Inspection on 31/01/07 for Wemyss Lodge

This inspection was carried out on 31st January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 12/01/06

Wemyss Lodge 16/06/05

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 Inspection 09:45 31st January – 1 February 2007 st 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 Wemyss Lodge DS0000039117.V328004.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. Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 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 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) Wemyss Lodge Limited Mrs Kay Josephine Thompson Care Home 53 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (53), of places Physical disability (2), Terminally ill (2) Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. No more than 2 physically disabled residents at any one time No more than 2 persons in receipt of terminal care at any one time No more than 22 persons in receipt of nursing care at any one time The minimum staffing levels shall be as agreed on the Notice of Proposal dated 24 March 2003 No more than 6 persons with dementia to receive personal care at any one time 12th January 2006 Date of last inspection 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 a car park to the front. 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, Mrs Kay Thompson and she is supported y a operations manager. There are registered nurses on duty at all times, supported by care assistants. Administration, catering, domestic, laundry and maintenance support services are also provided. The range of fees at the time of this report is £595 - £770 per week. Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 31st January and the 1st February 2007 in order to inspect all of the key minimum standards relating to care homes for elderly people. The inspector visited the home between 9.45 a.m. and 4.15 p.m. on the first day and 9.30 a.m. and 5.00 p.m. on the second day, making a total of 14 inspection hours. The inspector then met with Mrs Thompson, the registered manager, and Mrs Wemyss, the operations manager, in order to discuss the outcome of the visit. The findings from this inspection are based on a tour of the premises, speaking to residents, relatives, the managers and staff, and visiting frail residents. A number of records were inspected, including care plans, medication records and staff records. Comment cards were received from three residents’ relatives and two of the home’s General Practitioner’s (GP) following the inspection and their views are incorporated in this report. The judgements contained in this report have been made from evidence gathered during the inspection and take into account the views and experiences of people using the service. What the service does well: What has improved since the last inspection? What they could do better: Although generally of a good standard, care planning needs to improve in some areas to ensure that the care given reflects residents’ needs. The home needs to ensure that newly recruited staff members do not start employment Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 Page 6 until all the appropriate checks have been undertaken, no matter what job they undertake. All new staff should receive adequate induction training. 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. Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3. Standard 6 does not apply to this home. The manager visits potential residents prior to them moving into the home, but the assessment process requires improvement to ensure that the home can meet the person’s needs on admission. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Residents records reviewed by the inspector contained pre admission assessment forms that had been completed by the manager. The assessments were not very comprehensive and did not fully assess whether the home could meet the persons needs. In one case this resulted in a delay in providing appropriate pressure relief equipment. This was discussed with Mrs Thompson and a more comprehensive pre admission assessment form has been produced since this inspection. Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 Page 9 The information contained in the assessment was used to aid completion of individual care plans and a more comprehensive assessment was undertaken on admission. One resident and a relative confirmed that some pre admission assessment had taken place and that they had been involved in this. Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 Page 10 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): 7,8,9 and 10. Care planning is good but some improvement is required to ensure plans consistently reflect residents’ needs. Management and staff demonstrate a strong commitment to ensuring residents’ health and personal care needs are addressed and ensuring they are treated with dignity and respect. The medication procedures protect the residents. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The inspector reviewed the care of five residents, three females and two males between the ages of 80 and 102. They had varying physical, social and mental health needs. Some were new to the home and others had been at Wemyss Lodge for some time. The residents care plans were reviewed. They appeared to be an accurate reflection of assessed needs and were being regularly reviewed. Assessments for tissue viability, manual handling and nutrition were in place. Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 Page 11 Although generally good, the inspector did find some areas where care planning and assessment procedures required improvement to reflect best practice. Where a resident had been assessed as being at risk of developing pressure damage, plans were not always in place to direct care or record any preventative measures taken. Plans were not always in place for those residents who were terminally ill in order to ensure that the care they receive is what they would wish. These issues were discussed with Mrs Thompson after the first day of the inspection and some action had been taken to address the issues by the second day. As noted at the previous inspection, care needs to be taken to ensure that plans are legible. The inspector visited the residents and found that interventions were in place to meet their needs, such as pressure relief equipment, continence aids, manual handling equipment and fluid intake charts. Those who were assessed as nutritionally at risk were being weighed. Staff had