Inspection on 16/06/05 for Wemyss Lodge

This inspection was carried out on 16th June 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Wemyss Lodge 31/01/07

Wemyss Lodge 12/01/06

Wemyss Lodge 01/12/04

Wemyss Lodge 27/04/04

Wemyss Lodge 23/10/03

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Queensmount

Poldhu

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Wemyss Lodge Ermin Street Stratton St Margaret Swindon Wiltshire SN3 4LH Lead Inspector Steve Cousins Unannounced 16th June 2005 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. Wemyss Lodge D51 D01 s39117 WemyssLodge v226583 160605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Wemyss Lodge Address Ermin Street Stratton St Margaret Swindon Wiltshire SN3 4LH 01793 828227 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) Wemyss Lodge Limited Mrs Kay Josephine Thompson Care Home with Nursing 53 Category(ies) of OP - Old age 53 registration, with number PD - Physical disability 2 of places TI - Terminally ill 2 Wemyss Lodge D51 D01 s39117 WemyssLodge v226583 160605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 No more than 2 physically disabled residents at any one time 2 No more than 2 persons in receipt of terminal care at any one time 3 No more than 22 persons in receipt of nursing care at any one time 4 The minimum staffing levels shall be as agreed on the Notice of Proposal dated 24 March 2003 Date of last inspection 1st December 2004 Brief Description of the Service: Wemyss Lodge is a purpose built care home situated in a residential area of Stratton St Margaret, Swindon .The accommodation spreads over 2 floors with en-suite facilities provided in the majority of the rooms, double rooms are also available. Externally there is a pleasant, accessible garden and adequate parking spaces. The home is registered with the Commission for Social Care Inspection (CSCI) to provide nursing care and support, and residential accommodation for up to 53 elderly service users. The home has a full time registered manager and there is a registered nurse on duty at all times, supported by care assistants. Administration, catering, domestic, laundry and maintenance support services are also provided. Wemyss Lodge D51 D01 s39117 WemyssLodge v226583 160605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 9.45am and 4.45pm. There were 53 residents in the home. The findings from this inspection are based on a tour of the premises, speaking to residents, relatives and staff, and visiting frail residents. A number of records were inspected, including care plans and staff files. Service users are known as residents in this home and will be referred to as such throughout this report. The findings were discussed with Mrs Thompson, the registered manager, and Mrs Wemyss, the operations manager, at the end of the inspection. What the service does well: What has improved since the last inspection? What they could do better: Improvement could be made regarding the recording of staff training and care needs to be taken to ensure entries on care plans are legible. Wemyss Lodge D51 D01 s39117 WemyssLodge v226583 160605 Stage 4.doc Version 1.30 Page 6 Some toilet seats required replacing. It was noted during the inspection that some of the residents had mild dementia. Although they were receiving appropriate support and not having an adverse affect on other residents, the home is not curently registered to provide support for people with dementia. Since the inspection, the Commission has received an application from the home to register six places for residential dementia care. 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. Wemyss Lodge D51 D01 s39117 WemyssLodge v226583 160605 Stage 4.doc Version 1.30 Page 7 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 Wemyss Lodge D51 D01 s39117 WemyssLodge v226583 160605 Stage 4.doc Version 1.30 Page 8 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) 3,4 and 5 Residents’ needs are assessed and there are opportunities to visit before admission. The home has the capacity to meet their needs. EVIDENCE: Residents’ care plans contained satisfactory pre admission assessments, which had been carried out by the manager, with the involvement of the resident. Where appropriate, supporting information from care managers and relatives was available. A new resident had been admitted with a diagnosis of mild dementia. The home is not currently registered to accommodate those with this condition. The manager stated there were others with the condition within the home. Observation indicated that care was appropriate and it was recommend that the provider apply for a variation of registration to accommodate a set number of people with mild degree of dementia, for personal care only. Some residents had visited the home prior to moving in; others said that their