Inspection on 05/06/07 for Wellesley Lodge

This inspection was carried out on 5th June 2007.

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

The inspector 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 29/06/06

Wellesley Lodge 13/12/05

Wellesley Lodge 04/08/05

Wellesley Lodge 02/03/05

Wellesley Lodge 02/12/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Wellesley Lodge 41 Worcester Road Sutton Surrey SM2 6PY Lead Inspector Peter Stanley Key Unannounced Inspection 5th June 2007 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.V340335.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.V340335.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wellesley Lodge Address 41 Worcester Road Sutton Surrey SM2 6PY Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 8643 8860 020 8643 9086 Larcombeha@yahoo.co.uk Larcombe Housing Association Sally Anne Rochester Care Home 21 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (11) of places Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29th June 2006 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.V340335.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Wellesley Lodge is registered with the Commission For Social Care Inspection (CSCI) as a care home providing care for up to 21 older persons, with 10 places for older persons who have dementia. Training in dementia awareness has been provided for all care staff, and is being extended to the home’s ancillary staff. This was an unannounced key inspection of the home that took about six hours. The inspection involved discussion with the home’s registered manager, Ms Sally Rochester, 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 two relatives, and to staff on duty. 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 four recently admitted service users. Completed questionnaires were received from 10 residents and 3 relatives. The home has continued to make good progress in the last year, with evidence of a continuing commitment to maintaining and raising standards. As a result of this inspection 3 new requirements have been made, making 4 in total. 5 out of 6 requirements have been met from the previous inspection. There are also 7 recommendations, 3 of which have been bought forward from the previous inspection. The feedback from this inspection, and the questionnaires, evidences widespread satisfaction from both residents and relatives with the quality of care and support being provided. The home is regarded as providing a very pleasant, supportive and caring environment. Residents expressed many positive comments regarding the home and the caring attitudes of staff, and there was ample evidence of residents being provided with choice and flexibility in daily routines, and of being treated in a respectful and enabling way. There was evidence of substantial daily activities and flexibility of routines, with residents being able to exercise a high level of choice and control over their day-to-day lives. Residents are being consulted and involved in decision-making, whether in planning menus, arranging outings or regarding decisions that affect their individual and collective well-being. The positive and enabling culture within the home has been encouraged and promoted by the home’s registered manager, Sally Rochester. In the 15 months in which she has been in post, she has demonstrated a commitment to maintaining and raising standards, and to promoting an open, enabling and inclusive philosophy of care. There was one specific area of concern. While initial reviews for newly admitted residents are evidenced to have been held, the inspector noted that only a few Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 6 12 monthly care reviews for existing residents have been taking place, and that some reviews were overdue. Annual reviews are essential in ensuring that there is full consultation and discussion with the resident and his/her relatives, and involved professionals, regarding the person’s placement and the ability of the home to continue to meet the person’s care and support needs. This must, in future, be given a high priority. 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 home is able to demonstrate that it is obtaining full information regarding the health and support needs of prospective residents prior to their admission. Prospective residents, their friends and relatives are able to visit to assess the suitability of the home. Residents are being provided with written information detailing the terms and conditions of their placement. Residents’ care plans, detailing their health, personal and social care needs (and how these are being met) are being drawn up with the involvement of residents and their relatives/representatives. These are being reviewed on a monthly basis. The home is ensuring that residents’ health care needs are being fully met. Residents are being protected by the home’s medication policies, procedures and training. Residents are being treated with respect and their right to privacy is being maintained. Residents can be assured that, in the eventuality of their death, their wishes will be respected and that they and their family will be treated with care, sensitivity and respect. Residents are being provided with a full and varied range of opportunities for leisure and social activities. These are in accord with their social, cultural and religious interests and needs. Residents are being encouraged to maintain contact with their family and friends, with visitors being made welcome at the home. Residents have opportunities for developing and maintaining links with the local community. Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 7 Residents are able to exercise choice and control in their day-to-day activities and routines. Residents receive a wholesome and appealing diet, with choice being offered, in pleasant surroundings, and at times convenient to them. Residents and their relatives can be assured that the home has an appropriate complaints policy and procedure in place, and that their complaints will be listened to, taken seriously and acted upon. The legal rights of residents within the home are being protected and promoted. The protection of residents is being safeguarded by the home’s adult protection, policies and training. Residents are living in a safe, well-maintained environment, with access to safe, sufficient and comfortable facilities. Residents’ rooms are safe, comfortable and pleasantly decorated, reflecting residents’ personal identities, and being suited to their individual needs. The home presents as being clean, pleasant and hygienic. The home has the numbers and skill mix of staff sufficient to meet the needs presented by the home’s residents, and to ensure their safety. Residents are being safeguarded by satisfactory recruitment policy and procedures. Staff are being provided with the necessary induction and training with which to perform their work duties competently, and to safely meet the needs of residents. Residents are living in a home that is being competently managed, and run in a way which creates an open, positive and inclusive atmosphere. The home is consulting widely with residents, relatives and other stakeholders, and is able to evidence the home’s ability to meet its aims and objectives. The interests of residents are being safeguarded by the home’s record keeping, with records being kept secure, up to date and accurate. Generally, the health, safety and welfare of residents and staff are being appropriately promoted and protected. Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 8 What has improved since the last inspection? What they could do better: Twelve monthly care reviews must be held for all residents. It is recommended that two staff (one administering and one observing) be present for all administration of medication. This is in line with good practice, minimising the potential for any error to occur and thereby providing additional safeguarding for residents. The home should be reassessed by an occupational therapist to ensure that safety standards are being fully maintained, and that there are sufficient aids and adaptations in place. The carpeting in the first floor corridor is worn and must be replaced. The carpeting in Room 24 (a twin-bedded room) also needs to be replaced and the room requires some refurbishment. Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 9 The carpeting in the ground floor office should also be replaced, as this is accessed by residents and presents a potential risk. Through the regular and appropriate supervision of staff, good practice is being promoted and the welfare and best interests of residents protected. A system of annual appraisal does, however, need to be put in place. A health declaration must be completed prior to the appointment of all new members of staff. The present ‘medical form’ should be reviewed and revised. The inspector recommends that more senior care staff are enabled to undertake study for NVQ Level 3 qualifications. This would assist in raising standards of care for residents within the home. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 10 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 11 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 to 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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 home is able to demonstrate that it is obtaining full information regarding the health and support needs of prospective residents prior to their admission. Prospective residents, their friends and relatives are able to visit to assess the suitability of the home. Residents are being provided with written information detailing the terms and conditions of their placement. Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 12 EVIDENCE: The home provides care for 21 elderly residents, which includes 10 places for older persons with dementia. The number of residents who suffer from dementia has recently increased from 8 to 9. There are currently 12 residents 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 home has a Statement of Purpose and a Service User Guide in place. These provide all the information required by the Regulations for existing and potential residents and have been reviewed and updated in January 2007 by the registered manager. The Service User Guide has had some parts rephrased in plain English so as to make the Guide more user-friendly. Following the initial referral, relatives are encouraged to visit and see the home, and to ask questions about the home and the care provided. Should the application proceed, the prospective resident is then invited to visit and look round, to stay for lunch or tea, and to talk to staff, residents and any visiting relatives. A decision is then made regarding the person’s wishes and the offer of a place. Following admission, there is an initial six-week trial period. This is to ensure that the prospective resident has sufficient time in which to settle into their new environment, and to ensure that the home is able to fully meet their needs. At the end of the trial period, a review meeting is held, with the resident, his/her relatives, the resident’s key worker, and the care manager (if social services are involved) being present. The person’s circumstances, wishes and the suitability of the placement in meeting their needs are discussed. A decision is then made regarding whether or not to proceed with a permanent admission. The inspector has previously made it a requirement for all residents to have a care review meeting at least once every 12 months. This has not yet been met, and is a concern. The inspector understands that while initial six weekly and six monthly review meetings are being held for new admissions, few 12 monthly reviews are taking place. This was evidenced from the sampling of residents’ files. The manager was reminded of the need to ensure that every resident is reviewed at least 12 monthly and of the need for care reviews to be given a high priority. The timescale for meeting this requirement has been extended. Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 13 For each new resident that is admitted to the home, a full assessment is undertaken. 