been specifically allocated to look after the needs of a particularly frail resident on the nursing floor. The residents’ appeared to be having their personal hygiene needs met and those who were able to communicate indicated satisfaction with the care given. One resident told the inspector “I feel much better since I came in here, the girls are marvellous”. A relative commented that she was very happy with the care adding, “staff are very attentive, they note down what she eats and drinks and give supplements”. All residents are registered with a General Practitioner (GP). Records indicated that residents had access to their GP and that staff took prompt action when there was a health care need. Residents reported being able to see a GP when they needed to, one commenting “I do see my doctor, he’s very good’. Comment cards were received from two General Practitioners (GP’s) who attend the home. They both indicated that the staff communicated clearly and worked in partnership with them and agreed that staff demonstrated a clear understanding of the residents care needs. Both indicated that they were satisfied with the overall care provided, one adding ‘very much so’. The arrangements regarding administration of medication were reviewed and found to be satisfactory. Registered nurses are responsible for the administration of medicines in the home and Mrs Thompson stated that their competence was checked at induction. Medications were safely and securely stored and records of receipts, administration and disposals are maintained. Indirect observation confirmed that medication was being safely administered. One resident self-administered their medication and a risk assessment had been completed and reviewed. Another self-administered their eye drops and it was recommended as a matter of good practice, that a risk assessment be carried out to check their ability to do so effectively. The homely remedies list Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 Page 12 had not been reviewed for some time and it was recommended that this be done with the agreement of the residents respective GP’s. There was evidence to suggest that residents’ privacy and dignity was respected. One relative who was visiting during the inspection said that she felt her mother was “Treated like a treasured relative” and felt that the care “Couldn’t be better’ and added “They (the staff) make efforts to ensure that she is well dressed and coordinated; all are treated the same, not just Mum.” Of the three comment cards received from relatives, all felt that the home met the needs of their relative and gave the care they expected. Comments added included ‘Everything about Wemyss Lodge is very good ---- the care and attention is excellent.’ and ‘Everything is done to put the residents needs first.’ One relative stated on a comment card ‘my mother is always clean and well dressed and she cannot praise the staff highly enough’ and another reported ‘the care home treats my mother as a person – her primary carer ensures that she is always smartly dressed and happy in herself. Another felt the home ‘Settle new residents well. Make the resident feel important and cared for. Staff are very courteous to resident and relatives’. The inspector observed that staff paid particular attention to residents’ appearance and dress. Personal care was given behind closed doors and staff knocked on doors before entering a room. Indirect observation indicated that staff spoke in a friendly and respectful way to residents. For those with dementia, efforts were made to ensure that they were appropriately dressed and their personal hygiene needs were met. . Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 Page 13 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): 12,13,14 and 15. As noted at previous inspections, it is evident that the home makes every effort to meet the social and recreational needs of the residents and there is a focus on providing a homely, relaxing atmosphere. Residents are able to maintain contact with family and friends and as far as possible, have choice and control over their lives. Nutritious, balanced meals are available, which the residents appear to enjoy. Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. EVIDENCE: An activity coordinator is employed in the home for four days a week. An individual record of resident’s likes and dislikes and activities they have attended is kept. Records indicate that residents are offered a varied mixture of external and in-house activity. A monthly newsletter is produced and forthcoming events are displayed on a notice board. Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 Page 14 Those who were able to voice an opinion indicated that they were happy with the activity provided. One resident said to the inspector, “We go out in the summer in the van for a pub lunch. We always have things to do but I don’t always join in”. Visitors were in evidence throughout the two days of the inspection and several residents confirmed that they had visitors and were able to keep in contact with friends and relatives. Resident’s are able to have visitors in their own room or one of the communal areas. The three comment cards received from relatives all indicated that they were kept informed of important matters concerning the resident and, where applicable, consulted about their care. It appeared that, as far as possible, residents were being supported to exercise choice and control in their lives. Comments to indicate this included: “I don’t do much, but I don’t want to!” “I like my bed turned down quite early and the staff now do it routinely for me”. “I have my meals in my room because that’s what I prefer” and “I don’t get up until I want to”. One resident asked to move rooms and was able to do so. Residents’ were seen using the homes sitting areas and some chose to stay in their rooms. Some had brought in personal items and furniture. Those who wish to can attend religious services held in the home. All three relatives who returned comment cards responded ‘Always’ to the question ‘Does the care service support people to live the life they choose?’ Residents who were able to offer an opinion commented favourably on the meals provided and indicated that they were able to comment on the quality of the meals. Comments included “The food is very good”. “Food is very good and plenty of it”. One resident said, “If I don’t like a meal I tell the cook, who says she is happy to receive comments” and another “Food’s good, except sprouts!” There was evidence to suggest that residents had a say in what food is provided; an audit had been carried out in June, which had resulted in changes to the menu and the introduction of a sweet trolley with over five choices of sweet available. The menu appeared varied, nutritious and balanced, and any special diets are catered for. The inspector observed part of the lunchtime meal over two days. Residents who required assistance with their meals were provided with support from staff in a discreet and sensitive manner. Residents are able to eat in one of the two dining rooms or in their own rooms if they want to. Drinks and snacks are also available throughout the day. Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 Page 15 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 and 18. Residents and relatives’ complaints are taken seriously and promptly investigated. As far as possible, residents are protected from abuse. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A complaints procedure is available. Residents spoken to stated that they would complain if they had to, one saying, ”I’m happy here, I’m able to see the management team if there is a problem” and another “I’ve nothing to complain about, but I would if there was”. All three relatives who returned comment cards indicated that they were aware of how to make a complaint and all responded ‘Always’ to the question ‘Has the care service responded appropriately if you or the person using the service has raised concerns about their care?’ Two complaints had been recorded in the complaint file since the previous inspection. The complaints had been handled satisfactorily and promptly. One complainant confirmed this to be the case. No complaints have been received by CSCI since the previous inspection. Residents spoken to were all positive about the attitude of the staff and the way that they treated them. One told the inspector, “I feel very safe here” and another “Yes, I do feel safe”. Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 Page 16 The home has a ‘vulnerable adults’ policy. To ensure that the policy relates to the local procedures for reporting alleged abuse, this should be amended to state that staff could also report any alleged abuse to local agencies such as social services or the vulnerable adults unit. Staff members spoken to during the inspection confirmed that they had received training about abuse awareness and the majority were aware of how report alleged abuse. A review of staff employment documentation indicated that procedures for the protection of residents had been carried out, including Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks. (See staffing section). Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 Page 17 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): 19,20,21,23,24 and 26. The home meets, and in some areas, exceeds the standards, providing a clean, comfortable, well-equipped and safe environment for residents, which meets their needs. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Wemyss Lodge was purpose built as a nursing and residential home. A tour of the home indicated that the building and equipment are well maintained, all furniture is in a good condition and the home is well decorated. There are spacious communal areas on the ground floor of the home. A lift is installed to enable residents’ access to all communal areas and all corridors are accessible with ramps and handrails fitted where necessary. Mobility aids Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 Page 18 were available. There is a call bell system installed which was working. The home has a pleasant, accessible garden and patio area. Residents’ bedrooms were carpeted and pleasantly decorated and the majority have en suite toilets. Where required, equipment was in place to meet their individual needs. Residents spoken to indicated that they were satisfied with their accommodation. The home was very clean and tidy and free from unpleasant odours. One resident commented to the inspector about the maintenance and cleanliness of their room saying, “You only have to ask for something and it’s done” and another confirmed this saying “I only have to ask and it’s done quickly”. One comment card from a relative contained the remark ‘Her room/surroundings are clean and very well maintained’ and one frequent visitor told the inspector that the home was “very clean, no smells”. The laundry was very clean, tidy and the equipment in working order. Infection control precautions were in place with regard to dealing with soiled linen. The kitchen was clean and food safety checks were carried out. Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 Page 19 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): 27,28,29 and 30. Staff numbers and skill mix appear to meet the residents’ needs. The level of care assistants with an NVQ is commendable and staff had received mandatory training, however improvement is required in relation to induction training. Some recruitment procedures need to be more robust. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The number of care staff on both days of this unannounced inspection appeared to be enough to meet residents’ needs and call bells were answered without any undue delays. Duty rotas indicated compliance with the homes minimum staffing notice. Residents generally reported that there were enough staff to support them, one saying, “The staff are good, no problems day or night.” Another reported “Occasional delays in answering the call bell but I never felt compromised because of it”. Staff and the manager felt that there were generally enough care staff on duty to meet the needs of the residents. One visiting relative said, “They always seem to have enough staff”. Another felt that the home had a ‘stable’ staff group, which contributed to a consistently good level of care. Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 Page 20 In response to the question ‘Do care staff have the right skills and experience to look after people properly?’ contained in the relatives comment cards, two relatives replied ‘always’ and one ‘usually’. The standard of cleanliness in the home and the quality of the meals provided would indicate that the level of domestic and catering staff is appropriate. The recruitment records of three recently recruited staff members were reviewed. Criminal Record Bureau (CRB) checks had been obtained or applied for, and references and Protection of Vulnerable Adults (POVA) checks had been obtained. In one case these were not in place prior to the person starting employment. Other documentation required was in place. The arrangements for staff training were reviewed. A new training coordinator had been appointed in October 2006; who said that she was currently reviewing the mandatory training needs of all staff and had commenced monthly training sessions. Individual training records are kept. Mandatory training subjects included moving and handling, health and safety, food hygiene, first aid and infection control. It is recommended that the training coordinator undertake a risk assessment course in order to enhance her knowledge in this subject when delivering health and safety training. Records indicated that induction training had been sporadic for those staff that were employed earlier in the year and the manager reported that this was due to the lack of a trainer. The current induction training relates to the TOPPS standards. These have now been replaced by the Skills for Care common induction standards and the inspector recommended that any future induction training correspond to these standards. One new staff member described the manager and the other staff as “Very supportive”. National Vocational Qualification (NVQ) training is available for care staff and the manager reported that nearly all of the care assistants either had or were working to achieving NVQ (Care), which is commendable. The homes housekeeper, two domestic staff and three catering staff were also working towards achieving a relevant NVQ. Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 Page 21 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): 31,33,35 and 38. The registered manager is fit to run the home and does so effectively and in the best interests of its residents. Effective quality assurance systems are in place and are based on seeking the views of the residents. The arrangements for the management of health and safety protect the residents and staff. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 Page 22 Mrs Thompson, the registered manager is a registered nurse who is experienced in the care of elderly people. She is currently undertaking the Registered Managers Award (RMA). Mrs Thompson is supported in her role by Mrs Wemyss, the operations manager and Mr Freeland, the Registered Provider. Mrs Wemyss is also undertaking the RMA. There were positive comments from residents and relatives about the management team and both Mrs Thompson and Mrs Wemyss demonstrated a strong commitment to maintaining high standards in the home. Residents’ opinion on the service is obtained via monthly audits and Mr Freeland collates the information. Other audits are undertaken and the manager reported that changes are made as a result, such as the introduction of a sweet trolley. Residents and relatives comments indicated that the management team make themselves accessible and actively seek their views. Mrs Wemyss reported that a member of the administration team also works weekends in order to enhance communication with relatives, as this is the time when many visit. The arrangements relating to residents money were checked and found to be satisfactory. Transactions are recorded and signed. No staff member is an appointee or advocate for any resident’s finances. The arrangements for managing health and safety were reviewed. An external auditor undertakes an annual health and safety audit. This was last held in June 2006 and the auditor commented in his report ‘working conditions and arrangements at the home were very high’. Environmental health and safety risks assessments are in place as are individual moving and handling assessments for residents. Accidents are recorded appropriately and reviewed. Hot water temperatures are controlled and checked, and the system had been checked for Legionella. Radiators are covered. Moving and handling equipment is available. Records indicated that essential equipment and services were being regularly maintained. Hazardous substances were stored safely and staff are trained in there handling. Fire safety checks are undertaken and recorded. Records indicated that staff were not always taking bath temperatures and this was brought to managers attention during the inspection. Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 4 9 3 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 3 3 X 3 3 X 4 STAFFING Standard No Score 27 3 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 OP7 Regulation 15 (1) Timescale for action The registered person shall, after 01/03/07 consultation with the service user, or a representative, prepare a written plan as to how the service users needs in respect of their health and welfare are to be met. In relation to: • Risk of developing pressure damage. • End of life care The registered person shall not 02/02/07 employ a person to work at the care home unless he has obtained in respect of that person documents specified in paragraphs 1 to 9 of Schedule 2. In relation to: • Staff should not commence employment until they have been checked against the POVA list, and two satisfactory references have been received. The registered person shall ensure that persons employed to work at the care home receive training appropriate to the work DS0000039117.V328004.R01.S.doc Requirement 2 OP29 19 (1) Schedule 2 3 OP30 18(1,c,i) 02/02/07 Wemyss Lodge Version 5.2 Page 25 they are to perform. In relation to: • Induction training 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 Refer to Standard OP9 OP9 OP18 Good Practice Recommendations It is recommended that where a resident self-administers eye drops, a risk assessment be carried out to check their ability to do so effectively. It is recommended that the homely remedies list be reviewed with the agreement of the residents respective GP’s. It is recommended that the homes vulnerable adults policy be amended to state that staff can also report any alleged abuse to local agencies such as social services or the vulnerable adults unit. It is recommended that the training coordinator undertake a risk assessment course in order to enhance her knowledge in this subject when delivering health and safety training. It is recommended that the staff induction training programme be reviewed to ensure that it corresponds to the Skills for Care common induction standards. 4 OP30 5 OP30 Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Wemyss Lodge DS0000039117.V328004.R01.S.doc Version 5.2 Page 27 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!