relatives had looked around for them. Two relatives confirmed this. All spoken to were happy with the choice of home. Wemyss Lodge D51 D01 s39117 WemyssLodge v226583 160605 Stage 4.doc Version 1.30 Page 9 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 and 9. Care plans reflect health, personal and social needs. Residents’ health care needs are met and they are protected by the homes procedures regarding medication. EVIDENCE: Care plans seen were a good reflection of assessed needs and were reviewed monthly, although care needs to be taken to ensure that plans are legible. Social needs are also documented. Visits to residents indicated that appropriate equipment was in place to meet assessed needs and that interventions required were carried out and recorded. Frail residents were clean and comfortable and receiving adequate fluids and nutrition. Two residents with pressure sores were receiving appropriate treatment. Residents indicated they were able to see a doctor when required. Their comments included, ‘staff do all they can for me’, and ‘I’m well looked after’. One stated that her medical condition was ‘well managed’. Relatives also indicated satisfaction regarding the care and support given. The arrangements regarding medications were satisfactory. Two service users were self-medicating, both were risk assessed monthly. Wemyss Lodge D51 D01 s39117 WemyssLodge v226583 160605 Stage 4.doc Version 1.30 Page 10 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 and 15 Standards regarding social and nutritional needs are exceeded. Residents are able to maintain contact with family, friends and the community. EVIDENCE: Residents spoken with were happy with their lifestyle in the home. There is a good level of varied in house and external activity available for residents to participate in if they so wish, which was evidenced by individual records and included religious services. The environment is very homely and a good degree of social contact between residents’ was evident. One said that there was ‘plenty for me to do’ and another ‘enjoyed the outings’. There were no restrictions on visiting unless at the request of the resident and visitors were in the home throughout the inspection. Residents were receiving visitors in private. Links with the local community were maintained with trips to a local community centre and other local outings. There were very positive comments regarding the meals provided which included, ‘we have a wonderful choice’ and ‘the food is very good’. This was also reflected in a recent audit in which residents were asked their opinion of the food provided. The menu indicated a good choice of nutritious food and special diets are available. Residents can eat in the large dining room or in their room if they wish. Wemyss Lodge D51 D01 s39117 WemyssLodge v226583 160605 Stage 4.doc Version 1.30 Page 11 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 Complaints are taken seriously and investigated appropriately. As far as possible, residents are protected from potential abuse. EVIDENCE: Complaints were recorded and investigated promptly. It was evident through conversation that Mrs Thompson, the registered manager, treats any complaints seriously and communicates outcomes to complainants and staff as necessary. Residents and relatives spoken with knew whom to approach if they had a complaint or a problem and the complaints procedure was available. The CSCI had received one complaint since the last inspection, which had been investigated by the manager and appropriate action taken. The manager demonstrated a good awareness of abuse issues and reported that all staff had received a copy of the local guidelines for reporting suspected abuse. She and one of the nurses were due to attend a training session held by the local Vulnerable Adults Unit. CRB checks had been obtained for all staff and new staff have additional POVA checks before commencing employment. Protection of vulnerable adults is covered in staff induction and NVQ training. Wemyss Lodge D51 D01 s39117 WemyssLodge v226583 160605 Stage 4.doc Version 1.30 Page 12 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) 19,20,21,24 and 26 The home is safe, comfortable, and accessible and is well maintained. There are sufficient toilet and bathing facilities. The home is clean, pleasant and hygienic. EVIDENCE: Maintenance records and a tour of the home indicated that the building and equipment is well maintained. External areas are attractive and accessible. Compliance had been achieved with regard to fitting radiator covers and the installation of a disinfecting sluice facility. The maintenance person demonstrated a strong commitment to maintaining good standards throughout the home There are spacious communal areas, including a dining room, which were well lit, decorated and furnished. New