Inspection on 15/05/07 for Wessex Lodge

This inspection was carried out on 15th May 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 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

Wessex Lodge 28/04/06

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Wessex Lodge Jobson Close Newbury Road Whitchurch Hampshire RG28 7DX Lead Inspector Laurie Stride Unannounced Inspection 15th May 2007 11:30 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 Wessex Lodge DS0000065491.V336181.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. Wessex Lodge DS0000065491.V336181.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Wessex Lodge Address Jobson Close Newbury Road Whitchurch Hampshire RG28 7DX 01256 895982 01256 893523 wessex@hestiacare.co.uk 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) Hestia Care Limited Mrs Veronica Sharon Bovill Care Home 40 Category(ies) of Dementia (10), Old age, not falling within any registration, with number other category (40) of places Wessex Lodge DS0000065491.V336181.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th April 2006 Brief Description of the Service: Wessex Lodge is a large purpose built service registered to provide nursing care to forty people who are over the age of sixty-five. The home can also admit up to ten people who have Dementia. The homes is owned and managed by Hestia Care Ltd and the registered manager is Mrs Veronica Bovill. Accommodation is provided on three floors and there are forty individual bedrooms with en-suite facilities. The home is located close to the village of Whitchurch and its local amenities. The home shares a site with another registered nursing home Berehill which is also owned by Hestia Care Ltd. The manager provided information for the inspection to indicate that the fees for the home range from £520 to £850 per week. This report will be made available in the home to all people who use the service and visitors and it will be attached to the statement of purpose and service user’s guide. Wessex Lodge DS0000065491.V336181.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit was carried out on the 15th May 2007 as part of the key inspection of this service. Prior to the visit the registered manager had completed an annual quality assurance assessment (AQAA). Five of the people who live in the home had returned postal survey questionnaires, assisted by a family member or representative. Two other relatives of people who use the service and two healthcare professionals also returned survey questionnaires. This information, together with the previous inspection report and information gathered during the visit, provide the evidence on which this current report is based. The inspection visit took place over approximately seven and a half hours and the home’s registered manager assisted the inspector throughout. During the visit it was possible to meet some of the people who live in the home and talk in depth with two of them. The inspector also spoke with three members of the staff team, the registered manager and the owner of the service, read samples of the home’s records and viewed the premises. What the service does well: People who use the service were confident that the home could meet their needs and spoke highly of the manager and staff. The home promotes people’s independence, provides a good range of activities and asks for the views of those who use the service, in order to cater for their diverse needs and interests. Staff members feel very well supported by the manager and the training programme is developing to meet staff and service user’s needs. A well-balanced and varied diet is offered and this can be adjusted to meet individual needs and requirements. One person who lives in the home commented that it is a ‘well organised and harmonious home.’ Other comments included: ‘This is our first connection with a care home and its unbelievable, my mother is more than happy’. ‘I’m very happy and all the staff are fantastic’. ‘I am very happy to be here and I am looked after very well’. ‘A homely pleasant atmosphere. The residents are looked after well.’ Wessex Lodge DS0000065491.V336181.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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. Wessex Lodge DS0000065491.V336181.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 Wessex Lodge DS0000065491.V336181.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 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective people to use a service and their representatives have the information needed to choose a home that will meet their needs and also have their needs assessed prior to admission. This home does not provide intermediate care. EVIDENCE: The home provides a Statement of Purpose and a Service User Guide and this information was available to read in the home. A large print version of the Statement was also available. All of the people who returned survey questionnaires said they had received sufficient information to make a choice about moving to the home. In discussion with people who live in the home, one person said ‘I felt comfortable as soon as I walked in the door.’ Preadmission visits and trial periods had been arranged for people interested in Wessex Lodge DS0000065491.V336181.R01.S.doc Version 5.2 Page 9 using the service. Written contracts stating the terms and conditions of residence were seen on record. Records of admission were seen in respect of four people who live in the home and each had been assessed as to what their individual needs were. This included health care assessments with nursing intervention strategies. The assessments had been completed by the home’s registered manager and care managers’ assessments had also been obtained where applicable. The information gathered during the assessments had been used to develop written care plans for each person. Through discussion with people who live in the home and the information gathered by survey, it was evident that people who use the service and their representatives felt that they receive the care and support they need. This was further confirmed by healthcare professionals who returned questionnaires. Wessex Lodge DS0000065491.V336181.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 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who use the service generally receive appropriate health and personal care, based on their individual needs. However not all care plans clearly show how this will be achieved for each person. Improvements in medication practices have been made to ensure that people who use the service are better safeguarded. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Each person who lives in the home has a care plan and the inspector examined a sample of four of these plans during the visit to the home. The plans cover activities of daily living including eating and drinking, healthcare, mobility, personal care, social activities and any specific nursing interventions required. The care plan uses a form that has a number of standard statements in each of the areas of daily living and present actions that staff need to take. The person making the assessment deletes the parts that are not relevant. Some of the plans were difficult to understand because either the forms had not Wessex Lodge DS0000065491.V336181.R01.S.doc Version 5.2 Page 11 photocopied well and/or the deletions and hand-written amendments made them unclear. This could lead to confusion about the individuals needs. The manager had identified that care plans could be improved and said that the home is planning to introduce a new format in the future to enhance the current care planning system. This had also been discussed at the previous inspection visit. The care plan for one individual recently admitted to the home did not contain sufficient information to show how the service can meet all of this person’s previously assessed needs. The manager stated that she had contacted the individual’s care manager in relation to obtaining guidelines and further information on issues around previous alcohol dependency. A requirement has been made that care plans must contain clear and sufficient information to demonstrate that the home can meet all the needs of people who use the service. The inspector noted appropriately completed monitoring records for weight, fluid and nutritional needs. Regular assessment of risks related to pressure care, mobility and nutritional need are undertaken. At the previous inspection visit the requirement for a risk assessment had been identified in relation to a person for whom bed-rails are used. The registered manager had completed a general risk assessment in relation to the use of bedrails, but there was no specific risk assessment in the care plan for the person for whom bedrails are used. One person who lives in the home requires nursing care with a pressure ulcer and the intervention plans are appropriately documented. The records showed that staff in the home had contacted the tissue viability nurse for advice. The sample of records seen contained information to confirm regular contact with healthcare professionals, including visits by General Practitioners (GP). The inspector examined the medication practices in the service and looked at the storage and recording of medication. The home’s medication is stored appropriately and records are maintained of all medication administered and disposed of in the home. The correct facilities are available in the home for the safe disposal of unused medication. At the previous inspection visit a requirement had been made with regard to improving medication practices. This had been met. During this visit it was seen that any changes to medications are agreed with the GP and administration records had been completed correctly. One person who lives in the home is being supported to manage his/her own medication and this is documented and risk assessed. Wessex Lodge DS0000065491.V336181.R01.S.doc Version 5.2 Page 12 Through discussion with people who live in the home and the information gathered by survey, it was confirmed that people felt that staff assistance was received when required in a timely way. All felt that they receive the medical support they need. People who use the service also confirmed that staff provide support in a sensitive manner and respect their privacy and dignity. Wessex Lodge DS0000065491.V336181.