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 developed and expanded into a very comprehensive document. This includes sections on communications, mobility, memory, mood, transfers, continence, eating and drinking, and personal care. The inspector examined files for four residents who have been admitted within the last 12 months. Three of these were privately self-funded referrals, and one was referred by social services. The files evidenced that referral and assessment information had been obtained prior to admission, and that the home had undertaken an appropriate assessment for each resident. The inspector spoke with two residents who have recently been admitted. This indicated that both residents had settled in well, and that their needs are being well met. They also expressed the view that the home provides a pleasant and welcoming environment in which to live, and that staff are caring and respectful. The inspector also spoke to a number of other residents. This indicated that residents are generally very happy and satisfied with the home, and with the care and support being provided. The inspector observed residents to be very happy and settled in their environment, with good interaction taking place between staff and residents. Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 14 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 to 11 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ care plans, detailing their health, personal and social care needs (and how these are being met) are being drawn up with the involvement of residents and their relatives/representatives. These are being reviewed on a monthly basis. The home is ensuring that residents’ health care needs are being fully met. Residents are being protected by the home’s medication policies, procedures and training. Residents are being treated with respect and their right to privacy is being maintained. Residents can be assured that, in the eventuality of their death, their wishes will be respected and that they and their family will be treated with care, sensitivity and respect. Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 15 EVIDENCE: Each resident now has a personal information sheet which details emergency contacts, the circumstances and times of day which relatives wish to be kept informed and contacted. This also includes details of the person’s GP and social worker, and includes any essential medical information regarding any condition or disability. The home maintains a care plan for each resident, for which a photograph of the resident is attached to the front sheet. These are being presented in a structured and typed format, and provide a clear and comprehensive breakdown of residents’ care and support needs and how these are being addressed. The care plans are being developed so as to include a social profile of each resident, and generally indicate the involvement of residents in developing them. A more person-centred approach could, however, be developed, an approach which the present manager is keen to promote. The need for relevant training was identified, this being an ongoing recommendation. The inspector was advised that there is a course organised by the London Borough of Sutton, for which the manager is hopeful that, initially, some staff will be able to attend. Care plans and assessments are being maintained in separate files and provide considerable detail regarding residents’ assessed care and support needs. There was evidence of care plan reviews taking place with care plans being updated and amended when necessary. Care plans are generally being reviewed on a monthly basis, though some of those sampled were slightly overdue (by about 2 weeks). The health needs of service users are being generally well met. No specific health concerns came to light during the inspection. The home is served by a local GP group practice with which it enjoys a good relationship. Most residents are registered with this practice, though some residents (presently 4) exercise their wish to retain their own GP. There is a visiting district nurse who currently administers treatment for one resident on a weekly basis, and who attends as and when required for other residents. There is regular, periodic contact with visiting specialist health practitioners including physiotherapy, chiropody (both NHS and private), dental and optician services, and a specialist optical service visits 6 monthly for residents who have dementia. 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. Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 16 The home has previously addressed a number of concerns relating to the storage and dispensing of medication. 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 home now uses the services of a major pharmacy, resulting in the introduction of the monitored dosage system for dispensing and recording. The registered manager completes a monthly medication audit and completes occasional spot checks on staff that administer medication. The pharmacy also undertakes periodic inspections and training for staff. The inspector examined a sample of residents’ medication records. These were being appropriately maintained. A medication information sheet has been introduced for each resident. This includes a photo of the resident. 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. Accredited medication training has been extended to all staff, and is to be provided for two new staff members. The inspector discussed administration of medication with the manager and recommended that two staff (one administering and one observing) be present for all administration. This is in line with good practice, minimising the potential for any error to occur. A duplicate copy of each MAR sheet would be required for the second staff member (the observer) to sign. While residents are able to administer their own medication if they wish, no residents are presently doing so. Should this eventuality arise, this would be subject to a risk assessment. The 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 residents’ privacy and dignity, and are sensitive to individuals’ needs and rights. Visiting relatives and professionals are able to see residents in the privacy of their own rooms, or in the relative privacy of the smaller dining room. Staff and management were observed to interact with residents in a caring and respectful manner, and there was evidence of good, trusting relationships between staff and residents. The home meets the standard covering bereavement and loss. Wellesley Lodge is seen as a ‘home for life’, and given that the needs of each resident can continue to be met, then a resident would be enabled to remain at the home in their final days. There have been three 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 Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 17 family and friends fully informed and involved in any arrangements that are made. Details of residents’ wishes in the event of their serious illness/death are recorded. Staff at the home are undertaking relevant training, with six staff undertaking training in palliative care. A further seven staff are being booked on to training later in the year, in bereavement and loss. This is in line with a recommendation from the last inspection. Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 18 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12 to 15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are being provided with a full and varied range of opportunities for leisure and social activities. These are in accord with their social, cultural and religious interests and needs. Residents are being encouraged to maintain contact with their family and friends, with visitors being made welcome at the home. Residents have opportunities for developing and maintaining links with the local community. Residents are able to exercise choice and control in their day-to-day activities and routines. Residents receive a wholesome and appealing diet, with choice being offered, in pleasant surroundings, and at times convenient to them. EVIDENCE: Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 19 This home is evidenced to be providing a wide and varied range of activities and outings. A programme of activities is publicised on the notice board; this includes games and puzzles, sing-alongs, exercise sessions, reminiscence, and visiting entertainers, with an activity now being scheduled twice a day, for every morning and afternoon. There was evidence of both informal and organised activities being facilitated by staff, with residents being encouraged to participate and develop their interests. Staff were observed to interact in a positive way with residents, with residents being encouraged to interact and participate. A drawing and colouring session was in progress during the inspection in which six residents had chosen to participate. The inspector spoke to the participants and understood from the views expressed that these sessions provide a valued source of stimulation and enjoyment. The inspector received positive feedback from residents regarding the range of activities and leisure opportunities available, and there was evidence of resident involvement in planning activities and outings. Wherever possible, individuals are being encouraged to pursue their interests and hobbies. These include interests such as knitting, reading and gardening. Daily newspapers are delivered to the home and a mobile library visits once a month. The inspector was advised that there is also a talking books service, provided by Surrey Association for the Blind, that visits the home on a regular basis. 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. Residents are being consulted in resident meetings as to their interests and wishes. The manager has previously introduced a system for a staff member to escort two or three service users out for a short walk before lunch, with priority being given to those residents who do not benefit from visits by relatives or friends. Another tangible result was the setting up, in 2006, of occasional visits from a young brownies group (aged 5 to 10) called Rainbows. This has proved to be very popular with the residents. More recently a link with a local secondary school has been developed, with a regular arrangement (as part of the Duke of Edinburgh Award Scheme) whereby two boys visit the home and talk to and befriend a small number of residents. These both provide excellent examples of developing wider community links and of promoting positive emotional and social well-being within the resident group. Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 20 The home has links with the local church and volunteers from the church visit and assist with organised events and activities. Residents’ beliefs and religious beliefs are respected, with arrangements being made for individuals to attend services or receive visits where requested. There are monthly visits from church visitors, with an inter-denominational communion being held once a month. Links with activities in the wider community are encouraged wherever possible. Two residents attend a local Women’s Group, for social contact and activities, whilst two other residents, who are partially sighted, attend a once-weekly social group run by the Surrey Association for the Blind. 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 residents on organised group outings. Small group outings, using a mini-bus provided by Sutton Community Transport, are arranged to places such as Kew Gardens and Richmond Park, a programme of outings being publicised on the home’s notice board. Organised outings are arranged once or twice a month. Residents indicate their preferred choices from a wide range of options. These have included recent day trips to a local wildlife hospital, to a house and gardens in Reigate, and to a vineyard at Box Hill where residents enjoyed the views, and had tea. Pub lunches and trips out for afternoon tea are also arranged. A day trip to Brighton is presently being planned. There is also involvement from family and friends in arranging or attending organised events. Visiting musicians rotate in visiting the home once every two weeks, and there are twice-weekly exercise sessions, which a visiting organiser undertakes with residents. Residents indicate that they have considerable choice and control in their daily routines and activities, with staff being observed to be encouraging and facilitative in their interactions with residents. The ethos of the home in this regard is evidenced as being a very enabling one. Residents are able to handle their financial affairs for as long as is practical or for as long as they wish. Three residents are presently managing their own monies. There are regular monthly residents’ meetings and there is evidence of resident involvement and consultation regarding their preferences and daily activities. One resident sits as