furniture had been provided in the sun lounge. There were adequate numbers of toilets and bathrooms, which were clean and tidy. Some toilet seats needed to be replaced. Wemyss Lodge D51 D01 s39117 WemyssLodge v226583 160605 Stage 4.doc Version 1.30 Page 13 Bedrooms were homely and showed signs of personalisation. Adjustable beds were in use for those receiving nursing care. Many bedrooms had been redecorated, refurbished and carpeted. Residents were happy with their rooms. The home was very clean throughout and free from unpleasant odours. Infection control systems were in place and the laundry was clean and tidy. The kitchen was clean and food hygiene and safety measures were in place. Wemyss Lodge D51 D01 s39117 WemyssLodge v226583 160605 Stage 4.doc Version 1.30 Page 14 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) 27,29and 30. The numbers and skill mix of staff meets the residents’ needs and staff are trained and competent. Residents are protected and supported by recruitment practice. Recording practices could be improved. EVIDENCE: There were two nurses and eight care assistants on duty for 53 residents. Review of staff duty rotas indicated that staffing levels were stable and complied with the staffing notice. Levels of domestic, kitchen and laundry staff appear appropriate. Residents and relatives thought staff levels were satisfactory and one said ‘you never see staff just sitting around’. Administration, maintenance and activity staff are also employed. Recruitment practice appears satisfactory. Seven staff recruitment files were reviewed and the appropriate documentation was in place. Staff did not commence work before POVA checks had been obtained, however not all dates when checks had been received were recorded. It was recommended that this take place. Individual training records were kept which indicated staff had received mandatory, induction and other appropriate training. Staff confirmed this. A training coordinator was in post. Not all records were complete and it was difficult to assess the overall training completed. It is recommended that a training matrix be developed, which records the mandatory training all staff have received on a single document. Wemyss Lodge D51 D01 s39117 WemyssLodge v226583 160605 Stage 4.doc Version 1.30 Page 15 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 and 38 The registered manager is fit to run the home and the management team demonstrate strong leadership. The health safety and welfare of the residents and staff are promoted and protected. EVIDENCE: The registered manager is a nurse and has considerable knowledge and experience in the care of older people. Mrs Thompson has the title of matron and her primary role is a clinical one working alongside the nursing and care staff. Mrs Thompson is undertaking the Registered Managers Award. She is supported in her role by Mrs Wemyss, the operations manager, responsible for administration and general management; and by Mr Freeland, the registered provider. The arrangements regarding the management of health and safety were satisfactory. Fire safety tests were carried out, accidents are recorded and action taken as required. Emergency lighting had been upgraded and external doors were now alarmed. The water supply had been checked for Legionella. Wemyss Lodge D51 D01 s39117 WemyssLodge v226583 160605 Stage 4.doc Version 1.30 Page 16 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 x x 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 x 15 4 COMPLAINTS AND PROTECTION 4 3 3 x x 3 x 3 STAFFING Standard No Score 27 3 28 x 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 3 3 x x x x x x 3 Wemyss Lodge D51 D01 s39117 WemyssLodge v226583 160605 Stage 4.doc Version 1.30 Page 17 No 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 Regulation Requirement Timescale for action 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. 3. 4. Refer to Standard OP4 OP21 OP29 OP30 Good Practice Recommendations It is recommended that the provider apply for a variation of registration to accommodate a set number of people with mild dementia, for personal care only. It is recommended that older toilet seats be replaced. It is recommended that the date staff POVA 1st checks are obtained, be recorded in all cases It is recommended that, in order to easily evidence staff training, a single record indicating all mandatory training be kept. Wemyss Lodge D51 D01 s39117 WemyssLodge v226583 160605 Stage 4.doc Version 1.30 Page 18 Commission for Social Care Inspection Suite C, Avonbridge House Bath Road CHIPPENHAM Wiltshire SN15 2BB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Wemyss Lodge D51 D01 s39117 WemyssLodge v226583 160605 Stage 4.doc Version 1.30 Page 19 - 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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