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 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their lifestyle and receive a well-balanced and varied diet reflecting their likes and dislikes. Social and recreational activities meet individual’s expectations and the home seeks people’s views on these. EVIDENCE: The service has a member of staff who coordinates activities and events in the home. Daily activities are organised and the inspector observed people who use the service enjoying a session given by a visiting musician. An activity board is displayed in the lounge and the co-ordinator keeps a record of sessions and who has participated. They keep this under review to ensure everyone has an opportunity to participate in activities they enjoy. The survey questionnaire asked people who use the service if there are activities arranged by the home that they can take part in, one said always, four said usually. A relative commented ‘Very good activities, the musical activities are always remembered’. Two people who live in the home who Wessex Lodge DS0000065491.V336181.R01.S.doc Version 5.2 Page 14 spoke with the inspector were also positive in their comments on the activities provided. Activities include board games, bingo, music and movement, discussions and reminiscence work, arts and crafts and aromatherapy. Trips are organised to go to pubs for meals and skittles, shopping in Basingstoke and afternoon teas. Feedback from people who live in the home, family members and health professionals confirmed that the home is very open and relaxed and visitors are made welcome and actively encouraged. Local clergy also visit the service. People who live in the home commented on being consulted about their needs and wishes, given choice about what to do, how and where to spend their day and their preferred meals and drinks. Relatives and health professionals who returned questionnaires also indicated that the home supports individuals to live the life they choose. The inspector observed people who use the service throughout the visit and they were relaxed and appeared comfortable in their surroundings. One person who lives in the home said there was a good atmosphere in the home and they had made friends there. Staff were observed responding promptly to service users and supporting them with their requests. The home has a four-week menu that provides variety and alternatives are offered. The kitchen staff were aware of individual’s likes and dislikes and comments and suggestions about meals and mealtimes are invited from people who use the service. The chef was confident that they can cater for specific requirements of people’s cultural or religious needs and they would seek advice to ensure they could meet these needs correctly. The five people who returned questionnaires all indicated that they always liked the meals provided. Other people on the day of the visit were also very positive about the food provided, one said ‘the cooking is marvellous.’ The inspector observed the meal times in the home and these were relaxed and unhurried. Staff were available to give support to people at mealtimes if needed. Wessex Lodge DS0000065491.V336181.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 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service feel able to express their concerns and are protected by the home’s policies and procedures. This will be enhanced by the further training planned for staff. EVIDENCE: A complaints policy and procedure are in place and available to all service users and visitors to the home. A copy of the procedure was on display in the entrance hall of the home. The manager reported that no complaints have been received. People who use the service who were spoken with or who returned questionnaires felt they are treated with respect and confirmed that staff listen and act on what they say. They were aware of the complaints procedure and felt comfortable about taking any concerns to the manager or staff. The registered manager has established a sense of openness at the home so that people who use the service, their relatives and staff can voice their concerns. Discussion with people who use the service confirmed that they feel safe in the home and feel free to express themselves. They also confirmed that the manager meets with them regularly to ask their views. The home’s quality assurance questionnaire also encourages people to comment about the service. Wessex Lodge DS0000065491.V336181.R01.S.doc Version 5.2 Page 16 The home has copies of the local authority adult protection procedures and a whistle blowing policy. The manager stated that staff have been given a leaflet prepared by the home which identifies abuse and how to recognise the signs of abuse. The manager said that she had undertaken training provided by the local authority in order to be a trainer in this subject. Some staff have received this training and new staff members are introduced to the subject during their induction period. A new training package has been obtained including adult protection matters and all staff are to take part in this after July. Staff spoken with confirmed that they had received guidance in adult protection matters and demonstrated understanding of the procedures to follow if abuse is suspected. The manager had reported one adult protection referral in the last twelve months. Records were available to show that action had been taken and the home had followed the correct procedures. Wessex Lodge DS0000065491.V336181.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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a comfortable, clean and well-maintained environment enhanced by alternative communal areas and individually styled and furnished rooms to meet individual’s needs. This will be enhanced by the completion of clear risk assessment strategies for outdoor spaces. EVIDENCE: The home has been built on the grounds of another registered service and provides forty single bedrooms with en-suite facilities. The inspector toured the premises with the manager and discussed the facilities with people who live in the home during the visit. One person spoke of being pleasantly surprised when first coming to the home, saying it was not what they had expected, ‘it’s not like a care home’. A healthcare professional who completed a questionnaire commented that ‘the environment is not like a stereotypical nursing home. It is spacious, bright, modern, clean and the staff are friendly and available.’ Wessex Lodge DS0000065491.V336181.R01.S.doc Version 5.2 Page 18 Most people make use of the large lounge on the ground floor and individuals were also using additional seating in the dining area during the visit. A small lounge is available on each of the other two floors in the home, equipped with tea and coffee making facilities. These rooms are occasionally used by families visiting relatives and for services conducted by local clergy. The manager is looking at ways to make these rooms more user friendly. Since the previous inspection visit progress had been made with the work on the outside of the building, although the manager said there was still some landscaping work underway. A courtyard patio area can be accessed from two of the ground floor bedrooms and a communal area and these doors have ramped access. At the previous inspection visit the inspector had noted that there are no handrails and the door thresholds are much higher than the ramps. The manager had stated that they would need to complete risk assessments to ensure service users do not trip or slip in these areas. Since the last inspection, the manager had completed general risk assessments relating to residents being unaccompanied in the grounds and for people moving between floors using the stairwells. This partly meets a previous requirement, however risk assessments need to be individualised and be included in people’s care plans. The manager had identified there were areas in the grounds where handrails could be fitted to provide a safer environment for people who use the service, but these had not yet been fitted. There were notices on doors to stairwells reminding people who use the service that they should not use the stairs if unaccompanied by a member of staff. It was identified in the previous report that the dinning room does not provide sufficient seating facilities to cater for all people who use the service if they wish to take their meal in this area. The manager stated that many people prefer to eat their meals in their rooms, however should the need arise, arrangements could be made for there to be two sittings at mealtimes. The home was clean and tidy and free from any unpleasant smells. The home has a laundry with washing machine that has appropriate disinfection programmes. The room itself was clean and the floors and walls are readily cleanable to ensure the chances of infection and cross contamination is reduced. The inspector observed staff using appropriate protective equipment such as gloves and aprons and each floor of the building has an appropriate sluice facility. People who use the service and returned questionnaires all confirmed that the home is kept fresh and clean. Wessex Lodge DS0000065491.V336181.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service have confidence in the staff that care for them. Staff in the home are trained and in sufficient numbers to support the people who live there. This would be further enhanced through formal supervision for non-nursing staff. The homes’ recruitment procedures are robust and protect people who use the service. EVIDENCE: The manager provided information to confirm that sufficient staff are on duty throughout the day to meet the needs of people who use the service. A National Vocational Qualification (NVQ) programme is in operation in the home and the manager reported that a budget had been allocated for three staff to undertake level 3 and one staff member to commence a level 2 NVQ. Three of the staff team are currently undertaking NVQ level 2 training. Three members of staff have already obtained NVQ level 2 and another has NVQ level 3. Staff told the inspector that they have also attended training on Understanding Dementia, Moving and Handling people, Infection Control, Food Hygiene and Fire Safety. An induction programme is in place to train and develop staff. The Wessex Lodge DS0000065491.V336181.R01.S.doc Version 5.2 Page 20 manager had recently obtained a new induction training package to replace this with, which still meets the Skills for Care common induction standards. Staff members stated that they felt very well supported by their colleagues and the manager of the home. One said that if staff identify a training need then the home will try to implement this. Staff members spoken with were well motivated and had a good understanding of the aims of the home and its philosophy of care. The inspector examined staff training profiles and these included a record of training attended and certificates to support this record. The manager was required at the last inspection to update these records to demonstrate that staff have attended all mandatory training including Food Hygiene, First Aid, Health and Safety and Moving and Handling. During this visit the inspector was able to confirm that this requirement had been met. The manager has identified that training records could be further improved through using a clearer and easier format. A new training programme for the year is in place and will include care of the stroke resident, diabetes care, multiple sclerosis care, Parkinson’s disease and epilepsy. Four staff files were examined and found to contain appropriate application forms, two or three written references, proof of identity and a completed Criminal Records Bureau (CRB) check. A clinical supervision programme has been established in the home and trained nurses are receiving regular support with a documented record of these sessions. A formal supervision programme has yet to be established for nonnursing staff. A carer confirmed that regular informal supervision takes place People who use the service and spoke to the inspector or returned questionnaires indicated that they have confidence in the staff that care for them. One person commented that ‘I’m very happy and all the staff are fantastic’. Another wrote ‘we couldn’t ask for more’ with regard to the staff. Wessex Lodge DS0000065491.V336181.