a residents’ representative on the home’s interviewing panel. Overall, the inspector was impressed with the level and range of activity and user-involvement being promoted within this home. The inspector observed residents taking lunch in the very pleasant and homely dining areas. Views expressed by residents indicated that the food is very Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 21 good. Fresh vegetables and fresh ingredients are used, the quality of food served being well vetted. The inspector examined menus. These evidenced that the home is providing a good range of nutritious and appetising food with alternative options being offered to the main dish if required. A menu-planning group has been set up with residents. This has led to the introduction of an increased variety of foods including pasta dishes and other types of cuisine to complement the more traditional range of foods. A monthly barbecued lunch has been introduced and all residents now have the choice of a cooked Sunday breakfast. The manager advised that all staff involved in food preparation have completed food hygiene training. Evidence from this and previous inspections indicate that there is a good awareness of culinary good practice and of the dietary needs of residents. The inspector inspected the kitchen and found this to be clean with good standards of food hygiene being maintained. Fridge and freezer temperatures are being regularly logged, and a record of oven temperatures, when cooking meats, and other food products, is now being regularly recorded. Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 22 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 to 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and their relatives can be assured that the home has an appropriate complaints policy and procedure in place, and that their complaints will be listened to, taken seriously and acted upon. The legal rights of residents within the home are being protected and promoted. The protection of residents is being safeguarded by the home’s adult protection, policies and training. EVIDENCE: The home has an appropriate complaints policy and procedure, a summary of which appears in the Statement of Purpose and Service User Guide. A written complaints record is maintained, which details the nature of the complaint, the subsequent investigation and actions taken. The home logs both concerns and compliments and aims to be pro-active in resolving any concerns that arise. The home has received one complaint within the last 12 months. This related to concerns expressed by the relative of one resident. This was discussed with the registered manager. The inspector is satisfied that the complaint was fully Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 23 and properly investigated and that appropriate actions were taken to address the concerns that were raised. The home aims to protect residents’ legal rights by involving family and friends in respect of their contracts, benefits and monies, and in discussing any issues that may arise. All residents are registered to vote, and are supported where necessary to vote, usually by postal vote, or by attending the polling station. No adult protection allegations or concerns have been recorded. Views expressed to the inspector indicate that residents feel safe and secure in this home, and that they have good and trusting relationships with staff. The home has an appropriate policy and procedure in place for the protection of vulnerable adults. The home has a Whistle Blowing Policy in place for staff to reference should the need arise. All staff in the home have attended Sutton’s Vulnerable Adult protection training. The inspector spoke to a number of residents. This indicated that residents feel safe and secure living in the home. No adult protection issues or concerns have been identified. Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 24 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 to 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are living in a safe, well-maintained environment, with access to safe, sufficient and comfortable facilities. While the home would appear to have sufficient aids and adaptations with which to safely meet the needs of residents, it would be advisable for the home to ensure safety with an updated OT (Occupational Therapy) assessment. Residents’ rooms are safe, comfortable and pleasantly decorated, reflecting residents’ personal identities, and being suited to their individual needs. The home presents as being clean, pleasant and hygienic. EVIDENCE: Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 25 The inspector completed an inspection of the premises. The home presents as being well maintained and decorated, and as providing a pleasant, safe and comfortable environment. A maintenance and development programme is in place, regarding the renewal of the fabric and decoration of the home. This includes ongoing redecoration and re-carpeting of residents’ bedrooms, and of the home’s communal areas. Since the last inspection six bedrooms (Rooms 2, 7, 8, 11, 12 and 35) have been redecorated and refurbished, and new carpeting has been laid in the lounge and dining room, and in Rooms 26 and 28. The inspector noticed that the carpeting in the first floor corridor is looking worn and needs replacing. The carpeting in Room 24 (a twin-bedded room) also needs to be replaced and the room requires some refurbishment. A requirement applies. The home provides safe and comfortable indoor and outdoor communal facilities. Radiator covers have been fitted to all radiators in the home. There is ample space available for sitting, recreational and dining space, with very pleasant areas to sit including a light and airy sun lounge. There is a large and a smaller dining room. The kitchen was refurbished in 2005. There is a very pleasant, part-wooded, garden which residents are encouraged to access. On the day of inspection several residents, and visiting relatives/friends, were sitting out and enjoying the garden. Residents who spoke with the inspector indicated that they were very happy with their surroundings and with the facilities provided. All residents have their own bedroom. Two residents, a married couple, share a room in accordance with their expressed wishes. The