed. She has been relating her NVQ studies to practical issues and policies relating to the Home, and stated her intention to register to study for the Registered Managers Award (RMA). The manager must complete her NVQ Level 4 and the RMA to meet this standard. A requirement applies. The management style was observed to be open, positive and inclusive, with good interaction being observed between the manager and both staff and service users. Whilst it is early days, the inspector felt that the manager has managed to achieve a smooth transition from the previous long-standing incumbent, and to have maintained the confidence and good-will that exists in this home. Service users and staff who were spoken to by the inspector expressed positive views regarding the running of the home. Following a recent requirement (2-3 December 2004) the home has introduced quality assurance systems to assist in measuring the success of the home in meeting the aims and objectives set out in the Statement of Purpose. A monthly audit proforma has been developed, with which to monitor the quality of the service, and questionnaires have been given residents asking for their views of the home. This process needs to be further developed with the views of relatives/friends, relevant professionals and other visitors being canvassed. The home will need to produce an annual quality assurance Development Plan, to include feedback from service users and other parties, regarding the extent to which the Home is meeting its aims and objectives. Another requirement has been partially met, for the proprietors to evidence Regulation 26 monthly visits, with a written report for each visit being provided. The report for July 2005 was not, however, evidenced, hence the requirement still applies.
Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 26 The home has a charitable status, and thus operates on a not for profit basis. This can mean that there are limited resources. The management were asked to send to the local CSCI office a copy of their business and financial plan for the forthcoming year, so that the Commission could determine the financial viability of the home. This has now been complied with. Staff have access to a policies and procedures manual which is regularly updated by the management. New staff receive a local induction, and can then join a TOPSS based induction course run by a fellow charity. This charity also provides TOPSS based foundation training. In accordance with a previously made requirement, staff are now starting to receive formal supervision on a regular basis, and this is recorded. Bi-annual appraisals/reviews are also carried out. The inspector understands that all staff are currently being supervised by the Manager and Deputy Manager. The inspector discussed the need for the Manager to attend supervision and appraisal training with view to sharing more fully in the direct supervision of staff. The inspector also understands that the Deputy Manager is not currently receiving supervision. This must be provided by the Registered Manager, and evidenced on the next inspection. Requirements apply. The inspector looked at the supervision format and recommends that a new format is developed. This needs to provide separate headings for professional/practice issues, training/development, personal issues (sickness, leave etc) and actions/decisions agreed. To be signed by both the supervisor and supervisee. A requirement was made at the last announced inspection (in December 2004) regarding the need for risk assessments to be carried out re radiators (and covers fitted where appropriate); all radiators in the public areas, including the reception, lounge and dining areas, bathrooms and toilets, have now been covered. Service users bedrooms still require radiator covers; while risk assessments for service users have been carried out, these must be regularly reviewed. A requirement applies. Fire alarms are now being tested on a weekly basis. Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 27 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 1 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3
COMPLAINTS AND PROTECTION 3 3 3 3 3 3 x x STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 2 3 1 3 x 2 x 2 Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 28 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 14(1)(a) & (b) Requirement The registered manager must ensure that full and comprehensive information, regarding service users health and care needs, are obtained prior to admission. The registered manager must ensure that all controlled drugs are securely stored in a locked metal cupboard or container. This must comply with the Misuse of Drugs (Safe Custody) Regulations 1973. The registered manager must ensure that accredited medication training is extended to all care staff. The registered manager must ensure that all staff attend Suttons one-day Vulnerable Adult protection training. The registered manager must ensure that at least 50 of the care staff obtain an NVQ Level 2. Dementia awareness training must be extended to all staff. The quality assurance process needs to be further developed with the views of relatives/friends, relevant Timescale for action 1 October 2005 2. OP9 13(2), (4)(a) & (c) Within 28 days from date of inspection (4.8.05) 1 December 2005 1 March 2006 1 December 2005 1 December 2005 1 December 2005
Page 29 3. OP9 13 (2) 4. OP18 13 (6) 5. 6. 7. OP28 OP30 OP33 18 (1)(a) 18(1)(a) & (c) 24(1) & (3) Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 8. OP33 24(2) 9. OP33 26 10. OP31 9(2)(b)(i) 11. 12. OP36 OP36 18(2), 9(2)(b)(i) 18(2) 13. OP38 13 professionals and other visitors being canvassed. The registered provider/manager must compile an annual (Quality Assurance) Development Plan. This should provide feedback (including questionnaires), from service users, their relatives and representatives, visiting professionals and other visitors, in assessing the home’s performance in meeting the aims and objectives outlined in the Home’s Statement of Purpose. A copy of the Plan should be supplied to the CSCI. The registered provider must ensure that the home is visited on a monthly basis and a report of each visit produced. A copy should be available in the home, and a copy sent to the local CSCI office. The registered manager must complete study leading to an NVQ Level 4 and the Registered Managers Award. The registered manager must complete supervision and appraisal training. The Registered Manager must provide formal supervision for the Deputy Manager at least six times a year. Radiator covers must be fitted on all remaining radiators in the home, and risk assessments for service users reviewed where appropriate. 1 March 2006 Time-scale extended to 1 October 2005 1 July 2006 1 December 2005 1 October 2006 Time-scale extended to 1 April 2006 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations
G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 30 Wellesley Lodge 1. 2. 3. 4. 5. Standard OP 30 OP30 OP30 OP30 OP36 A staff training record needs to be included on each staff file. This should provide a record of all training completed (with dates) and training that is scheduled. Bereavement training needs to be extended to all staff. Training in managing continence needs to be provided for all staff. There needs to be further First Aider training, to include night staff. The inspector looked at the supervision format and recommends that a new format is developed. This needs to provide separate headings for professional/practice issues, training/development, personal issues (sickness, leave etc) and actions/decisions agreed. To be signed by both the supervisor and supervisee. Wellesley Lodge G53 S7169 WellesleyLodge V221876 040805 stage4.doc Version 1.40 Page 31 Commission for Social Care Inspection 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
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