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 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who live in the home are supported by a service that is managed in a generally effective and open manner. However, the home still needs to address some areas of health and safety to fully demonstrate that people who use the service are kept safe. There are systems to ensure the views of people who live in the home are acknowledged and used as part of the development of the service. EVIDENCE: The manager has completed an NVQ level 4 in management and is a first level registered nurse. Staff made positive comments about the level of support they receive from the manager and that they found the management of the Wessex Lodge DS0000065491.V336181.R01.S.doc Version 5.2 Page 22 home to be open and approachable. This was also supported by comments from health professionals, people who use the service and their and their relatives. The home has made improvements in a number of areas and met all but one of the four previous requirements. The areas identified in this report, regarding care plans and risk assessment strategies, need to be addressed to fully demonstrate the effectiveness of the home’s management. There is a quality assurance system in operation and the home’s resident questionnaires were in the process of being returned. The manager said she will be looking to see if there are any issues or trends identified so that the home can take appropriate action. For example, it had become apparent that some people who use the service were not aware of a particular policy, so the manager was planning to remind people through meetings and to provide a clear and simple leaflet explaining the policy. Records were seen of the home’s audit action plan, which includes a description of the issues and action to betaken. Records of a pharmacy audit were also seen. The manager holds tea parties each month for people who live in the home. These occasions are used discuss any matters that are important to people. Records are kept of these meetings. The inspector met with the owner of the home, who outlined the development plans for the service. This included computerisation and elements of standardisation across the homes in the group and the development of a new line management structure. This will provide enhanced managerial and administrative support for the home. The home has records in place to confirm that regulation 26 visits are taking place. The manager confirmed that the home does not keep or manage any monies for people who live in the home. Individuals need to make their own arrangements for this with their families or legal representatives. Staff undergo health and safety awareness training as part of their induction, food hygiene, first aid and risk assessment are included in the training programme for all staff. The home also has a general health and safety risk analysis and risk management procedure to ensure safe systems and practices are maintained. At the last inspection a requirement was made with regard to risk assessing the use of bedrails, the potential risks to residents when accessing the outdoor Wessex Lodge DS0000065491.V336181.R01.S.doc Version 5.2 Page 23 spaces and access to the open stairwells. The inspector saw that the manager had completed general risk assessments in relation to these issues, however these were not individualised and there was no specific risk assessment in the care plan for the person for whom bedrails are used (something about this should be in the health and personal care section). This requirement is therefore partially amended and repeated in this report. All windows are appropriately restricted to prevent falls. The home keeps up to date records to demonstrate that fire checks and equipment tests are carried out regularly and staff receive training and instruction. There are procedures for evacuating residents that have been agreed following advice from the Fire Safety Officer. Wessex Lodge DS0000065491.V336181.R01.S.doc Version 5.2 Page 24 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Wessex Lodge DS0000065491.V336181.R01.S.doc Version 5.2 Page 25 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 OP7 Regulation 15 Requirement Care plans must contain clear and sufficient information to demonstrate that the home can meet all the needs of people who use the service. The registered manager must ensure that people who use the service are kept safe by the completion of a full risk assessment and any necessary follow up action, for each individual, that includes use of bedrails, risk of falls when using outdoor areas and open stairwells. This is a partially repeated requirement. Previous timescale of 02/06/06 has not been met. Timescale for action 15/07/07 2. OP38 13 15/07/07 Wessex Lodge DS0000065491.V336181.R01.S.doc Version 5.2 Page 26 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Wessex Lodge DS0000065491.V336181.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Wessex Lodge DS0000065491.V336181.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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