inspector looked at a number of bedrooms and found these to be generally safe, comfortable and satisfactory. Residents’ rooms reflect their individual tastes and identities, and include personal photos and mementoes. Individuals are able to bring personal possessions and items of furniture with them to the home. While eight of the bedrooms fall below 10 m2, there is sufficient communal space to compensate. The inspector spoke to a number of residents who indicated that they were pleased with the facilities provided and very satisfied with their rooms. All rooms have appropriate door locks, which can be opened from the outside if necessary. Magnetic door guards (to enable self-closing) have been fitted to all bedroom doors. There are toilets on all floors, which are accessible for residents and close to their bedrooms. These are functioning, regularly cleaned and contain supplies of paper towels and liquid soap. The home has two accessible ‘Parker’ baths, and a shower. The upstairs first floor bathroom has been renovated and includes a bath hoist. Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 26 The home presents as safe, with sufficient aids and adaptations in place. A lift, ramps, grab rails, raised toilet seats, zimmer frames, and other aids and adaptations, are observed to be present in the home. An emergency lifting cushion and a set of mechanical weighing scales have also recently been purchased. The home was last assessed by an occupational therapist, in February 2005, when it received a positive report. The inspector recommends that the home should be reassessed to ensure that safety standards are being fully maintained, and that there are sufficient aids and adaptations in place. The home generally presents as being clean, pleasant and hygienic. All cleaning fluids and agents are now kept in a separate shed outside of the home. This is kept locked. Clear procedures are in place regarding the risk of cross-infection. An outstanding requirement, for all staff to undertake infection control training, is in the process of being met, all domestic and kitchen staff having completed this training. A rolling programme of training is in place. Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 27 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27 to 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has the numbers and skill mix of staff sufficient to meet the needs presented by the home’s residents, and to ensure their safety. Residents are being safeguarded by satisfactory recruitment policy and procedures. Staff are being provided with the necessary induction and training with which to perform their work duties competently, and to safely meet the needs of residents. EVIDENCE: The home is evidenced to have sufficient numbers and skill mix of staff. The home employs 14 care staff, 6 of whom are senior care staff. The home also employs 7 auxiliary staff, which includes 2 cooks, 2 kitchen assistants, three cleaners and a handyman. Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 28 Inspection of files evidences that staff have obtained relevant qualifications. 8 care staff have obtained an NVQ Level 2 social care qualification, while 3 others are currently studying for this qualification. The inspector was advised that 6 support staff are doing an NVQ Level 2 in customer services. Just 2 staff have achieved an NVQ Level 3. This is on the low side, and the inspector recommends that more senior and experienced staff are enabled to study for this qualification. This would provide a nucleus of staff who are more highly qualified, which would assist in raising standards of care within the home. The home maintains 4 staff on duty throughout the day (together with the person in charge), both on weekdays and at weekends, with 2 waking staff being on duty overnight. One senior care worker and one care worker work overnight with a back-up sleep-in carer. The manager or deputy manager is on-call if required. On the day of inspection appropriate numbers of staff were found to be on duty. The home has recruited two 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. However, one staff file did not include a signed health declaration; a requirement applies. The inspector did not feel that the home’s existing ‘medical form’ provides sufficient information regarding the applicant’s medical history. The medical form should be reviewed and updated, and a more comprehensive health declaration put in place. The home has a comprehensive and ongoing programme of induction and training in place. 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. A staff training record is being included on each staff file. This details the training completed and scheduled (with dates) for each member of staff. The home has been prioritising staff training in dementia awareness, there being a rolling programme in place. 15 staff have so far completed this training, with 3 others due to attend on 6.06.07. The manager confirmed that this training is being extended to all staff who work in the home. Training in bereavement and loss is planned for 6 staff in September 2007, 6 other staff having recently undertaken training in palliative care. The inspector has previously identified a need for training in person-centred care planning. The manager confirmed that the home is hoping to access Sutton’s training for 2 or 3 staff, with view to this being eventually being rolled out to all care staff. Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 29 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31 to 33, 36 to 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are living in a home that is being competently managed, and run in a way which creates an open, positive and inclusive atmosphere. The home is consulting widely with residents, relatives and other stakeholders, and is able to evidence the home’s ability to meet its aims and objectives. Through the regular and appropriate supervision of staff, good practice is being promoted and the welfare and best interests of residents protected. A system of annual appraisal does, however, need to be put in place. The interests of residents are being safeguarded by the home’s record keeping, with records being kept secure, up to date and accurate. Generally, the health, safety and welfare of residents and staff are being appropriately promoted and protected. Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 30 EVIDENCE: The home’s registered manager, Ms Sally Rochester, has relevant management qualifications (Registered Managers Award and NVQ4), and has had extensive previous experience in both community care and residential care management for older people. In the period of 15 months since taking over as manager, Ms Rochester has been able to demonstrate a commitment to maintaining and raising standards at the home and to promoting an open and inclusive philosophy of care. Both residents and staff have expressed positive views about the manager, and is perceived to be caring, supportive and enabling in her approach. Throughout the inspection, the manager presented as being very knowledgeable and competent, and demonstrated an awareness and understanding of the needs of older people, including those who have dementia. She has made a concerted effort to address previous shortcomings and to develop services that are flexible and responsive to residents’ needs and wishes. With the support of the Board of Directors, there is a planned programme of restructuring and development to assist in taking the home forward and build on previous progress. 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. There has been a high rate of returns, which generally indicate a high level of satisfaction with the home. An annual quality assurance Development Plan has still to be completed for 2007, a plan having been completed for 2006. The inspector has examined a sample of staff supervision notes and evidenced that all staff are receiving regular two-monthly supervision. Supervision is being divided between the manager and deputy manager. A supervision format has been developed which provides separate headings for professional/practice issues, training/development and personal issues such as sickness, leave etc. The format has been further revised so as to provide Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 31 sufficient space for the recording of main discussion points discussed, and the actions/decisions agreed. A recommendation for supervision and appraisal training has still to be acted upon. The manager advised that this will be implemented as part of a wider programme of planned change. The manager has previously advised that she is planning to develop an appraisal system for appraising the development and performance of staff. This has still to be developed, and needs to be prioritised. A requirement applies. Generally, the home’s record keeping, policies and procedures are safeguarding residents’ best interests. The inspector examined a wide range of records including staff and service users files, incident and accident forms, and other documentation. These were generally well maintained, kept up-to-date, and are stored securely in the office’s lockable filing cabinets. The manager is now ensuring that all the home’s policies and procedures are being reviewed on an annual basis. A checklist is also being maintained detailing when these were last reviewed. The home has evidenced that it has completed all health and safety checks within the required time-scales. Fridge/freezer temperatures are being checked on a daily basis. A record of oven temperature is also now being maintained. Fire inspection reports and risk assessments for the home are in place. Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 32 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 25CHOICE 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 X 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 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 3 3 3 3 3 2 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 2 3 3 2 3 3 Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 33 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 must 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. Unmet from previous inspection. 2 OP24 16(2)(c) The carpeting in the first floor corridor is worn and must be replaced. The carpeting in Room 24 (a twin-bedded room) needs to be replaced and the room requires some refurbishment. The carpeting in the ground floor office should also be replaced, as this is accessed by residents and presents a potential risk. 3 OP29 19(1)(a) & (b), Schedule A signed health declaration must be evidenced for all staff prior to their appointment at the home. DS0000007169.V340335.R01.S.doc Timescale for action 30/09/07 31/10/07 30/06/07 Wellesley Lodge Version 5.2 Page 34 2, No.6 See also recommendation No.5 4 OP36 18(1)(a) & (c) A system of staff appraisal, which assesses competency, and includes a pre-appraisal selfevaluation, must be developed. 31/10/07 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 OP9 Good Practice Recommendations All care staff should undertake training in person-centred care planning. It is recommended that two staff (one administering and one observing) be present for all administration of medication. This is in line with good practice, minimising the potential for any error to occur and thereby providing additional safeguarding for residents. A duplicate copy of each MAR sheet would be required for the second staff member (the observer) to sign. 3 OP22 The home should be reassessed by an occupational therapist to ensure that safety standards are being fully maintained, and that there are sufficient aids and adaptations in place. This would assist in ensuring high standards of safety for all residents within the home. 4 OP27 The inspector recommends that more senior care staff are enabled to undertake study for NVQ Level 3 qualifications. This would assist in raising standards of care for residents within the home. Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 35 5 6 7 OP29 OP36 OP36 A more comprehensive health declaration should be put in place. The registered manager and deputy manager should aim to undertake supervision and appraisal training. 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. Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 36 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wellesley Lodge DS0000007169.V340335.R01.S.doc Version 5.2 Page 37 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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